The medical information on this site is provided as a resource for information only, and is not to be used or relied upon for any diagnostic or treatment purposes and is not intended to create any patient-physician relationship. Readers are advised to seek professional guidance regarding the diagnosis and treatment of their medical concerns.
Inhaled (Smoked & Vaporized)
Based on current legislation in Louisiana, legalized medical marijuana does allow for inhaled forms, in the form of a multi-dose inhaler, but this product is not available yet. Louisiana law does not allow for the use of plant product in any form of administration including oral forms, edibles or inhaled/vaped.
Smoked cannabis refers to direct ignition of the cannabis plant and inhalation of the smoke from combustion, whereas vaporization is a method of delivering inhaled cannabis while decreasing the number of toxic byproducts produced by combustion.
The reason for caution with inhaled drugs is that in general inhaled drugs have more immediate and higher blood levels associated with this means of administration. Therefore, especially in the case of cannabis-based products, there is a greater risk for side effects, especially cognitive dysfunction such as sedation, confusion and impaired decision making and problem solving. Also, with inhaled medications there is greater difficulty in accurately determining dosage unless provided with inhaler devices designed to deliver specific amounts of drug. Additionally, due to the heightened and immediacy of drug-induced effect associated with inhalation, there is an increased risk for abuse and addiction compared with other means of administration such as sublingual, buccal or oral.
Furthermore, oral or buccal cannabinoids have greater evidence of effectiveness than smoked cannabis does, especially for the treatment of neuropathic pain, and there is no evidence that smoked cannabis is more effective than pharmaceutical cannabinoids. Pharmaceutical cannabinoids are also safer and associated with fewer side effects compared with plant-based products.
Based on recommendations established by health agencies in Canada, the following information including indications, contraindications, precautions, and dosing of smoked cannabis are based on levels of evidence. The availability of evidence is mostly level II (well conducted observational studies) and level III (expert opinion).
Over-the-Counter Cannabinoid Medications:
Prescription Cannabis-Based Medications:
Clinical Applications of Cannabis:
Cannabis – Anxiety (coming soon)
Cannabis – Headaches (coming soon)
Cannabis – Inflammatory Bowel Disease (coming soon)
Cannabis – Neuroinflammation (coming soon)
Cannabis – Pain (coming soon)
Cannabis – Sleep (coming soon)
The Medical Science of Cannabis:
Cannabinoids and Terpenes:
Cannabinoids & Terpenes – An Overview (coming soon)
Terpenes – An Overview (coming soon)
Key to Links:
Grey text – handout
Red text – another page on this website
Blue text – Journal publication
Marijuana – Inhaled (Smoked & Vaporized)
At the current time, Louisiana legislation for medical marijuana does not permit products to be inhaled, either by smoking or vaping. It is not yet known what products and their potencies will be provided under current Louisiana legislstion.
The use of inhaled marijuana or marijuana products is not endorsed, encouraged or recommended.
Oral or buccal cannabinoids have far greater evidence of effectiveness than smoked cannabis does for the treatment of neuropathic pain and there is no evidence that smoked cannabis is a more effective analgesic than pharmaceutical cannabinoids. Pharmaceutical cannabinoids are also safer, with fewer cognitive effects.
The legality of inhaled forms of medical marijuana (dried plant) varies from state to state but it is not always based 0n scientific evidence of effectiveness or safety. Because Canadian guidelines for inhaled cannabis are based on research, they are presented here as a means of informing those who may elect to engage in the use of inhaled marijuana, legally or illegally, in an effort to reduce harm.
- Most common route of administration, but not recommended (joints, bongs, pipes, etc.)
- Combustion heats cannabis to 600–900 °C produces toxic biproducts ncluding: tar, PAH (polycyclic aromatic hydrocarbons), carbon monoxide (CO) and ammonia (NH3).
- Chronic use associated with respiratory symptoms (bronchitis, cough, phlegm), but not lung cancer nor COPD (if cannabis only). Mixing cannabis with tobacco increases respiratory/cancer risk
- 30–50% of cannabis is lost to ‘side-stream’ smoke
- Vaping heats cannabis to 160–230 °C. This reduces carbon monoxide (CO) exposure but does not completely eliminate exposure to PAH (polycyclic aromatic hydrocarbons).
- Vaporisation produces significantly less other harmful biproducts vs. smoking.
- Reducesd pulmonary symptoms are reported compared to smoking.
- Smoking/Vaping onset: 5–10 minutes
- Smoking/Vaping duration: 2-4 hours
- Rapid action, advantage for acute or episodic symptoms (nausea/pain).
- Juicing cannabis or making cannabis teas do not allow for adequate decarboxylation of THCA and CBDA, the relatively inactive components rhat are found in the raw plant that require heat to be converted to the nore active forms, THC and CBD.
- Oils, capsules and other oral routes have become increasingly popular due to convenience and accuracy of dosing.
- Edibles (brownies/cookies) are often more difficult to dose and lead to accidental ingestions, especially children. There are a growing number of reports of accidental overdosing with edidles leading to extreme side effects including panic attacks, paranoia and psychotic-like symptoms
- Tinctures and lozenges designed to be held in the mouth or under the tongue to allow for more rapid absorption into the blood through the oral mucosa have intermediate onset between inhaled and oral but have limited research.
- Oral onset: 60-180 minutes
- Oral duration: 6-8 hours
- Less odor, convenient and discrete, advantageous for chronic disease/ symptoms but titrating dosing is more difficult.
Oromucosal (Sublingual & Buccal)
- Oromucosal onset: 15–45 minutes
- Oromucosal duration: 6-8 hours
The Canadian Experience
In Canada, the medical indications for inhaled marijuana (dried plant) are limited to those patients with severe neuropathic (nerve) pain who have experienced inadequate pain relief or intolerable side effects with trials of standard treatments including: NSAIDs, anticonvulsants (gabapentin (Neurontin) or pregabalin (Lyrica), antidepressants (duloxetine/Cymbalta) and amitriptyline/Elavil, or opioids (tramadol, hydrocodone etc.) and have not responded to adequate trials of pharmaceutical cannabinoids.
THC vs. CBD:
Of the three species of cannabis identified (Cannabis sativa, C. indica, and C. ruderalis), C. sativa contains higher THC than CBD levels while the C. indica is richer in CBD compared to THC. CBD reduces the psychotropic actions of THC, possibly by inhibiting THC metabolism and the formation of its primary psychoactive metabolite, 11-OH-THC.
To summarize, a higher THC:CBD ratio is associated with more prominent psychoactive symptoms, whereas lower THC:CBD ratio suppresses psychoactive symptoms and has more sedative and relaxing effects.
Canadian Guidelines Contraindicating Use of Inhaled Cannabis Products:
Inhaled cannabis is contraindicated in:
- Patients who are 25 years of age or younger
- Patients who have a current, past, or strong family history of psychosis
- Patients who have a current or past cannabis use disorder (marijuana addiction)
- Patients who have a current substance use disorder (chemical or behavioral)
- Patients who have cardiovascular or respiratory disease
- Patients who are pregnant or planning to become pregnant
Inhaled cannabis should be used with caution in:
- Patients who smoke tobacco
- Patients who are at increased risk of cardiovascular disease
- Patients who have anxiety or mood disorders
- Patients who are taking high doses of opioids or benzodiazepines
- Do not operate dangerous equipment or perform potentially dangerous activities after use
- Do not combine with tobacco
- Do not use with alcohol, opioids, or sedating drugs
- Keep cannabis safely stored under lock and key
- The maximum recommended dose is 1 inhalation 4 times per day (approximately 400 mg per day) of dried cannabis containing up to 9% THC.
Cannabis users should be advised not to drive for at least:
- Three to four (3 to 4) hours after smoking
- Six (6) hours after oral ingestion
- Eight (8) hours if they experience a subjective “high”
Dosing – Dried Cannabis
- The determination of dosing is one of the major stumbling blocks in the study of medical marijuana. This is because marijuana, a plant, varies widely in the amount and ratios of the pharmacologically active constituents present depending on a multitude of variables. Depending on the plant there may be over 100 pharmacologically active constituents all of which vary depending on the genetics of the plant, the conditions in which the plant was grown, how and when it was harvested and other variables. As such there is a huge variability in the potency and expected effects between different plants.
- As noted above, the major pharmacologically active constituents found in marijuana are the cannabinoids THC and cannabidiol (CBD). The average contents of THC and CBD in dried plant preparations of marijuana confiscated from 1993 to 2008 in the United States were 4.5 and 0.4, respectively, although these contents vary widely. In the last decade these percentages have increased in different strains to more than 5-10 times as potent.
- In addition to the cannabinoids there are other constituents found in marijuana that may contribute significantly to the pharmacologic effects. Include in these other constituents are the terpenes, fragrant chemicals that often give the notable scents associated with marijuana leaves and flowers. Their pharmacologic roles are currently being studied.
- It is also believed there may be an “entourage” effect in which the synergistic actions of the many pharmacologic agents in marijuana contribute to the overall effects, both therapeutic and adverse. Thus it may not be the amount of THC and/or CBD that singularly determine the pharmacologic effects but the overall combination and ratios of the many pharmacologic constituents present in the plants.
Dosing – Inhaled Cannabis (Smoked and Vaped)
Based on Canadian guidelines published in 2014, smoked cannabis might be indicated for patients with severe neuropathic pain conditions who have not responded to adequate trials of pharmaceutical cannabinoids and standard analgesics. Smoked cannabis is contraindicated in patients who are 25 years of age or younger; who have a current, past, or strong family history of psychosis; who have a current or past cannabis use disorder (marijuana addiction); who have a current substance use disorder (addiction to other drugs); who have cardiovascular or respiratory disease; or who are pregnant or planning to become pregnant. It should be used with caution in patients who smoke tobacco, who are at increased risk of cardiovascular disease, who have anxiety or mood disorders, or who are taking high doses of opioids or benzodiazepines.
Based on these Canadian guidelines, when smoking is advised (which it is generally not), initial dosing recommendations for smoked marijuana are usually for small amounts of lower-potency marijuana. For example, the starting recommended dosing is 1 inhalation of a “joint” (with up to a 9% THC maximum) once per day. This can be increased to a maximum recommended dose of 1 inhalation 4 times a day, resulting in approximately half a “joint” per day (or up to 400 mg). People should not operate dangerous equipment or perform potentially dangerous activities after use. This includes no driving for a minimum of 3 to 4 hours after inhaled medical marijuana, 6 hours after oral ingestion, and for at least 8 hours if they experience a subjective “high.”
Higher doses are sometimes used. It should be noted that if patients use a 5 gram (current maximum) dose of 15% THC, this represents approximately a 20 times higher dose than the recommended 400 mg of 9% THC. Higher doses, especially at this level are associated with significantly higher risk of adverse side effects (see below). In marijuana resin, which is commonly referred to as hash or hashish, the mean contents of THC, CBD, and CBN are 14.1, 2.5, and 1.9%, respectively. Other commercial products including oils and edibles may contain higher potencies still.
Blood and Plasma Levels
Blood consists of solid components including red and white blood cells and a liquid component, plasma. Because cannabinoids do not absorb significantly into blood cells, almost all cannabinoids found in blood are in plasma. Therefore, when assessing blood levels, a blood level will represent an amount representing only about 50% of plasma levels which should be taken into account when reading about blood levels vs plasma levels. Plasma levels are generally the preferred measurement.
The average contents of Δ9-THC, CBD, and CBN in dried plant preparations of marijuana are 3.1, 0.3, and 0.3%, respectively although these contents vary widely. In marijuana resin (hashish) the mean contents of Δ9-THC, CBD, and CBN are 5.2, 4.2, and 1.7%, respectively. Smoking a single marijuana cigarette containing 34 mg Δ9-THC (the content of a 3.55% plant preparation) results in a plasma peak level of Δ9-THC at 162 ng/ml (0.516 μM). A peak level of plasma concentration of CBD is been reported to be 114 ng/ml (0.363 μM) after smoking 20 mg of CBD. How these levels correlate with clinical effects varies from individual to individual, but it is not unexpected that blood levels of cannabanoids may have future legal implications.
National Academy of Sciences
This website appears to be good resource for exploring medical marijuana.
- Simplified guideline for prescribing medical cannabinoids in primary care – Canadian Family Physician – 2018
- Physician Recommendation of Medical Cannabis Guidelines Calif Medical Assoc – 2011
- Prescribing smoked cannabis for chronic noncancer pain. Preliminary recommendations – Canadian Family Physician – 2014
Medical Marijuana – Vaping
- Drug Vaping – From the Dangers of Misuse to New Therapeutic Devices – 2016
- Drug vaping applied to cannabis – Is “Cannavaping” a therapeutic alternative to marijuana? – 2016
- Toking, Vaping, and Eating for Health or Fun: Marijuana Use Patterns in Adults, U.S., 2014. – PubMed – NCBI
Emphasis on Education
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