CRx MAGAZINE

Spring 2020

Beyond the Smoke: Cannabis Under the Tongue

Sublingual administration of cannabis is trending.

According to 2018 cannabis industry data, the medical segment made up $7.2 billion of cannabis revenue share, the largest share and growing.1 This growth is attributed to the increasing acceptance of cannabis as a treatment for chronic diseases such as pain, cancer, and mental disorders. Yet traditional methods of cannabis consumption are not among the top trends in medical applications. In April 2019, Forbes reported that cannabis-infused sublingual products were the fastest-growing cannabis product category in 2018, a trend also credited to the medical segment.2 The advantages of using sublingual products include avoiding smoke and other byproducts of combustion, known cannabinoid concentrations, accurate dose administration, the ability to titrate and track doses, and discretion.3

Sublingual Administration of Cannabis
Sublingual cannabis comes in a few different forms—from tinctures and sprays to strips and tablets—that dissolve under the tongue. However, these are not the same as edibles. Rather than being absorbed through the digestive system, sublingual products are absorbed through the mucosal membranes under the tongue, on the inside of the cheeks, and on the gums. Because of the dense concentration of capillaries under the tongue and around the mouth, products held in the mouth are delivered directly to the bloodstream, which makes cannabis administration quick and easy.2

Many medical cannabis patients prefer to use sublingual products rather than smoke or vape to avoid the exposure to smoke and other byproducts of combustion. Moreover, for novice users, these products are superior to edibles because they limit first-pass liver metabolism and thus the conversion of delta-9-THC to the more psychoactive form 11-hydroxy-THC, which may cause an extra-intense high that’s been known to make medical cannabis users uneasy. Another benefit of avoiding the digestive system is that the effects of sublingual products can usually be felt within 15 minutes and last for two to three hours, which is more like the bioavailability of smoking or vaping and unlike that of edibles. It makes sublingual products a good choice for fast, short action for patients who need episodic symptom relief without feeling the effects of cannabis all day.

Anecdotally, patients have successfully used sublingual cannabis products to treat occasional mild panic attacks because the fast-acting sublingual can mute the panic attack before it escalates into something that affects normal daily activities. When the panic attack has been averted and the effects of cannabis have worn off, patients can go on with their day. If the anxiety continues, precise doses can be administered to help control the physical and mental symptoms. This is superior to edibles, which may take too long to avert the panic attack and because the effects may last longer than necessary.

Types of Sublingual Products

Tinctures
By definition, a tincture is an herbal solution made with alcohol as the primary extraction solvent. In commercial cannabis products, the term tincture is often used to describe any concentrated liquid preparations that are meant to be applied topically or sublingually. Sublingual products prepared in alcohol can be absorbed through the mucosal membranes of the mouth quickly, providing symptom relief in as little as 15 minutes, while oil preparations may take up to 30 minutes for full onset of symptom relief.

Tablets or Lozenges
These are exactly what they sound like—small, usually round discs that patients put in their mouths. However, unlike other kinds of tablets or lozenges, they aren’t intended to be swallowed or sucked on. They slip under the tongue, where they dissolve quickly and deliver cannabis directly to the bloodstream. There’s no harm in swallowing or sucking on them, but symptom relief may be delayed by as much as two hours and the duration of action might be longer than desired.

Sprays
A cannabis spray is cannabis extract mixed with a solvent (alcohol or oil) and packaged in a spray bottle. To use, patients shake the bottle and spray under the tongue and on the inside of their cheeks. As with other sublingual products, holding the spray in the mouth for as long as possible will provide for maximum absorption. Accurate dosing requires a bit of math: Patients will need to look at the total amount of THC and/or CBD in the bottle and divide it by the number of doses in the bottle (or the size of the dose listed).

Strips
Strips are tiny pieces of cannabis film that are placed under the tongue. While they are a relatively new method of administration, the market for them is growing because they’re discreet and fast acting. Strips are about the size of a nickel and as thin as a sheet of paper, making them easy to transport and consume. To use them, patients place the strip under the tongue (not on top—the tongue won’t absorb much; the film needs to stick to the membranes under the tongue) and hold it there for at least five minutes or until it dissolves. Some manufacturers recommend not talking while a strip is in place to avoid moving it around the mouth, which can diminish the strip’s effects.

How to Use Sublingual Cannabis Products Effectively
One reason the usefulness of sublingual cannabis has been called into question pertains to incorrect administration. It’s imperative that the sublingual product stay in contact with the mucosal membranes under the tongue for as long as possible. The mistake most patients make is holding it under the tongue for only a few seconds. When educating patients, emphasize that for maximum absorption, they should hold the product under the tongue for 10 minutes. While this may seem difficult, there are a few steps to follow to make it easier:

• swallow all the saliva in the mouth;
• put the product under the tongue;
• use the tongue to move oil around the mouth (even the cheeks and gums will absorb the cannabinoids) or stick the tablet or strip to the bottom of the mouth; and
• don’t eat or drink anything for 10 minutes.

Microdosing With Sublinguals
Microdosing—a growing trend in medical cannabis use where less is more—is a common use for sublingual products because it’s easy to take small, exact doses to control symptoms while avoiding the intoxicating effects of THC that may interfere with daily life. While a “regular” dose of THC is 5 to 10 mg, a microdose is 2.5 mg or less. This type of precise dosing is difficult with smoking and vaping and even with edibles since other factors influence absorption through the digestive tract.

Because this small amount is used to keep cannabinoid signaling constant (avoiding peaks and valleys), it’s important that microdoses be used consistently over time. For instance, in one patient using microdosing to control chronic low-level anxiety, a CBD:THC tincture (containing 2.5 mg CBD and 2.5 mg THC per half dropper) was administered every six hours during the day plus a dose before bed to control symptoms on a daily basis. It took 14 days to see maximum anxiety relief. When microdosing was discontinued, anxiety symptoms returned within two days.

Conclusion
The availability and price of sublingual products vary from state to state. In order to provide the best advice to patients, inquire with local dispensaries as to the type and price of the sublingual products they sell. It’s also important to research the quality of the raw cannabis used, the solvents used to extract cannabinoids, the carrier solvents, and the testing done to determine cannabinoid content. As with any medical cannabis treatment, the goal is maximum symptom relief with minimal or acceptable intoxicating effects. Start treatment with a small dose, no more than 5 mg THC, and keep track of symptoms for two to three hours. If more relief is desired, patients should be advised to increase the dose by no more than 5 mg THC at a time.

— Bonnie Johnson, MS, RDN, is a registered dietitian nutritionist, food industry consultant, speaker, and certified cannabis consultant. She spends much of her volunteer time educating a variety of audiences about the benefits and potential risks of using cannabis to treat chronic pain, anxiety, insomnia, and other ailments. As a consultant, she works with the food and cannabis industries to bring science-based education to health care professionals and category-changing products to market.

References

1. U.S. cannabis market size, share & trends analysis report by cannabis type (medical, recreational), by product type (buds, oils, tincture), by medical application, (chronic pain, mental disorder, cancer), and segment forecasts, 2019–2025. Grand View Research website. https://www.grandviewresearch.com/industry-analysis/us-cannabis-market. Published July 2019. Accessed January 21, 2020.

2. Weed J. As new cannabis products gain traction, ‘pass the joint’ may turn to ‘pass the eye-dropper.’ Forbes. April 1, 2019. https://www.forbes.com/sites/julieweed/2019/04/01/pass-the-joint-may-trun-to-pass-the-weed-eyedropper/#6e1d57ecde03. Accessed January 21, 2020.

3. Grant I, Hampton Atkinson J, Gouaux B, Wilsey B. Medical marijuana: clearing away the smoke. Open Neurol J. 2012;6:18-25.

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