Daily Dose Q&A

What are some of the heavy metals that may be present in some cannabinoid preparations?
Heavy metals, such as arsenic, cadmium, lead and mercury may be present in cannabinoid-based products. It is important to look at a certificate of analysis to determine if heavy metals have been detected in a product.
What should be listed on a Certificate of Analysis (CoA)?
First, a Certificate of Analysis (CoA) should be from an independent and properly certified testing laboratory, and not from the retailer. CoA should show the amount and concentration of major cannabinoids and terpenes present in the tested sample, as well as testing data regarding the lack of (or presence of) microbial organisms, fungal contaminants, the levels of heavy metals, and amount of pesticide and residual solvents.
Respiratory depression is associated with the overdose of opioids or benzodiazepines. Is respiratory depression associated with an overdose of cannabinoids? Why or why not?
Respiratory depression is not associated with cannabinoid use because CB1 receptors are not located in the midbrain, the part of the brain responsible for respiratory drive.
Levinsohn EA, Hill KP. Clinical uses of cannabis and cannabinoids in the United States. J Neurol Sci. 2020 Apr 15;411:116717. doi: 10.1016/j.jns.2020.116717. Epub 2020 Jan 30. PMID: 32044684. https://pubmed.ncbi.nlm.nih.gov/32044684/
Cannabinoids are metabolized by many of the same cytochrome P450 enzymes as warfarin. In fact, THC, CBD and CBN can inhibit the hydroxylation of warfarin, and thus lead to an increase in INR. Do cannabinoids also affect the metabolism of heparin? Is the metabolism of direct oral anticoagulants (DOACs), including rivaroxaban, edoxaban, and apixaban, impacted by cannabinoids?
While cannabinoids do not alter the metabolism of heparin, cannabinoids may impact the metabolism of DOACs. DOAC levels may increase, leading to an increased risk of bleeding.
Jessica Greger, PharmD, Vernice Bates, MD, Laszlo Mechtler, MD, and Fran Gengo, PharmD. A Review of Cannabis and Interactions With Anticoagulant and Antiplatelet Agents. The Journal of Clinical Pharmacology 2019, 0(0) 1–7. https://accp1.onlinelibrary.wiley.com/doi/abs/10.1002/jcph.1557?af=R
Chronic pelvic pain affects up to 15% of women in the United States. Cannabinoid receptors are expressed on reproductive tissues (including the uterus) and non-reproductive pelvic tissues. Do patients with chronic pelvic pain use cannabinoid-based products to ameliorate their symptoms?
The conclusions of a survey of 122 chronic pelvic pain female patients indicated that up to 23% report using cannabinoid-based products as an adjunct to their prescribed therapies. The patients use a variety of formulations and doses of cannabinoid-based products, and most report daily or weekly use. Most users report improvement in symptoms, but did acknowledge that side effects are common.
Carrubba, Aakriti R. MD; Spaulding, Aaron C. PhD; Ebbert, Jon O. MD; DeStephano, Christopher C. MD, MPH Patient-Reported Use of Medical Cannabis for Management of Chronic Pelvic Pain [12H], Obstetrics & Gynecology: May 2020 - Volume 135 - Issue - p 84S doi: 10.1097/01.AOG.0000665024.52449.e7. https://journals.lww.com/greenjournal/abstract/2020/05001/patient_reported_use_of_medical_cannabis_for.293.aspx