[[{“value”:”
There are many ways to get high from marijuana. Historically, marijuana exposure has usually taken the form of smoked joints, blunts, or pipes. Other means of consumption include using a bong (ie, water pipe) or oral ingestion (ie, edibles).1 Vaping involves inhaling an aerosol vapor derived from a liquid or dry material that is heated using an electronic device, or e-cigarette. Dry herb vapes heat dry marijuana flower without the use of additional liquid.2 Vitamin E acetate is an oily chemical added to THC vaping liquids to change its consistency and is a CDC toxin of concern.3
An increasingly popular method of consuming marijuana is dabbing, which refers to the inhalation of vapors containing extremely concentrated tetrahydrocannabinol (THC) derived from marijuana-based concentrates, extracts, and oils such as butane hash oil (BHO). Dabbing differs from the use of traditional flower cannabis because of the high THC content and the presence of unpurged butane and other impurities.1
“Think of what smoking crack was to snorting cocaine or fentanyl to oxycodone or beer to distilled spirits. There are definitely parallels in that the user gets a rapid high dose, but the drug is the same,” said Russell Bowler, MD, PhD, Chair Genomic Sciences and System Biology at the Cleveland Clinic, in an email interview with Pulmonology Advisor.
Although many think dabbing is new, its origins trace back to the Vietnam war, when it was thought that soldiers would extract THC into liquid concentrate by using solvents, including acetone or petrol. Users would then smear the liquid concentrate onto rolling paper or saturate tobacco with it.
Butane extraction entails passing liquid butane through raw marijuana vegetation. THC and other hydrophobic compounds dissolve in the butane and are filtered out with the butane. The butane is then either allowed to evaporate or actively purged with heat or a vacuum. The end product yields much higher levels of THC compared with flower cannabis and goes by many names, depending on its consistency: dabs, honeycomb, shatter, oil, or wax. This BHO is manufactured in commercial environments using modern closed-loop equipment or in home garages using steel tubes, screens, and Pyrex dishes. Home production of BHO is sometimes referred to as “blasting.”
Blasting is not only illegal but a fire hazard. Even a spark from static electricity can set of an explosion. These explosions, which have occurred in garages, mobile homes, or abandoned homes, have caused severe burn injuries or death.
“These concerns are mitigated when consumers purchase products from regulated manufacturers in recreational and medicinal states which use closed-loop processes that more effectively recover solvents, but the interest in and availability of dabs suggest that illegal amateur open system production is rampant in both prohibition and recreational marijuana states,” wrote authors in Substance Abuse and Rehabilitation.4
BHO or other cannabis concentrates can be placed in a dab rig. The dab rig is a tabletop device consisting of a heated surface, and the concentrate is aerosolized and filtered through water before inhalation. At the correct temperature, dabbing is a type of vaporization. Combustion occurs, however, if a blowtorch is used to heat the surface.
Dab or wax pens are portable and battery operated. Consequently, they are usually temperature controlled. Concentrates are applied directly to the heating coil and aerosolized for inhalation. Dab pens are a little bigger than vape pens because they require larger batteries to vaporize concentrates.
Due to very high levels of THC and the presence of contaminants, clinicians should discourage their patients from cannabis dabbing via either a dab rig or pen. Individuals typically purchase these products online or in unregulated retail spaces.5
Increased THC levels in BHO make its use much riskier than traditional methods of consumption like smoking joints or eating marijuana-infused food products. These high concentrations are present in the first breath and raise the chance of dependence and addiction.
Case reports in the literature describe acute and chronic lung impairment secondary to BHO dabbing, such as pneumonitis, pneumonia, and acute hypoxemic lung failure. Dabbing also results in structural brain changes, cognitive dysfunction, psychosis, and acute psychosis. Other effects include hypertension, tachycardia, temporary loss of consciousness, antegrade anesthesia, lethargy, and hallucinations. In extreme cases, end-organ damage has occurred via serotonergic and sympathomimetic pathways.1
“Most of the complications from dabbing are related to the extremely high dose of THC that is delivered (psychosis, dependence, and so forth),” said Dr Bowler. “There are also the physical risks of burns (open flame). I think most of the severe e-cigarette or vaping use-associated lung injury (EVALI) cases were vaping, not dabbing. It was the vitamin E added to vapes that was the problem.”
Dabbing is often only one way that marijuana users consume the drug. One study found that among 6174 U.S. adult users aged 18 and older, 33.7% engaged in multiple methods of marijuana use, with 14.5% dabbing.6
Dr Bowler advised, “The big message about dabbing is that if your patient is doing it, they are very likely highly addicted to THC and at risk for all the things that come with addiction and withdrawal (eg, hyperemesis syndrome). Also concerning is the high temperature open flame (burn risk) with possible inhalation of other toxic compounds (acute lung injury such as EVALI).”
Authors of a case report published in the Cleveland Clinic Journal of Medicine recommend EVALI as a differential diagnosis if patients report vaping or dabbing within 90 days of symptoms onset, exhibit pulmonary infiltrates on imaging, and lack any other potential etiologies. Patient history is often notable for a gradual onset of constitutional, gastrointestinal, or respiratory symptoms.7
Health care providers should also be on the lookout for cannabis withdrawal syndrome, which often accompanies abstinence after prolonged or heavy use of cannabis. Signs and symptoms of withdrawal include anxiety, depression, irritability, depression, insomnia, and so forth.
“Little detailed, informative literature for professionals and researchers regarding treatment for addiction to BHO dabbing exists, hindering an optimal response to the issue,” according to a review published in Nursing. “Many substance abuse rehabilitation centers in the US maintain that they provide BHO dabbing rehabilitation services. These facilities assert that rehabilitation for BHO dabbing is no different than rehabilitation for other marijuana use.”1
Behavioral modification treatments include cognitive behavioral therapy; motivational interviewing; and contingency management, which involves the use of incentives or rewards to reinforce positive behaviors.1
References:
“}]] Cannabis dabbing, an increasingly popular way to consume highly concentrated THC, has been linked to pulmonary and neurologic impairments. Read More
