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 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.
The Oregon state legislature is still wrestling with this issue. As of this writing, it is legal for massage therapists to use the infused lotions that clients with marijuana prescriptions bring with them to a session. It is expected that this status will stay in place; the open question is whether infused lotions will be legal for massage therapists to use for their other clients as well.
Marijuana is also legal for recreational use in Washington State, but the massage licensing board has identified cannabis-infused lotions as medications, and the administration of medications is considered to be outside the scope of massage therapy. This means that even if your clients purchase lotion for their personal use, at this time it is illegal for a massage therapist to apply it during a session.
Elsewhere: at this point, the only way to obtain these products legally is to live in a state where they are available either by prescription (and you have such a prescription) or for recreational use. THC-infused lotions are more closely controlled than those with just CBD, so some states allow the interstate mailing of CBD-infused lotions.
Interestingly, none of these laws apply to other topical products, because their ingredients have never been regulated as controlled substances.
Conclusion
The main takeaways from all of this boil down to a couple of key points.
1. Cannabis-infused lotions might be useful tools in our work, especially when we know more about their potency, reliability, and long-term effects.
2. Cannabis laws are in a state of flux, and probably will be for the next several years. Don’t assume anything; check with your state board if you have any doubt in your mind about legally using these products in your practice, even if you live in a state where recreational or medical marijuana is legal.
A Call to Action
If you have an opinion about whether massage therapists should or should not be allowed to use these products in your state, voice those thoughts to your state massage therapy board and to your marijuana legislative board, if you have one. In the meantime, let’s keep an eye on this moving target.
Resources
Baca, R. “THC-Infused Lotion Takes Massage to the Next Level.” The Denver Post (June 17, 2014). Accessed July 2015. www.denverpost.com/marijuana/ci_25974338/thc-infused-lotion-takes-massage-next-level.
Burnett, M. and A. Reiman. “How Did Marijuana Become Illegal in the First Place?” Drug Policy Alliance. Accessed July 2015. www.drugpolicy.org/blog/how-did-marijuana-become-illegal-first-place.
Caterina, M. “TRP Channel Cannabinoid Receptors in Skin Sensation, Homeostasis, and Inflammation.” American Chemical Society. ACS Chemical Neuroscience 5 (2014): 1,107–16.
ProCon.org. “23 Legal Medical Marijuana States and DC.” Accessed July 2015. http://medicalmarijuana.procon.org/view.resource.php?resourceID=000881.
Ständer, S. et al. “Distribution of Cannabinoid Receptor 1 (CB1) and 2 (CB2) on Sensory Nerve Fibers and Adnexal Structures in Human Skin.” Journal of Dermatological Science 38, no. 3 (June 2005): 177–88.
Ruth Werner, BCTMB is a former massage therapist, a writer, and an NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2016), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.
Acknowledgments: Several people generously helped in the preparation of this article:
James Kennedy at Apothecanna patiently walked me through some of the chemistry of the lotions, and some of the legislative complexities of this field. He supplies a large massage clinic in Denver, and collects feedback from therapists and clients about his products.
Julie Crispin, LMT, of Portland, Oregon, gets such good results for herself and her clients using cannabis-infused lotion that she is now working to make this option available to every client, not just the ones with medical marijuana cards. She wants to be known as a resource for good information about cannabis-infused lotions and massage therapy, especially for clients living in chronic pain.
A representative at the governor’s office in Alaska generously spent time with me to discuss the formation of a legislative scaffold for marijuana in that state, and what it might mean for massage therapists—a previously unthought-of constituency.
Erica Olson of Steamboat Springs, Colorado, gets a shout-out for walking me through her experiences with urinalysis, and homemade lotions, and cannabis soothing her sunburn.
Numerous Facebook friends and acquaintances took time out to share experiences. It’s not a scientific gathering of information, but it did reveal some fascinating points of view. Many thanks, my friends.