Cloud-Chasing and Gummi Bears - Peel Region

Cloud-Chasing and Gummi Bears:A vaping and edibles update for primary care

December 4, 2019

Dr. Peter SelbyMBBS, CCFP, FCFP, MHSc, dipABAM, DFASAMChief – Medicine in Psychiatry Division, Clinical Scientist – Addictions, CAMH

Professor, DFCM, Psychiatry, and the Dalla Lana School of Public Health, University of Toronto@drpselby www.nicotinedependenceclinic.com

http://www.nicotinedependenceclinic.com/

Presenter Biography

Peter Selby is the Chief of Medicine in Psychiatry Division and a Clinician Scientist at the Centre for Addiction and Mental Health (CAMH). He is a Professor in the Departments of Family and Community Medicine, Psychiatry, and the Dalla Lana School of Public Health at the University of Toronto. He is also a Clinician Scientist in the Department of Family and Community Medicine. His research focus is on innovative methods to understand and treat addictive behaviours and their comorbidities. He also uses technology to combine clinical medicine and public health methods to scale up and test health interventions. His cohort of 240,000 treated smokers in Ontario is an example.

He has received grant funding totaling over 85 million dollars from CIHR, NIH, and Ministry of Health and has published 150 peer reviewed publications. He has published 6 books (including 5 edited), is the author of 31 book chapters, and 38 research reports prepared for the government. He is the Chair of the Medical Education Council for the American Society of Addiction Medicine. Dr. Selby mentors Fellows in Addiction Medicine and Addiction Psychiatry, junior investigators and medical students. The use of innovative methods to communicate messages makes Dr. Selby a sought after speaker for various topics including addictive disorders, motivational interviewing, and health behavior change at individual and system levels.

Peter Selby, MBBS, CCFP, FCFP, MHSc, DipABAM, DFASAMChief, Medicine in Psychiatry Division, Centre for Addiction and Mental Health (CAMH)Clinician Scientist, Addictions Division, Centre for Addiction and Mental Health (CAMH)Professor, Departments of Family and Community Medicine and Psychiatry, and Dalla Lana School of Public Health, University of [email protected](416) 535-8501 ext. 36859

mailto:[email protected]

Grants/Research Support:• CAMH, Health Canada, OMOH, CIHR, CCSA, PHAC, Pfizer Inc./Canada, OLA,

• Medical Psychiatry Alliance, ECHO, CCSRI, CCO, OICR, Ontario Brain Institute,

• McLaughlin Centre, AHSC/AFP, WSIB, NIH, AFMC, Shoppers Drug Mart,

• Bhasin Consulting Fund Inc., Patient-Centered Outcomes Research Institute

Speaking Engagements (Content not subject to sponsors approval)/Honoraria:• Pfizer Canada Inc., ABBVie, Bristol-Myers Squibb

Consulting Fees: • Pfizer Inc./Canada, Evidera Inc., Johnson & Johnson Group of Companies,

• Medcan Clinic, Inflexxion Inc., V-CC Systems Inc., MedPlan Communications,

• Kataka Medical Communications, Miller Medical Communications, Nvision

• Insight Group, Sun Life Financial

Other: (Received drugs free/discounted for study through open tender process)• Johnson & Johnson, Novartis, Pfizer Inc.

NO TOBACCO or CANNABIS or VAPING or ALCOHOL or FOOD INDUSTRY FUNDING

Disclosures

Mitigating Potential Bias

In order to mitigate the potential for bias, all thematerial presented herein is based explicitly onevidence-based research.

Copyright © 2017, CAMH

Learning Objectives

5

1Describe various vaping and dabbing delivery systems and the health outcomes of vaping and dabbing

2Describe the safety and effectiveness of vaping products as a smoking cessation aid

Identify current regulations on cannabis edibles and their health impacts

Discuss challenging case studies

3 4


Describe various vaping and dabbing delivery systems and the health outcomes of vaping and dabbing

1

6


Interest in Heat Not Burn is Rising

From 2015 to 2017, average monthly queries for heat not burn tobacco

increased by 2,956% compared to 7% for e-cigarettes Caputi et al., 2017


Objective Design Participants Main Outcome

Measures

Results

Examine differences

in vaping and

smoking prevalence

among adolescents

Repeat online

cross sectional

surveys

National samples, 16-

19yo

2017-2018

Canada (n=7891)

England (n=7897)

US (n=8140)

Prevalence of

vaping and smoking

in past 30 days,

past 7 days, and on

15 or more days in

the past month

Vaping: Increase in

Canada (P<0.001

for all)

Ø England

Smoking:

Increase in Canada

(P<0.001), modest

increase in England,

Ø US

14

Prevalence of vaping and smoking among adolescents in Canada, England, and the United States

Hammond et al 2019

polling question

What is dabbing?A) A hip hop dance

B) Inhaling the vapors of concentrated THC

C) A term coined by rapper Bow Wow

D) The act of using gauze to soak up blood

Copyright © 2017, CAMH17

Inhalation:Dabbing

Stogner and Miller 2015

• Dabbing is the inhalation of vaporized butane-

extracted cannabis products

• Butane is used in production, not during

administration, and is (mostly) purged from product

prior to use

• The THC concentration in dab is (conservatively)

3-4x greater than in flower cannabis

polling question

Odds of developing Cannabis Use Disorder is how many

times higher for adolescents than for adults?

A) 1-2x higher

B) 2-3x higher

C) 4-7x higher

D) 10x higher


Cannabis Dependence and Addiction

Winters and Lee, 2008; Hasin et al., 2015Winters and Lee, 2008; Hasin et al., 2015; National Institute on Drug Abuse (2017)

Cannabis dependence becomes addiction when the individual cannot stop substance use, despite

interfering with several aspects of life

• Odds of developing CUD 4-7 times higher for adolescents (12-18 yr. old) vs. adults (22-26 yr. old)


Cannabis Use Disorders/ Addiction

Approximately 9% of cannabis users will develop dependence vs 68%of individuals using nicotine

• 17% if start using in their teens

• 20-25% if daily cannabis use

• Psychological dependence: cravings for the “high” feeling associated with use

• Physical Dependence: quit attempt after long term use can lead to mild withdrawal syndrome, lasting up to one week

• Disturbed sleep• Irritability• Anxiety

Anthony et al., 1994; Lopez-Quintero et al., 2011; NIH, 2017

• Upset stomach• Loss of appetite


Short Term:

Attention

Memory

Motor function

Poor cognitive function

Coordination/balance

Decreased blood pressure

Increased heart rate

Anxiety, fear, distrust, or panic → “bad trip”

Cannabis Use: Adverse Health EffectsEffects are dependent on dose, route of administration, user’s previous experience, and setting

Hall and Degenhardt., 2009; Maistro et al., 2013; Rocchetti et al., 2013; Volkow et al., 2014; Gunn et al., 2016


Long Term:All of the short-term effects +Increased risk of psychosis, depression, anxietyBrain

•Reduced hippocampal volume

•Increased cognitive impairments among adolescent users (reduced neural connectivity)

Respiratory Effects•Bronchitis

•Airflow Obstruction

•Bullous Disease & Emphysema

•Legionnaires’ Disease

Heart•Myocardial infarction, stroke and transient ischemic attacks

Cancer•Lung cancer, Testicular cancer (?)

•Larynx and esophageal cancer

Reproductive Effects•Slows fetal growth

•Greater risk of fetal malformation, anemia and cognitive impairments

Hall and Degenhardt., 2009; Maistro et al., 2013; Rocchetti et al., 2013; Volkow et al., 2014; Gunn et al., 2016

Cannabis Use: Adverse Health Effects


What are the effects of cannabis smoke on the airways?

Biehl,JR et al. 2015

➢ Increase in respiratory symptoms:cough, dyspnea, sputum

➢Concordant physiological changes observed of chronic bronchitis/ loss of ciliahyperplasia of goblet cells, edema/swelling of airways

➢CB1 receptors on SM are dose dependent


# of

Studies

Risk Ratio (RR)

(95% CI)

What does this mean? Limitations

Current/

former

cannabis use

vs. never

smoked

cannabis

N = 13 1.22*

(1.00 – 1.5)

Cannabis smoking, with

or without concurrent

tobacco use is

associated with a

increased future risk of

developing lung cancer

Study follow-up may

be too short to

observe clinical

development of lung

cancer

Cannabis Smoking and Risk of Lung Cancer: Meta-Analysis

Risk of lung cancer associated with cannabis smoking

*p = 0.05

Bouti et al., 2014


• ~three-fold increase in amount of tar inhaled and deposited into respiratory tract

• ~two thirds greater puff volume

• one-third deeper inhalation

• 4-fold longer breath-holding time

• ~ five-fold higher blood carboxyhemoglobin level

Compared to tobacco, smoking cannabis cigarette

associated with:

Relative Harms: Cannabis vs Tobacco

Wu et al., 1988; Bouti et al., 2014


Tobacco:

• Reduce frequency and number of cigarettes smoked

• Smokeless forms of tobacco

• Non-tobacco products (i.e. NRT)

Cannabis:

• Avoid mixing with tobacco

• Reduce depth of inhalation and breath-holding time

• Alternative methods of delivery (i.e. edibles, vaporizers)

• Lower THC concentration

Harm Reduction Strategies

Rodu and Godshall, 2006


Describe the safety and effectiveness of vaping products as a smoking cessation aid

2


E-cigarette vs Tobacco

• Non-combustible delivery of

nicotine → reduced harm

– Nicotine not classified as a

carcinogen by International Agency

for Research on Cancer

– Meta-analysis of 35 clinical trials

reported no increased risk of CVD or

other detrimental health effects

associated with nicotine intake

• E-cigarettes are less harmful

than smoked tobacco


Comparison of Toxicants: Conventional

Cigarettes vs E-cigarettes

Toxic Compound

Conventional

Cigarette (µg in

mainstream

smoke)

E-cigarette (µg per

15 puffs)

Average Ratio

(Conventional

Cigarettes vs E-

cigarette)

Formaldehyde 1.6 - 52 0.20 – 5.61 9

Acetaldehyde 52 - 140 0.11 – 1.36 450

Acrolein 2.4 - 62 0.07 – 4.19 15

Toluene 8.3 - 70 0.02 – 0.63 120

NNN 0.005 – 0.19 0.00008–0.00043 380

NNK 0.012 – 0.11 0.0001 –0.00283 40

Goniewicz et al. 2014

NNN: N’-nitrosonornicotineNNK: 4-(methylonitrosoamino)-1-(3-pirydyl)-l-butanone


Do e-cig help smokers quit? The early evidence

• Evidence from randomized controlled trials

– Bullen et al, Lancet 2013:382:1629-37

• 1st gen e-cigs (with and without nicotine) vs patch

• No sig difference in 6-month abstinence

– Caponnetto et al, PLoS One 2013

• E-cig with different doses of nicotine cartridge

• Decreased smoking and ~10% abstinence regardless of dose (in smokers

not interested in quitting)

– Halpern et al, NEJM 2018;378:2302-10

• Randomized to e-cigs (cigalikes), NRT, incentives

• Only 20% ‘engaged’

• V. low 6-month abstinence 0.1% to 2.9%



Most recent RCTs


Study Population Method Results

Hajek et al

2019

E-cigarettes vs

NRT

N=886

Adults from UK

National Health

Service stop-

smoking

services

Smokers

randomized to either

NRT or e-cigarette,

Both received

behavioural support

1-year abstinence rate:

18% in the e-cig group

9.9% in NRT group

E-cigarettes were more effective

for smoking cessation than NRT

Walker et al

2019

Patches in

combination

with e-

cigarettes

N=1124

Gen pop

Adult smokers

New Zealand

Motivated to quit

E-cig naïve

Smokers were

randomized 1:4:4,

patches only

(n=125);

patches + nicotine

e-cig (n=500)

Patches + nicotine

free e-cig (n=499)

Withdrew/lost to FU

50% in patches group;

32% in nicotine e-cig;

33% in nicotine-free e-cig

Patches + nicotine e-cig showed

modest improvement in smoking

cessation over that obtained from

patch + nicotine free e-cig


Acute Lung Distress and Vaping

Study Population Symptoms Method Findings

Layden et al.

2019

Pulmonary

illness related to

e-cig us in

Wisconsin

N=53

83% male

Median age = 19

Sample from

people reporting

e-cig use in the

90 days before

symptom onset

respiratory

symptoms

(98%),

gastrointestinal

symptoms

(81%), and

constitutional

symptoms

(100%).

Medical

record

abstraction

and case

patient

interviews

94% of the patients

were hospitalized,

32% underwent

intubation and

mechanical

ventilation, and one

death was reported

Suggests additional research is needed


• CDC has identified vitamin E acetate as a chemical of concern among people with

EVALI

• Vitamin E acetate is used as an additive, most notably as a thickening agent in THC-

containing e-cigarette, or vaping, products

• CDC recommends that people should not use THC-containing e-cigarette, or vaping,

products, particularly from informal sources like friends, or family, or in-person or

online dealers

• In addition, people should not add any substance to e-cigarette or vaping products

that are not intended by the manufacturer

38

Acute Lung Distress and Vaping

Recent case clusters of E-cigarette or Vaping

Associated Lung Injury (EVALI)


Vaping e-liquids expose user to several potentially harmful chemicals

39

Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth

• Diacetyl (flavouring compound associated with bronchiolitis obliterans with

inhalational exposure – “popcorn lung”)

• Case: 17y/o previously healthy Cdn

• severe acute bronchiolitis causing near-fatal hypercapnic respiratory failure and chronic airflow obstruction

• Calls for further research on the potentially toxic components of e-liquids


Identify current regulations on cannabis edibles and their health impacts

340


Use of Edibles

Canadian Cannabis Survey

Canadian Cannabis Survey (CCS), 2018

n=12,958

41% of cannabis users reported using edibles

Increase from 32% in 2017

In all provinces, edibles were the second most commonly reported product of use (39-51%) amongst cannabis users, behind dried flower/leaf (80-87%)


• Harder to titrate the intoxicating effects due to delayed/variable onset of effects

• Accidental “overdose” following ingestion of additional doses

• At high doses THC can produce anxiety, panic attacks, and/or psychotic symptoms, increased heart rate and changes in blood pressure

42

Challenges Associated with Edibles

MacCoun et al 2015

Different pharmacokinetic and metabolic effects of cannabis when ingested rather than smoked


1 mg of Δ9-THC contained in an edible produces a behavioral effect similar to 5.71 mg of Δ9-THC contained

in smokable cannabis

43

Challenges Associated with Edibles

Barrus et al 2016


Discuss challenging case studies

444

Case Studies

Vaping and Cannabis Edibles

Case Study # 1

Kerri is a 34 year old woman who used vaping to quit smoking in the past. She has come back to you in her first trimester of pregnancy and is concerned that vaping could be harmful to the baby. She has heard that champix and zyban are effective to help people quit smoking and would like a prescription for either one. Her husband smokes and has no interest in quitting. Neither of them smoke or vape inside the home. Kerri has no family support and limited contact with friends.

How would you advise?

What resources would you provide/refer to?

Clinical Guidance

✓ Advise her to stop vaping, as the long term health effects and effects on the fetus are yet unknown.

✓ Assess for depression/ anxiety.

✓ First try behavioral strategies for cessation (i.e. changing her routines, using 4d (deep breathing, distract, drink water, delay) individual, group or telephone counselling).

✓ Suggest husband attend an appointment and utilize motivational interviewing to assess readiness and provide support to client

✓ Suggest she join the Pregnets online forum as it would also provide some needed social support.

✓ If behavioral strategies are not effective, then begin using intermittent NRT (i.e. gum, lozenge) to manage cravings, ONLY once she has entered her second trimester.

✓ - * Champix and Zyban have not been approved for use in pregnancy.

Resources:

▪ Pregnets website and online support

▪ Telehealth for supportive telephone counselling

▪ Smokers Helpline online support

▪ Region of Peel Public Health website (Parentinginpeel.ca)

Case Study # 2

A parent comes to see you because she recently found out that her 14 year old son is vaping. He tells her he got the vape pen from a friend and he was vaping to quit smoking. The parent did not know that her son was smoking. Both are scared about vaping because of all the news about the illnesses and deaths in the media. He is worried that if he stops vaping, he will return to smoking. The parent has resorted to buying vapes for her son to reduce the risk of him buying them online illegally and/ or getting illegal products from his friends.



Clinical Guidance✓ Inform parent that although purchasing legitimate vaping products for her son

reduces the risks associated with defective vaping products (i.e. burns and injuries from batteries), there are still risks. Also, it is illegal to supply e-cigarettes to anyone under the age of 19 (Smoke Free Ontario Act, 2017).

✓Advise the parent that it is not safe for youth to use any nicotine products, including cigarettes and vaping products. Youth can become addicted to nicotine much quicker than adults, and it can alter teen brain development.

✓Advise her that her son should stop vaping immediately and not return to smoking cigarettes. He should first try behavioral strategies for cessation (i.e. changing routines, identifying and avoiding triggers, developing effective strategies for stress management, etc.).

✓ If he is still having cravings that he cannot manage, advise her to bring him in to speak with you (or his doctor if different) or pharmacist about using intermittent NRT (i.e. gum, lozenge).

Resources:

▪ Peel Public Health community resources sheet (especially noting Youth Substance Abuse Program (YSAP) of Peel)

▪ Region of Peel Public Health website

▪ Health Canada’s tip sheet “Talking with your teen about vaping”

▪ Notanexperiment.ca

Case Study #3

A 25 year old female school landscaper has had a third visit to the ED in 3 weeks due to excess vomiting. She presents mildly dehydrated and after a day or two of admission with IV fluids and antiemetics she feels better but returns within a week with recurrent vomiting.

• No medical or psychiatric diagnosis• Consumes 2-3 edibles/day• Alcohol (3 to 4 beers on the weekend)• Tobacco (20 cpd)• Denies other substances currently. Past use of LSD, mushrooms but none in the last 3

months• Afebrile, vitals stable and no evidence of raised intracranial pressure. Pregnancy tests are

negative• Notices that a warm bath stops her nausea and vomiting




Questions &Discussion

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Cloud-Chasing and Gummi Bears - Peel Region

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