Regulated versus unregulated cannabis — In addition to limiting interactions with the unregulated market and with the criminal justice system, regulated cannabis is safer and more predictable. Unregulated cannabis has been found in many studies to be contaminated with harmful pesticides, heavy metals, molds, microbes, or mycotoxins [14-19]. Most states with legalized cannabis test regulated cannabis for these contaminants, in addition to confirming cannabinoid dosing and labeling [6,18]. However, the ways in which regulation and testing are implemented differ by state. (See ‘Medical cannabis policy in the United States’ above.)

Cannabis formulations and routes of administration

Cannabinoid content — Medical cannabis has varying concentrations and ratios of cannabinoids, and formulations are usually characterized by the ratio of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). In most states, it is mandated that cannabinoid content is reported on medical cannabis product labels [6]. The National Institutes of Health determined that a “standard unit” of THC is 5 mg, particularly for purposes of reporting research results [20]. Pharmacology of cannabinoids and the endocannabinoid system are discussed separately. (See “Cannabis (marijuana): Acute intoxication”, section on ‘Pharmacology and toxicity’.)

US Food and Drug Administration-approved cannabinoids — Four cannabinoid-based medications are approved for use by the US Food and Drug Administration (FDA):

Epidiolex (cannabidiol) is the only plant-derived cannabinoid approved for medical use by the FDA. It is approved for the management of several childhood seizure disorders and is administered as an oral solution that is swallowed and processed as an ingested product [21].


Marinol (dronabinol) is a synthetic cannabinoid similar to THC and administered as a capsule. It is FDA-approved for anorexia associated with acquired immunodeficiency syndrome (AIDS) and chemotherapy-induced nausea and vomiting [22].


Syndros (dronabinol) contains the same active ingredient as Marinol but is an oral solution and processed as an ingested product [23]. It is FDA-approved for anorexia associated with AIDS and chemotherapy-induced nausea and vomiting.


Cesamet (nabilone) is a synthetic cannabinoid similar to THC administered orally as a capsule. It is approved by the FDA for the management of chemotherapy-induced nausea and vomiting, but it is not currently available in the United States [24].


Cannabinoid products available at state-licensed dispensaries (not FDA approved) — There are varied routes of administration of medical cannabis available to patients depending on the state in which they live. Medical cannabis products are different from the FDA-approved products listed above in that they are not synthetic but rather are derived directly from the cannabis plant. They are not regulated by the federal government but rather by state medical cannabis programs. Not all products are available in all states.

Inhaled – Administered as either combusted dried cannabis flower in a rolled cigarette or pipe or in a battery-operated vaporizer device. Vaporized cannabis products may use dried whole cannabis flower or an oil-based concentrate of specific doses of THC and CBD. This is the most familiar route to most patients. In unregulated use, dried cannabis flower is sometimes mixed with tobacco or rolled in cigar papers, exposing individuals to nicotine [25].


Ingested – Administered as capsules, chewable candies (gummies), or baked goods. Baked goods may have whole cannabis flower mixed into them, while capsules and candies usually contain cannabinoids extracted from the plant.


Sublingual/oral mucosal – Administered as an oral solution or a spray under the tongue or sprayed on the mucosa of the mouth. These solutions contain extracted cannabinoids.


Suppository – Oil-based cannabinoid extract administered rectally.


Topical – Extracted cannabinoids administered topically as lotions or gels.


Dabs and waxes – Traditionally popular with people who use cannabis heavily, these are cannabinoid concentrates with very high concentrations of THC, often >60 percent, applied to a hot platform and inhaled [26]. This translates to up to 15 mg of THC in a single inhalation.


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