The most important aspect of your medical cannabis intake, by far, is its quality.
Ensuring that your cannabis is pure (organically grown, ethically extracted, cleanly processed, etc.) is paramount for anyone who wants to take the plant in order to feel their best. When these elements are in place, cannabis is able to do what nature intended it to: communicate with the endocannabinoid system and its receptors to promote homeostasis and health.
As effective as medical cannabis can be, however, it has one potential downside: bioavailability.
If you smoke a gram of cannabis, for example, you may only be getting the active cannabinoids from one-tenth of that gram into your bloodstream. In other words, the bioavailability of smoking cannabis is often only 10%, but it can vary wildly between “2 [and] 56%, due in part to intra- and inter-subject variability in smoking dynamics.”
That’s not necessarily a bad thing. Delivery of cannabis’ active ingredients via smoking has its own set of benefits. But for patients who require large, specific doses, there may be better options.
Delivery Methods: 3 Categories, Endless Products
There are three major categories that delivery methods fall into. Medical cannabis can be inhaled, ingested, or applied topically. Each of these three methods has its own pros and cons, and each provides an opportunity to utilize various products.
Inhalation is the most popular delivery method, perhaps for good reason. It’s convenient, simple, and very experiential. Indeed, the experience that goes along with merely burning something has been enjoyed since ancient times.
When cannabis is inhaled, its gasses directly enter the lungs en route to absorption into the bloodstream. This whole process happens almost instantaneously—a convenience that makes inhalation almost universally popular.
Inhalation products: Because inhalation is so popular, there are lots of different inhalation-specific products. These products can be divided into two major categories: smokable products and vaporizing products.
Smokable products are the older of the two categories, and they’re also perhaps more diverse. Cannabis can be smoked in many ways: it can be wrapped with rolling paper into a joint or blunt, placed in the ‘bowl’ of a pipe or a bong, and more. Usually, cannabis flower is broken up into small pieces (either by hand, with scissors or with a specialized grinder) prior to being placed into the medium of choice and combusted.
Smoking cannabis can become too harsh on the lungs over time. Unlike tobacco, cannabis smoke hasn’t been definitively implicated as a risk factor for lung cancer, though one study did find a strong correlation. While the carcinogens in cannabis smoke may be counteracted by THC’s anti-tumor properties, there are probably still healthier choices. That’s where vaporization comes in.
In the past decade or so, vaporizing cannabis has exploded in popularity. Today one can find large, portable vaporizers, as well as much smaller handheld vaporizers called vape pens. Both types function almost like a small oven, gradually heating cannabis flower to a temperature that’s high enough to liberate cannabinoids, terpenes, and plant compounds — but low enough to avoid rapid combustion. Compared to smoking, vaporizing cannabis results in a gentler overall experience.
Another possible option: cannabis concentrates can be smoked and/or vaped, too. Indeed, an entire product market has emerged for this very purpose. Water bongs are often topped with heatable plates designed specifically for burning cannabis oils and waxes.
Inhalation’s Pharmacology: While the experience may be gentle, vaporizing is actually the most bioavailable inhalation method. Several studies show that vaping may deliver at least 34% of medical cannabis’ active ingredients (i.e., cannabinoids and terpenes) into the bloodstream. According to Dr. Ethan Russo’s book Cannabis Therapeutics in HIV/AIDS, the bioavailability of many terpenes is roughly equivalent to their cannabinoid counterparts. In the world of cannabis pharmacology, these are excellent rates.
Once this 30-50% makes it into the bloodstream it quickly crosses the blood-brain barrier, where cannabinoids like THC and CBN cause an uplifting, cerebral effect. Increased binding to CB1 receptors in the brain may cause feelings of calmness and bliss. It’s no wonder that inhalation, whether by smoking or vaping, is such a relaxing experience.
Ingestion is the second of the primary delivery methods. The cannabis is absorbed through the GI tract. It includes two options of its own: eating medicinal cannabis and its derivatives or taking them sublingually. Because of that, ingestion is probably the most diverse of all delivery methods.
Both types of ingestion are subject to the slow-burn of human metabolism, so they kick in slowly and provide lasting health benefits. Yet both methods are also subject to hepatic liver metabolism, which greatly reduces their absorption rates. More on that below.
Ingestible products: This delivery method includes edibles, pills, capsules, powders, and tablets. Cannabis edibles, in particular, have come into their own in recent years. Today everything from THC-rich brownies to cannabinoid-infused drinks is available—the combinations are nearly endless.
While psychotropic edibles are often used recreationally or for pain relief, there’s a growing market for ‘gentler’ CBD-centric edibles, too. Cannabidiol-rich health foods are starting to emerge as their own niche. With pro-athletes testifying to the benefits of CBD (and even starting their own CBD brands) this market seems poised to only grow with time.
When it comes to THC-rich edibles, some caution might be needed. Don’t forget that edibles of any type kick in very slowly—meaning it’s virtually impossible to dose based off of initial effects. Edibles are correlated with increased emergency room visits. The best safeguard is simply to check your edible’s nutrition label for cannabinoid content and make sure you don’t exceed your normal dose. As the State of Colorado encourages: “start low, go slow.”
One way to safeguard against dosing inaccuracies is through the use of pills, capsules, and tablets. These delivery methods come prepackaged with their individual dosages specified; for example, one brand might make cannabis oil capsules that contain 4 mg of THC and 1 mg of CBD each. Though the longer onset times of these products make dosing by feel difficult, their standardization more than makes up for it. Cannabis-infused capsules and tablets also have the potential advantage of reaching the digestive system more intact, so they may be ideal for patients with IBS, Chron’s disease, SIBO, etc.
Of course, you can also ingest cannabis products a little more directly. Eating raw cannabis leaves is a time-tested way to get trace cannabinoids into your system. Though compounds like CBDA and THCA aren’t all that active within the endocannabinoid system, they carry their own sets of health benefits.
For example, studies have shown that CBDA (the unheated acid form of CBD) may directly activate the type of serotonin receptors that reduce stress and anxiety. Raw cannabis is also strongly antimicrobial. Unfortunately, current restrictions on cannabis cultivation mean that raw cannabis leaves and flowers aren’t available to everyone. If you have access to them, though, go for it.
Cannabis concentrates can also be eaten directly; in fact, this type of ingestion might just be history’s most established. Across India, Egypt, and the Middle East, a concentrated plant resin called hashish was especially popular. Smoking cannabis, while commonplace today, didn’t actually become standard until the 1500s.
This mode of delivery is somewhat less common today. But ingestion of concentrates like hash, crystalline cannabis powders, or even Rick Simpson Oil can still be beneficial to patients who want a very simple—but very strong—health solution. A 2013 case report documented how RSO-style cannabis resin worked as “an effective treatment for ALL” (acute lymphoblastic leukemia) in a “rapid dose-dependent” manner. Though all patients experienced side effects such as increased alertness, decreased memory, and increased hunger, cannabis repeatedly lowered blast cell count, a marker of leukemia.
Don’t forget about the second type of ingestible products: sublinguals. This category includes tinctures, oils, and sprays that are made with some combination of cannabis extract and carrier oil. As you might expect, tinctures are meant to be taken sublingually, i.e. held under the tongue.
As of 2019, cannabis oils are more popular than ever. That’s no truer than in the case of CBD oils, which themselves are projected to hit $22 billion in annual sales by 2022. THC + CBD blends are also available on today’s market.
You can even get CBD: THC blends with specific ratios. From a medical standpoint, this emergence is pretty exciting. It’s likely that different ratios work best for different health conditions; for example, a 20:1 CBD: THC ratio appears efficacious in cases of pediatric epilepsy, while a 1:1 ratio appears promising for autoimmune conditions like MS.
Ingestible pharmacology: Let’s look at the sublingual variety of ingestibles and their pharmacology first. The history of tinctures is surprisingly rich; alcohol-based tinctures first made their way onto pharmacy shelves over a hundred years ago. And now sublingual products are experiencing a resurgence, likely for one simple reason: because they work.
The longer an oil is held under your tongue, the higher its absorption rate rises. That’s because the mouth itself contains blood vessels which serve as targets that cannabinoids can easily access. That allows the bioavailability of tinctures to reach 30-40%.
Some patients may find that they prefer an alcohol-based, sprayable cannabis tincture over conventional oil-based cannabis oils. These alcohol-based formulations are likely to be higher in cannabis’s water-soluble ingredients (like chlorophyll and glycosides) than other options, which could be better for certain patients’ biochemical needs.
For those who want an even higher absorption rate, cannabis oil can be taken within a suppository. While unconventional, this method provides both the fast absorption of vaporization and the lasting relief of edibles.
Medical cannabis suppositories may be an ideal delivery method for cancer patients, who find that this method allows ultra-high THC dosages to be taken without ultra-high psychotropic effects. According to MD and cannabis expert Dr. Allan Frankel, the efficacy of cannabis suppositories is unproven, but patient experience is pointing to distinctive health benefits.
The pharmacology of edible products, on the other hand, is much lower. Edibles are fully susceptible to the slower hepatic metabolism that comes when ingested cannabinoids are processed through the digestive tract and liver. That means their absorption rates are drastically lower, hovering around 10%.
But edibles are still a great choice for some. They’re convenient and discreet, and with practice, they’re actually very easy to dose. Edibles may be ideal for those with gut health issues like SIBO, Crohn’s Disease, or IBS. There’s even some initial evidence that cannabinoids can help strengthen and ‘seal up’ damaged gut linings.
Topical application is the third and final delivery method on the list. Though slightly more straightforward than the other two categories, even the world of cannabis topicals has diversified in modern times. Topicals have also taken a quantum leap forward in their technology.
Topical products include balms, salves, and creams. Generally, these types of topicals are made by combining a cannabis extract/concentrate with a base like beeswax, shea butter, or coconut oil. Topicals vary in strength and consistency; often they come in a 1 oz jar with ~250 milligrams of total cannabinoids. That’s great for the average person, but those with intense pain may have trouble finding something strong enough.
For these patients, getting medical cannabis in the form of a transdermal patch may be the best option. Recent advancements in technology have seen these cannabinoid-rich transdermal patches double the normal efficacy of topicals.
The pharmacology of topicals: Topicals have low absorption rates and don’t generally pass through dermal layers into the bloodstream. However, they do activate CB2 endocannabinoid receptors in the skin to provide powerful localized relief. This is especially true of time-release transdermals, which may saturate endocannabinoid receptors more and more over time. There’s also some evidence, courtesy of a 2004 study, that CBD topicals absorb better than ones containing THC.
Keep in mind that topicals, just like other ‘uncombusted’ delivery methods, need to be decarboxylated prior to use. Topicals also commonly combine cannabinoids and specific terpenes from essential oils to boost absorption. It’s possible that the low molecular mass of certain terpenes helps them better permeate the skin — bringing cannabinoids like THC and CBD with them—in what’s known as the entourage effect.
Overall, topicals are ideal for those who don’t want intoxication to impact their day-to-day life. Their ability to provide relief without euphoria may also be a boon for patients who already find themselves ‘maxed out’ on their current CBN or THC dose.
Indeed, virtually anyone can use a topical in conjunction with their normal cannabis regimen. Even athletes are beginning to acknowledge their usefulness when it comes to reducing muscle soreness and pain. Maybe it goes without saying that topicals are also great for the skin, but this benefit deserves a mention, too.