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As of this writing, 23 states and the District of Columbia have enacted laws to legalize the medical use of marijuana. Marijuana for recreational use is legal in Alaska, Colorado, Oregon, and Washington. Marijuana for medical or recreational use is available in several forms that go far beyond the dry, dusty leaves that many of us geezers associate with our college years. It is commercially available in food products, in various forms for smoking and inhaling, and as topical applications for the skin in a medium of lotion, oil, ointment, gel, or spray. M&B's September/October 2012 Pathology Perspectives column, "Topical Medications," focused on some of the issues surrounding medicated skin creams, especially hormone supplements. At that time, marijuana- infused lotion wasn't on our radar, but that has definitely changed. Even though the skin is a mostly impermeable barrier, some substances can penetrate it and gain access to the bloodstream. For example, topical applications of testosterone or estrogen suspend these hormones in chemicals that can accomplish this process, which is called transcutaneous absorption. This is an issue for massage therapists who don't want to be inadvertently exposed to hormonal medications. But what if a client arrives with a marijuana-infused gel on her skin? HISTORY OF MARIJUANA IN THE UNITED STATES From the early days of the American colonies (George Washington farmed hemp) until the early 1900s, cannabis was probably in every medicine cabinet in the country. It was typically used in salves and ointments for muscle aches and other common complaints. Then in the 1920s, at the conclusion of the Mexican Revolution, a large influx of Mexicans entered the country, bringing with them their own traditions for using marihuana. Suddenly this substance became suspect. Hearings in the 1930s claimed that it would make men of color violent and prone to attacking white women. Individual states began outlawing it, and the Marijuana Tax Act of 1937 essentially prohibited it nationally. In 1970, the Comprehensive Drug Abuse Prevention and Control Act classified cannabis and its subtypes as a Schedule 1 substance: more potentially dangerous than tobacco, alcohol, cocaine, and many other drugs. The criteria for being a Schedule 1 substance include: • The substance has a high potential for abuse. • The substance has no currently accepted medical use in treatment in the United States. • There is a lack of accepted safety for use of the drug or other substance under medical supervision. The intention at the time was that marijuana might be coded differently after some research, but that never happened. In short, marijuana is kept as a Schedule 1 substance not because the research suggests that it is dangerous, but because there is a lack of research suggesting potential benefit. And it's difficult to do research on a prohibited product, so trying to change its classification is problematic. WHAT THE CLAIMS SAY Proponents of cannabis-infused topical applications claim the lotions help reduce pain and inflammation, without any psychogenic effect. Several of the people with whom I communicated for this article made the case that their clients love the products, that they themselves have reduced symptoms of pain in their hands and arms, and that they see substantially better impact than with other topical pain relievers or anti-inflammatories. That is important information, and might be of interest to massage therapists who live with work-related hand and arm pain. In addition, some therapists report that the level of overall relaxation they and their clients achieve can be much more profound than they see with standard massage therapy lubricants. All this said, I have not found any record of a successfully conducted, blinded comparison test of a cannabis- infused lotion to a noninfused lotion for client feedback or experience. This begs the question: what is really the active ingredient—the ingredients of cannabis, other ingredients in the lotion, or the massage itself? HOW DO THESE PRODUCTS WORK? Cannabinoid (CBD) receptors were discovered in cells of the brain and spinal cord a long time ago. These receptors are attuned to several chemical triggers, including anandamide—a type of endogenous CBD, and one of the brain chemicals associated with "runner's high." More recently we have found CBD receptors in many other places, included on keratinocytes of the epidermis, and in cells that line hair shafts and sebaceous glands. These sites may be receptive to several other chemicals that can be derived from cannabis, but for this discussion we'll stick to tetrahydrocannabinol (THC)—a chemical compound that is the main psychoactive constituent of cannabis—and cannabinoids. When skin cell CBD receptors are activated in mice, several changes happen. The stimulated cells secrete chemicals that have both direct and indirect influence on inflammation, even deep to the epidermis. This in turn has impact on sensory neurons, including nociceptors. Interestingly, scientists have also found that topical cannabis inhibits some skin activity—a finding that may be very important for people with psoriasis, dermatitis, or eczema. With more research, we will know more about whether cannabis-infused lotions might help this population. These discoveries may explain why cannabis-infused lotions seem to be effective mediators of inflammation and related pain. However, mice are not always an accurate analogue to humans, and it may be found that different mechanisms are at work when people report benefit. WHAT ARE SOME IMPLICATIONS FOR MASSAGE THERAPISTS? If you use any pain-relieving topical applications in your practice (such as Biofreeze, CryoDerm, Prossage, or China-Gel) or anything with arnica or eucalyptus in it (Topricin, Tiger Balm, etc.), you are already working toward the same goals that cannabis- infused lotions intend to address. The question is, which are the best interventions for you and your clients? The massage therapists who spoke to me had no hesitation about this: they absolutely prefer cannabis-infused lotions. LOTS OF QUESTIONS Almost no research on cannabis-infused lotions has been published in the last 80 years, and essentially none has been done on humans. Consequently, we don't know very much about how it works as a topical application, the best dosage or concentration, what the safest transfer medium might be, or how it affects the users and people who apply the lotion over the long term. All of these are still unanswered questions. The fact that anyone can download a recipe to make their own infused lotion gives some insight into the variability of products that might be on the market. If we produce something unreliable for our clients, homemade products can pose a potential risk. Of course, there's also a risk to us if our clients bring us a homemade lotion they want us to apply. Other unanswered questions include: How much of the cannabis gets into the bloodstream if a person uses infused lotions for several hours each day? Some people, including manufacturers, say little to none; some consumers who feel a systemic relaxation even with a local application say it definitely enters the bloodstream. At what point might that material cross the blood-brain barrier for psychogenic effect? Are there any potential risks to working with this product over the F r e e S O A P n o t e s w i t h M a s s a g e B o o k f o r A B M P m e m b e r s : a b m p . u s / M a s s a g e b o o k 39 education Cannabis-Infused Lotions & Oils Weeding Out Fact from Fiction By Ruth Werner PATHOLOGY PERSPECTIVES 38 m a s s a g e & b o d y w o r k s e p t e m b e r / o c t o b e r 2 0 1 5 READER FORUM EMAIL YOUR LETTERS TO EDITOR@ABMP.COM. INCLUDE YOUR FULL NAME AND THE CITY AND STATE IN WHICH YOU RESIDE. WE RESERVE THE RIGHT TO EDIT LETTERS FOR LENGTH AND CLARITY. CANNABIS & MASSAGE I enjoyed Ruth Werner's article on cannabis in the September/October 2015 issue ["Cannabis-Infused Lotions & Oils," page 38]. The author discussed a number of concerns regarding the use of this drug. While I feel there is a legitimate place for the use of medical marijuana, especially to suppress the nausea and vomiting that accompanies chemotherapy, I feel strongly that laws to legalize cannabis, even for medical use, must be carefully crafted. As Werner stated in her article, legalization of cannabis in several states has caused confusion. When it comes to massage therapists using topical preparation containing cannabis, there are questions regarding who supplies the topical preparation, what the allowable percentage of cannabis is, and whether the use will result in the client and/or therapist testing positive. In short, there are quite a few areas that remain vague under the law. JO-ANN I. CRAWLEY CLEVELAND, GEORGIA FROM FACEBOOK I'm so sick of the stigma attached to [cannabis]. It is an oil that has medicinal properties, just like other essential oils and herbs have medicinal properties. [Cannabis-infused topical creams and lotions] do not get you high! They just reduce inflammation and thus pain. ALICE LESMEISTER WINEBRENNER I don't see how this is any different from working on a client with Biofreeze or Tiger Balm. EDI BEILIN I am not a consumer of marijuana, but I do think we need to consider the possible topical anti-inflammatory benefits of THC creams, as they will eventually become legal in many states. After all, this is truly just an herbal liniment with analgesic properties like Tiger Balm. Let's keep our minds open and wait for clinical research to yield results before we put down the inevitable addition of THC creams into the practice of massage. BRANDON SAGGIO I think it's funny that we, as massage therapists, utilize all sorts of different essences from all sorts of plants, and we are OK with doing so. But the minute someone says hemp or cannabis, it becomes a major no-no regardless of the form it's in. What is the difference between using a natural rose oil and using a natural cannabis oil? BECKA SYKES BROKEN TRUST My history was very similar to Emma K.'s in many ways [Massage & Bodywork, "Broken Trust: I Was Victimized by My Bodywork Practitioner," September/October 2015, page 76]. Reading the account she bravely shared helped me become aware, work with my therapist, and heal from PTSD in many forms: molestation at a young long term? Will it impair people to a dangerous level? Probably not, based on currently available anecdotes, but no one has yet published any data on those important points. DRUG TESTING? A frequent pragmatic question about the use of infused lotions has to do with whether users can pass a drug test. Unfortunately, the answer to this question is not clear, either. Many sources say users cannot test positive, but others say users definitely do. An educated guess is that this may depend on the potency of the marijuana derivative in the lotion medium, as well as what that medium is—some could be more amenable to transcutaneous absorption than others. Also, drug tests come in many forms, and they are highly susceptible to both false positive and false negative findings. When asked, massage therapists using infused lotions at a high-volume facility in Denver reported no positive drug tests for themselves or their clients. The kind of drug test used in most employment situations is a urine test. So far, users of low-concentration THC- or CBD-infused lotions do not tend to test positive in this context. That said, more intrusive drug tests that look at blood or hair samples may have a different finding. Also, because these lotions have been available for a relatively short period of time, we don't know if drug test results might change with long-term usage. For those living in states with legal marijuana, take-home urinalysis tests are often available at dispensaries or head shops. These are a way to monitor how you process infused lotions. LEGAL ISSUES? Colorado, the first state to legalize marijuana for recreational use, does not regulate how massage therapists use infused lotions in practice—they can provide it for their clients, or their clients can bring it with them. However, they are not allowed to sell products for their clients to take home, and adding a surcharge specifically for the cannabis-infused lotions may be legally questionable. Alaska has legalized the recreational use of marijuana, but the issue of topical applications has not been addressed in the law. The Marijuana Legislative Board is still being formed, and it will create some structure for how the laws are applied. Conceivably, clients could bring their own lotion to their massage, but if massage therapists offer the lotion as a treatment option—and especially if they increase the fee for this costly application—it could be construed as selling marijuana without a license. F r e e S O A P n o t e s w i t h M a s s a g e B o o k f o r A B M P m e m b e r s : a b m p . u s / M a s s a g e b o o k 41 Some therapists report that the level of overall relaxation they and their clients achieve can be much more profound than they see with standard massage therapy lubricants. PATHOLOGY PERSPECTIVES C h e c k o u t A B M P 's l a t e s t n e w s a n d b l o g p o s t s . Av a i l a b l e a t w w w. a b m p . c o m . 11 age, and being manipulated and sexually violated by a bodywork therapist and as a patient in the OR. As I sat with tears and relief while I read Emma K.'s story, I looked at these occurrences for what they were: nonconsensual sexual assaults. We need to talk with one another and educate the public that these are not "normal" or "acceptable." My clients are told before their sessions that if anything doesn't feel right for their bodies, they need to inform me immediately. That is their right and obligation. Through exploring these events with a professional, people can come to feel whole again. It was not our fault. Bringing this into the light helps us integrate and heal. I know attention to this subject has touched and healed many of us! ANONYMOUS YOU'RE WELCOME! Great job on the magazine. We look forward to every issue. Every single article has something valuable to teach us. We highly recommend ABMP! SANDRA CORNELSON ANTHONY, KANSAS

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