Risks and realities of overconsumption
“Edibles only start working when they hear you talking shit about them.”
I can’t remember where I first heard this saying, but based on my experience it’s pretty accurate. Weed infused in various candies, brownies, or cookies generally takes much longer to kick in and there’s inevitably a few moments half-an-hour post-consumption in which I say, out loud: “I’m not sure this thing is working.” Then, like one of Mike Tyson’s fists to the face, the full might of a deceptively delicious baked confection takes hold, and for the next few hours—I’m high. High high. And sometimes, too high.
I don’t remember the first time I greened out (consuming to the point of discomfort), but I can recall it happening to me several times throughout the last decade. Bad trips are how I learned my early limitations, and to steer clear of crossfading (mixing weed with booze), and that edibles are entirely different beast than, say, a bong or joint. Each time, however, once the room stopped rippling, or I threw up enough times to exhaust myself into a mild coma, I’d chalk it up to a negative trial outcome and move on. But for so many of my friends, family, and cannabis industry colleagues, a similar experience was traumatizing enough to put them off of any future interactions with the plant. And I don’t blame them. It only takes a quick scroll through Reddit to confirm the number of terrible types of high there are out there.
Now that edibles have made their way into the legal marketplace, these conversations about dangerous levels of overconsumption, the risks of cannabis infused edibles, and spikes in emergency room visits have created a bit of a tizzy. Some prove the fears are overblown, while others warn of a sugary plague soon to be unleashed on society. With headlines conjuring images of hospitals flooded with clammy, queasy faces and a flurry of gurneys carting around dazed and confused teenagers, it’s hard not to be slightly wary of the new edible products hitting the shelves. But a lot of these articles—and much of the information available to consumers—miss several key points in the conversation.
A distinction in terminology
It’s no secret the cannabis industry is mired in debate on proper terminology. For example, there is a heated tug-of-war regarding what to call the pre-regulation market. “Black market” is still tossed around by old school growers, industry heads, and consumers alike. Various newcomers and branding agents, however, argue that term stems from a negative history, instead promoting newfangled labels like “legacy market”, “unregulated economy”, “post-legal”, or the “great unwashed underground”. (Okay, that last one was a bit of a jab at what I like to call a stigmatization movement.)
Then there are terms about the plant itself: do we pay tribute to its historic roots in continuing to call it “weed”, “pot”, or “grass”, or do we demystify and drop drug war expressions by sticking to scientific terms like “cannabis”? Furthermore, do we correct historically inaccurate terms like “strain” when we actually mean “cultivar”, or has it become so widely adopted by the culture that it can be used synonymously?
The jury is still out.
One word that does need some clarification, making its way into common parlance mostly by way of scare tactic, is “overdose”. While the medical definition is fitting—usually a variation of “more than the normal or recommended amount of something, often a drug”—its general understanding aligns it closer to fatal interactions, addiction, hospitalization, and suicide. “Poisoning” is another commonly used term, going so far as to be applied in an official capacity by the federal government, to discuss tetrahydrocannabinol (THC) overconsumption.
When it comes to cannabis, what the media tends to call an “overdose” or “poisoning” can range from nausea and racing thoughts, all the way to vomiting and severe psychological delusion. In this case, does it help to label a minor side effect with such harsh terminology? Or, conversely, does lumping in a major side effect with the trivialized associations of “greening out” diminish the impact? In a country grappling with an overdose crisis, claiming nearly 14,000 lives in just four years, there needs to be a distinction in the conversations around negative cannabis interactions.
Dr. Pippa Hawley, the medical director of the palliative care program at BC Cancer, and one of a few doctors in Canada consulting on the medical uses of cannabis, believes we need to be more tactful in our dialogue.
“I prefer to avoid using colloquial terms because it tends to stigmatize the patient, or the patient can stigmatize themselves, if we use terms like ‘greening out’,” she tells me over the phone.
“I would also say ‘overdose’ is probably not the appropriate term, either. People tend to associate the term ‘overdose’ with people being found not breathing from, say, opioids. It implies that people will die from the overdose, which is the way that term is frequently used in the media.”
Hawley instead refers to the aforementioned occurrences as “inappropriate dosing” or “accidental overconsumption” as we continue to talk.
It’s easy to overconsume, but not always severe
The physical and psychological manifestations of a negative drug interaction can look very different depending on the consumer, but it can be a very easy trap to fall into for someone inexperienced.
“Effectively, [overconsumption] means someone is taking more than they need for whatever symptom they're taking it for. Or they’ve accidentally taken more than they needed because they didn't understand the concentration,” says Hawley. This tends to happen where there is a lack of consumer education.
Hawley uses the example of a consumer taking a low concentration cannabis oil, who accidentally repurchases what looks like the same product, but with a significantly higher level of THC. While the individual believes they’re taking the same dose by volume, the product can carry a lot more of the psychoactive cannabinoid.
While it would be nearly impossible to identify how often these instances take place among all Canadians, BC’s Drug and Poison Information Centre (DPIC) logged 2,318 cannabis-related calls between 2013 to 2018.
What does that look like?
Hawley says anxiety, nausea, drowsiness, and vomiting are the most common signs of an accidental overconsumption, however commonly associated psychological effects can also be uncomfortable for new or low-dose consumers. This can include confusion, hallucinations, incoherence, and paranoia.
“There are people out there who do take very large doses and can feel quite euphoric, but for people who’ve never felt that before that can also be perceived as a negative thing. They can feel quite dizzy, and spacey, unsteady on their feet,” she adds.
The side effect Hawley is referring to is often dubbed ‘the spins’: where the environment around an individual starts to appear and feel as if it is shifting. One’s eyesight can be distorted and equilibrium thrown off.
The incident Hawley says she encounters most frequently as a healthcare practitioner is when patients are treating a symptom that’s “difficult to measure against” with cannabis products.
“When we take [cannabis] for pain, we adjust depending on how well it works to reduce the pain. So, for example, you’d take one dose, wait four hours to see if it alleviates any of the discomfort, then you may take another one depending on the results,” she explains.
“With people trying to take cannabis-related products for things they can’t feel the effects of, like trying to cure cancer, they are at risk of taking excessive amounts.”
In an instance where a patient is titrating (or dosing) the result against a subperceptual ailment, it can be incredibly difficult to know when to stop increasing the dosage. It can even cause a paradoxical effect of exacerbating a patient’s symptoms and lead them to believe they need a higher dose.
“We know that too much THC can cause nausea, but it can also help nausea in small doses. So, if someone takes a little bit and it helps reduce their nausea, they may then also think if they take more, it’ll get even better. But then they can get even more nauseated from too much THC,” says Hawley. This can lead to what’s called cannabis-induced hyperemesis syndrome, better understood as severe bouts of vomiting.
The same thing can happen when it comes to anxiety, Hawley adds.
“You can get anxiety-relief from relatively low doses of cannabis, but it may not be 100 per cent relief, so [a consumer] may take more thinking they’ll get even more of the same effect, but you get a… promotion of anxiety as opposed to the relief of it. That’s when you can get yourself into a psychotic state.”
While a standard dose—10 milligrams, as recommended by Health Canada—is not likely to induce a state of psychosis a healthy adult consumer, none of the potential negative side effects are particularly desirable.
As the data is so limited at this point, the only thing most healthcare professionals are willing to conclude is that there is a non-linear relationship between cannabis consumption and symptom relief. And furthermore, that relationship is highly specific to each patient.
Where to begin
Chef Adam Barski, the co-founder of the infused events company High End Dinner Series, says the key to consuming cannabis responsibly lies in building trust between the producer, or prescriber, and consumer.
“The most powerful tool in navigating these conversations is knowledge and information,” he tells me. “Once the consumer hears the knowledge being shared with them, they generally begin to get more comfortable with the idea. And as long as they follow my recommended consuming instructions, and it results in a good experience for them, then that immediately builds trust.”
Barski has been producing infused baked goods for over 12 years, which started when a friend of his was hospitalized and needed a smoke-free method of consumption. Since then, he has researched the responsible titration of various consumption methods to ensure his consumers enjoy their cannabis experience. He suggests starting as low as possible—even as little as one milligram of THC—and giving the plant plenty of time to interact with your system.
“What you want to achieve with the process is to find your baseline for consuming edible cannabis,” he says, suggesting an initial dose maximum of five milligrams of THC and waiting a full 24 hours before consuming orally again.
“If you feel like you need more, add an extra two to five milligrams at a time. Many people can feel cannabis at as low as one milligram. And only a few people will need ‘epic’ amounts, relative to the one to five milligram amount. The point is to find your baseline amount and consume within that dosage area for the effect that you are looking for.”
In a paper published by the European Journal of Medicine, Dr. Caroline McCallum and Dr. Ethan Russo unpack common methods of cannabis administration and dosing. They write the “general approach to cannabis initiation is ‘start low, go slow, and stay low’.”
When it comes to smoking, they suggest “patients should start with one inhalation and wait 15 minutes. Then, they may increase by one inhalation every 15 to 30 minutes until desired symptom control has been achieved.”
Tips to avoid overconsumption
“Overconsumption can really only be prevented one way, and that's by the person consuming only the amount they are comfortable with,” says Barski, adding that when it comes to edibles, it’s important to undershoot. “When it comes to our events, plates, and edibles that I share with others, I share at lower dose amounts that will even leave the novice comfortable.”
He adds that while he’s yet to have a negative incident during one of his infused events, it doesn't mean he’s not prepared for such an outcome. While some of his baked goods come with high doses of THC and cannabidiol (CBD), some reaching above 100 milligrams for very experienced recreational consumers and patients looking to treat medical ailments, he only serves very low doses at his dinners.
“When it comes to THC and CBD ratios, we like to serve an item alongside meals that contains only CBD… We deliberately add CBD to make sure the experience is an even, enjoyable flow, as CBD helps to suppress some of the effects of THC.”
It has been found that the addition of CBD can reduce some of the psychedelic and physical effects of THC, making it useful in the prevention of accidental overconsumption.
Hawley recommends her patients begin with mucosal absorption of an infused oil in a low concentrated solution, which is done by holding drops of the cannabis product in the mouth and allowing it to soak into oral tissue. She then recommends waiting no less than four hours and, ideally, up to eight to feel the full effects.
Health Canada has placed a failsafe on the edible products available through the legal channels, allowing only for a maximum of 10 milligrams of THC per unit per package. This doesn't mean higher potency products aren't available in licensed dispensaries, as some infused oils, capsules, and concentrates can reach up to 1,000 milligrams for consumers looking for stronger doses.
And, of course, every stoner has their own home remedies to help assuage the discomfort of a bad trip. While there are no double-blind clinical trials to reinforce anecdotal cures, numerous consumers suggest staying hydrated, drinking citrus-based juices, chewing peppercorns, and cold showers can help quell negative side effects of cannabis. When all else fails, a long nap is considered to be the most common respite.
Are edibles really higher risk?
The simple answer? Yes.
There is no ambiguity as to why overconsumption is such a heavily discussed risk when it comes to edible or ingestible products.
While the American Centre for Disease Control and Prevention says “fatal overdose is unlikely,” and Health Canada says “cannabis poisoning is not generally known to be fatal”, this does not inherently render overconsumption harmless. In 2014 alone, cannabis accounted for $208.85 million in costs to the Canadian healthcare system.
When it comes to smoking cannabis, there is a tendency to consume less for two reasons. First, inhalation is generally not a comfortable method for novice consumers, often inducing coughing or pain in the throat and lungs. This makes it easier to slowly build a tolerance alongside their developing aptitude for smoking. Second, the effects of cannabinoids manifest almost immediately when inhaled, giving the consumer a good sense of the effects up front.
Edibles, on the other hand, present a higher risk of overconsumption for the opposite reasons. Often cannabis infused products present in chocolate bars, baked goods, gummies or hard candy, making them hard to put down. The effects can take up to two hours to manifest and up to 12 hours for acute effects to subside. It can also take several times for your endocannabinoid system to learn to interact with cannabis.
The reason eating cannabis differs from that of inhalation is due to the way cannabis is absorbed and subsequently reacts within the body. When weed is smoked, the THC, still oil-soluble, doesn’t easily break down in a mostly-water-based bloodstream. As it passes through your lungs, via the alveoli, the compounds aren’t given much of an opportunity to metabolize. When you ingest cannabis orally, saliva immediately starts to break down THC, and as it passes through the gastrointestinal tract (the stomach and liver) it converts into 11-hydroxy-THC. Once metabolized, these compounds become more bioavailable for diffusion throughout the body and across the blood-brain barrier. So, while this chemical interaction may take longer, the cannabinoids are able to better connect to the body’s endocannabinoid lock-and-key-type system, often resulting in a more durable, potent high.
While waiting for the effects to kick in, however, consumers fall prey to the idea that in not feeling any impact, the answer is to ingest more. This puts consumers at risk of cumulative dosing.
There is also a longstanding belief system circulating within drug culture regarding overconsumption that needs to be addressed. There exists a mentality that THC-induced death is impossible. While there are currently no known deaths by “cannabis overdose”, this argument fails to acknowledge that these experiences can be both traumatizing and lead to severe health complications. The paranoia, increased blood pressure or heart rate, and general shock stemming from the intensity of a high the someone isn't prepared to handle is enough to convince someone they might die.
I, myself, have had to repeat the mantra, “don’t worry, this won’t kill you.”
While toxicity of THC has never resulted in a fatality, the side effects of the high do contribute to major health risks, including severe psychosis and myocardial infarction. In early 2019, the Canadian Journal of Cardiology published a report on a 70-year-old male admitted for a heart attack after consuming a lollipop infused with 90 milligrams of THC. The individual, who was also being medicated for stable coronary artery disease, presented with crushing chest pain, diaphoresis, and pallor, which began within 30 minutes of consumption. Doctors concluded the strain these effects put on his body is what likely caused his attack, triggering a response in the sympathetic nervous system. While he survived, the outcome of accidentally consuming too much of an edible he took to help him sleep and reduce pain was incredibly dangerous.
In the 2010 documentary The Downside of High, filmmakers follow the stories of three B.C. teenagers who, alongside their doctors, attributed their aggravated mental health conditions to cannabis consumption. One of the individuals profiled, Ben, told interviewers that when he got high, the delusions were so profound that it caused him to believe there were tiny people in his house trying to kill him and snakes trying to swallow him. The psychosis got so out of hand, gradually worsening over multiple consumption experiences, that he tried jumping off his roof, twice, before being admitted to hospital for a year.
“In a healthy person, [overconsumption] may be uncomfortable, but then they get over it without too much psychical taxation,” confirms Hawley. “But it can have very severe consequences, especially the psychosis that comes from taking a big dose, for someone with a fragile brain. For the elderly or medically unwell, an overconsumption can mess them up for quite long periods and some don't really recover from a bad episode of delirium. It’s not something to be played around with.”
To be fair, the “you can’t die” sentiment mostly stems from drug war era activists who were forced to fight against years of corporate fear-mongering propaganda, media scare tactics, and political misinformation campaigns aimed at stopping the proliferation of plant medicines. Alternatively, it comes from individuals, like myself, who have had really bad trips but still lived to tell the tale.
But, it needs to be acknowledged that when people say: “you can’t die from cannabis”, while it may be factually accurate regarding the drug’s biochemical interactions with the body, the resulting mental and physical reactions of an overconsumption can be terrifying and, possibly, life-threatening.
A call for more information
As of July 2019, 45 per cent of Canadians live within 10 kilometres of a legal cannabis retailer. But despite the availability of products, including the recent addition of concentrates and edibles, there is a stark lack of corresponding information about how to safely consume any of them.
As Health Canada regulations effectively handicap both producers and retailers when discussing the perceived or potential effects of their products, and many Canadians don't have access to a doctor willing to discuss experimental treatment, many consumers are left in a lurch when searching for simple advice.
“It’s so inadequate at the moment,” says Hawley, adding that while there is good information on the Health Canada website, it’s designed for people with a very high reading level and medical knowledge.
“They [Health Canada] don't have very good information in terms that regular patients can understand, plus it’s not easily accessible. You have to know to go there. It’s not advertised that it’s where the information is held.”
This means the weight of dispelling that information falls on the shoulders of medical professionals—many of whom weren’t provided with cannabis-related courses during their education.
The educational landscape is changing slowly, as institutions begin to introduce workshops and programming focusing on various elements of the legal industry. When it comes to prescribing cannabis, however, this could mean waiting for a whole generational turnover in the medical system before seeing adequate access to consultations for patients.
“We have to retrofit the knowledge to the people who are already in practice,” says Hawley.
“We really need a modular course doctors and healthcare professionals can take. We have a one-hour course on Methadone for people who are considering prescribing it for pain and it’s excellent. People can do the course and it gives them all the information they need, and there should be no reason why we can't do that for cannabis.”
Continuing Medical Education (CME) organizations have also started to host cannabis-focused conferences for healthcare practitioners, but Hawley says there are issues with these systems of information, too.
“Often, these talks are being given by people with a conflict of interest, sponsored by industry. Or that have a particular focus, like an addictions focus, where they're talking about the dangers of it, rather than the benefits and the details for prescribers.”
She adds that these platforms are preaching to the converted.
“The ones who don't show up are the ones who don't know anything about it [cannabis] and, as such are frightened of it,” she says. “The ones that are knowledgeable get more knowledgeable, and the ones who aren’t get more entrenched in their opposition.”
Hawley says it's frustrating not having a place to turn as a medical professional for information, adding that many of the issues stemming from overconsumption could be alleviated if consumers had a reliable source—similar to that of a pharmacy.
“I’ve tried to do my best at the institution I work for to make information packages for both patients and healthcare professionals that give them as much information as possible,” she says.
“But not a lot of people would think to look at the BC Cancer website for something not related to cancer. What about if someone has severe arthritis, or irritable bowel syndrome, or anxiety? There are all sorts of reasons why people turn to cannabis, and cancer certainly is not the majority. All those other consumers don't have anywhere else to go.”