Chances are you’ve heard the news: Over 380 people who use vapes appeared in emergency rooms across the country, racked with nausea or chills or unable to catch their breath. Some recovered quickly. Others found themselves caught in a sudden and intractable decline and might have died had they waited longer to seek care. Seven deaths have been confirmed in California, Illinois, Minnesota, Oregon, Indiana and Kansas. Many of those affected were young and in good health.
Right now there are more questions than answers on the exact substance, or substances, causing this illness. What we do know is vitamin E acetate was found in many of the vaping devices linked to related illnesses, but not all of them. “No conclusions can be drawn as to what compound or compounds are the causes of injury” until more information is available, cautioned an editorial in the New England Journal of Medicine.
But the overarching cause is clear. “The rise in vaping-associated illnesses is a frightening public health phenomenon,” said Governor Andrew Cuomo of New York. The spread of this vaping-related illness has been termed an epidemic.
As headlines grow bleaker, some vape users will likely embark on the long and difficult process of disentangling themselves from the vape devices linked to illness. It’s what many public health officials are calling for, including the Centers for Disease Control and Prevention. “Our advice is quite simple,” said Cuomo. “Don’t do it because we don’t know if it’s safe.”
But for people living with chronic illness or other health and mental health conditions, quitting might not be so simple.
CBD and THC, active ingredients found in cannabis plants, are often used in vaping fluid. They’re also used by many people living with chronic illness to manage their symptoms. While only one CBD-derived product has Food and Drug Administration (FDA) approval — for the treatment of Lennox-Gastaut syndrome and Dravet syndrome, both of which are rare seizure disorders — preliminary studies suggest that cannabis derivatives have promise for the treatment of a range of conditions, from glaucoma to anxiety and chronic pain.
The news about vaping products can complicate matters for people who use CBD or THC-containing vapes to manage their chronic illness. To help navigate these issues and shed some light on the health risks of vaping, The Mighty spoke to Meghan Cirulis, M.D., a physician and researcher at the University of Utah. She has led a number of studies on lung diseases and was recently involved in research for the New England Journal of Medicine identifying markers physicians could use to diagnose vaping-induced lung injury. We also spoke to Michele Ross, Ph.D., a neuroscientist who writes The Mighty’s “Chronically Cannabis” column, and rounded up a list of alternative cannabis products for people who would like to quit vaping but need cannabis products to manage their conditions.
Is there a safe way to vape?
“At this stage, I would say no,” Dr. Cirulis said. “Until we figure this out, I think vaping puts people at immediate risk of health consequences that can be severe, even fatal.”
She added that while some vape products may seem safer than others, we can’t make reliable risk assessments until these products are studied more. Cirulis said that while a “higher proportion of cases” have been linked to e-cigarettes containing CBD and THC, she “wouldn’t consider any product higher or lower risk” until more information is available. “We have definitely seen cases in patients only using nicotine products,” she noted.
A lot of discussion has centered on legal versus illegal e-cigarettes, but Cirulis said that at the moment, it’s not clear commercial vapes are safer than “street” vapes. “Some of the cases have reported use of only commercial e-liquids — so I wouldn’t say any product is ‘safe’ currently,” she told us.
This is in part because even legally sold vape products are subject to very little government oversight. “I have found it interesting that we still don’t really know exactly what is causing the issue,” said Cirulis. “I think [it] speaks to how poorly regulated the e-cigarette market really is — we have no idea what is in even the commercially sold e-liquids.”
If you’re going to vape regardless of the potential risks, Dr. Ross recommends not using a liquid and only vaping using the actual cannabis flower.
“Vaping cannabis flower is always safer than vaping cannabis concentrates,” Ross said.” Vaporizing heats up the air around the cannabis flower, releasing cannabinoids like THC and CBD and terpenes without burning the cannabis the way that smoking cannabis in a pipe or joint can.”
How Does Vaping-Illness Present?
Cirulis has noticed a pattern of symptoms in people who come to her center for help. “Based on experience from our center, and what the other centers have reported, most patients are presenting with some combination of cough and shortness of breath, nausea, vomiting, and systemic symptoms like fever or chills,” she said. For some patients, symptoms like nausea or vomiting can appear before respiratory problems.
The “spectrum” of what happens next is “quite variable,” Cirulis said. The study she and her colleagues published in the New England Journal of Medicine details the cases of six patients. “Several cases had mild symptoms (but enough to seek medical attention),” she said. “The worst cases landed in the intensive care unit on high levels of oxygen therapy or with a breathing tube and medical ventilation.”
In one case, “because the [patient’s] lungs were so sick,” they had to be bypassed entirely — a machine filled the patient’s blood with oxygen.
Cirulis and her colleagues did find a few constants: all patients admitted with vaping-related lung injuries had a “significant inflammatory reaction” due to their habit. And all of their lungs contained lipid-laden macrophages, which are associated with other conditions that impact the lungs and make it hard to breathe. It’s not yet clear why these macrophages are there, but they could help doctors diagnose the vaping-related illness in the future.
What Substances Cause Vaping Illness?
“As far as I am aware, we still don’t have a specific culprit,” said Cirulis. While vitamin E acetate has been found in many vaping devices linked to lung injuries, it hasn’t been found in all of them. “So there is likely something else (either in addition to or instead of the vitamin E acetate),” she said.
Alternatives to Vaping
There are a lot of unknowns when it comes to vaping cannabis products. Fortunately, several alternatives to vaping exist and may be safer methods for getting CBD or THC while researchers sort out what’s causing vape-related illness.
“The safest way is to use products that have been lab-tested by a third-party, no matter whether it’s a gummy, lotion, vape pen, or flower,” Ross advised. “Without lab testing, you have no idea whether you’re ingesting toxic chemicals that can make your chronic illness worse, or cause serious health problems.”
We’ve listed a few alternatives you may want to try below.
Oils and Tinctures
CBD oils and tinctures are applied in droplets under the tongue. It’s easy to control how much you’re taking, and you can’t get high off of it because it does not contain THC, which is the type of cannabidiol that gets you “high.” And CBD seems to be safe: According to the World Health Organization, “it is generally well tolerated, with a good safety profile … at present, there are no case reports of abuse or dependence relating to the use of pure CBD.”
The FDA doesn’t regulate CBD or any cannabis-related products, for that matter. It’s important, then, to do some research into companies before you buy — pure CBD may be safe, but other substances found in these products may not be. You should also tell your doctor that you’re using CBD, since it can interact with certain medicines — taking it with antidepressants or opioids could be dangerous.
“Make sure you are buying a product that is from the legal market,” Ross said, adding:
This means a brand that has a cannabis license to manufacture and a dispensary that is licensed to sell marijuana. Legal products are not allowed to have unsafe substances in them, and third-party lab testing confirms their safety. The legal market also issues recalls if products are found to be unsafe after sold.
You can also use topicals if you have physical pain like joint or muscular pain.
THC or CBD Edibles
Edibles are effective for much longer than cannabis that is smoked. The effects of smoked cannabis generally wear off after three hours. Edibles, on the other hand, peak at the three-hour mark and can be effective for up to 24 hours.
If you think edibles are a good option for you, there are a few important caveats you should consider. First, edibles take longer than inhaled products to start working — sometimes 90 minutes or longer. Most people who have used THC have “overdosed” at one point, experiencing “severe … behavioral impairment,” according to one study, and sometimes ending up in the hospital.
For edibles users, these overdoses tend to happen because people expect to feel a difference immediately. When they don’t feel anything, they reach for more edibles and end up consuming a larger dose than is necessary or safe. When it comes to edibles, keep in mind that you may not feel anything for several hours — it’s completely normal. Start low and go slow.
Another concern is that dosage can vary a lot within a single product or even between batches. Labels showing how much THC or CBD is in a product are frequently inaccurate. When eating edibles, it’s always a good idea to start off with a small amount and build gradually. As with any cannabis product or supplement, make sure to tell your doctor what you’re trying so they can help monitor for interactions with any other medications you may be taking.
Many edible products contain THC exclusively, and many overstate the amount of CBD that is in there. It’s important to read the labeling and vet companies you choose to buy from. It’s also important to store all edibles safely — kids and pets may be tempted to try them, especially if they look like sweets. CBD-only edibles are out there, too.