OK, I (Adam) live in London, and to my knowledge butane hash oil (BHO), a.k.a shatter, honey, or wax, has not yet made a significant mark on the UK or European cannabis market. It is here, though, for sure. The occasional patient I see in clinic, the off-the-cuff remark from the police, even the odd report of a corner street explosion. But, to my knowledge we are not anywhere close to the US when it comes to this new potent form of cannabis with THC percentages running at 60-80 percent.

It’s for this reason we asked Mallory Loflin (ML) to co-write this piece with the Global Drug Survey (GDS) because we wanted to make sure we knew what we were talking about

As a general rule anytime "man" starts messing with nature, the outcomes, at least when it relates to drugs, is generally not good, or at least not from a public health perspective an improvement on the original. I’m not saying purification and distillation does not make a drug more fun (well I guess chewing coca leaves and running up the mountain after your goat is hardly fun compared to what some people get up to on cocaine) but messing with nature does come at a cost. And, as we roll out the 2015 GDS which is set to be the biggest drug survey ever with a target of 120,000 people and which has a huge focus on BHO, we thought it might be worth speculating whether the reinvention and promotion of hash oil and the explosion of vaping devices is going to turn out to be good, bad, or rather ugly.

Learning from the past

The history of drugs suggests that nature tends to restrict the potential of psychoactive substances to create large scale dependence and social unrest. Leave most compounds in their natural state, place some culture-bound rituals around them, don’t package and distribute them, avoid laborious processes to permit consumption through routes other than swallowing and most of all give purification/distillation a wide berth, and many of the most troublesome drugs of the 21st century would be less problematic. And whilst I look towards technology and invention as the next great leaps in making drug use safer for people, our recent history suggests that these same advances have circumvented nature's inherent harm reduction strategies and made the use of most drugs more dangerous and risky.

From the isolation and purification of cocaine and morphine from their plant based origins, to the distillation of alcohol from fermented fruits, arecoline and other psychoactive alkaloids from areca nut and the methylation of amphetamine to methamphetamine -- almost without exception the development of a more potent form of drugs is associated with greater addiction potential and consequently risks of harms. The development of a more potent form of drug is often partnered with a more efficient/ rapid route of delivery. For cocaine hydrochloride and morphine it was the capacity of the drug to be injected leading to rapid reinforcement whilst for crack cocaine and methamphetamine subtle molecular alteration allowed the drug to be smoked leading to a more rapid onset of action with a shorter, more intense high.

But that is not the whole story. What’s missing is the "why." The drive to isolate, modify and purify was not, we assume, to increase the harms associated with the use of the drug but was a byproduct of scientific advancement and well intentioned medical and pharmaceutical interests in broadening the therapeutic efficacy and availability of these plants' "healing" properties. And, in a similar fashion the context for the rise of many of these new, potent forms of cannabis such as BHO and other concentrates was the demand by those with medical conditions for preparations that could minimize smoking-related harms and facilitate easier adoption of oral consumption.

So, just like the synthesis of opium to morphine, developed out of the poppy for therapeutic application, and greatly improved on the medicinal potential of the poppy’s original derivative, opium, the movement to create a stronger and more potent form of cannabis might be a good thing. And these potential harm reduction benefits (through having to smoke less combustible products or the use of a vape pen and promotion of oral use) could extend to the non-medical use community.

What does the evidence say? Early research conducted by ML and Mitch Earlywine suggests recreational users did indeed prefer BHO to traditionally smoked flower cannabis because the effects were stronger and onset of the high more rapid. For a medicinal user who relies on cannabis to alleviate symptoms, this is a very desirable property. But ML’s study of about 350 users of BHO does suggest that some concerns might be warranted. Although her analyses revealed that using "dabs" created no more problems or accidents than using flower cannabis, users did report that "dabs" led to the development of higher tolerance and withdrawal, suggesting that the practice might be more likely to lead to symptoms of addiction or dependence.

The future?

As parts of the world drift into revising the regulation of cannabis, the appearance of BHO in parts of the US raises concerns about whether history is about to repeat itself. We worry that cannabis purification and reformulation combined with the commercialization of the cannabis industry in partnership with a new generation of vaporizers ("safe delivery devices") might lead to greater cannabis harms. We worry that the cannabis industry might start to think like the tobacco industry where CEOs embraced (then buried) the realization that users dependent on your product are good for profits. We worry that edibles coming in the form of chocolate bars with 16 segments where each one is a dose are going to lead to all sorts of white-outs. Really who ever has only one piece of chocolate? And, what happens when your edibles bar is the only "munchie"’ food around?

While we don’t have much evidence for this, we at least wanted to give it a bit of thought before we punch the numbers from the responses we get in from the 2015 GDS. There’s a reason that almost all medications carry warning labels and why medical doctors and pharmacists discuss ways to reduce dependency risk with their patients. We see no reason why the cannabis industry should not follow suit. Being cognizant of safety when making recommendations to cannabis patients and consumers is not antithetical to the goals of the cannabis industry. In fact, being fully up front that some people become dependent and that the use of cannabis -- especially heavy, regular use and consumption by the young, those with mental illness, or those who are pregnant, for example -- can be harmful is totally essential and will only create respect within the wider community.

For a movement that needs to distinguish itself from the tobacco and alcohol industries, dispensaries would be well served by advocating the establishment of risk indexes to inform recommendations for use and best practices for safety.

Where does BHO fall in that index? That’s what we’re trying to find out. In the meantime if you want to see how your use of cannabis compares to thousands of other people around the world go to https://www.drugsmeter.com and try the cannabis app.

An objective, independent and informed GDS brings together leading experts to ask you questions about drugs and alcohol so together we can help make a difference to the way people talk about drugs, think about drugs and use them. As always our results will be published exclusively with our global media partners in June 2015. Take part in the Global Drug Survey 2015. Everything is anonymous and confidential, so please take the time to share your experiences anytime up until Dec 20, 2014.