metabolized by the cytochrome P450 system (Devitt-Lee 2015; Zendulka et al. 2016). Many common EOL drugs are metabolized by this enzyme system and therefore, may potentially interact with CBD. These drugs include steroids, benzodiazepines, anti-psychotics, and NSAIDS. Additional drugs that may interact with CBD include warfarin (Theisen 2017) and chemotherapy (Theisen 2017; Abrams 2017). These interactions are not a certainty. However, this is an area of caution, as evidence-based guidelines are currently unavailable.
Fourth, Cardiovascular effects associated with THC, such as tachycardia, supine hypertension and orthostatic hypotension are reported in the literature (Jones, 2002; Franz & Frishman, 2016). Franz & Frishman state that in healthy subjects, these effects diminish after several exposures. However, both Jones and Franz & Frishman state that some health risks may be associated with cannabis for patients with cardiovascular disease. According to Russo (2015), evidence regarding the cardiovascular effects of THC was gained in formal clinical trials associated with nabiximols. Russo reports that in early studies of nabiximols, rapid titration and high doses of THC (130 mg/day) were allowed, and adverse cardiovascular effects were seen occasionally. However, with slower titration and maximum dosing of THC at 32.4 mg/day, these effects were reduced to less than 2%. No studies exist examining the cardiovascular effects of cannabis in EOL populations.
Lastly, immunocompromise and sensitivity to chemicals is common in EOL patients. Exposure to particulate toxins (McPartland & Pruitt, 1997), and molds/fungi (McPartland & Pruitt; Ruchlemer et al. 2015) are important cannabis considerations for individuals with immune sensitivity. Particulates are reduced with the use of a vaporization apparatus (McPartland & Pruitt). Molds and fungi can be removed by various methods of sterilization, though this results in a loss of active cannabinoid compounds (Ruchlemer et al.). Systemic pesticides are also a concern for frail and EOL populations. A study by Torres et al. (2017) revealed that 86% of randomly selected cannabis clones from California's regulated industry tested positive for pesticides. Many tested positive for more than one pesticide. According to Land (2017), a chemist and faculty member at the University of California at Davis, the current problems with contamination will be avoided only by production that starts from seed, and utilizes sustainable growing methods, such as predator pests.
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