Journal of Analytical Toxicology

Reber, Jami D; Karschner, Erin L; Seither, Joshua Z; Knittel, Jessica L; Dozier, Katherine V; Walterscheid, Jeffrey P

doi: 10.1093/jat/bkac007pmid: 35265983

Abstract Among the abundance of cannabinoids identified in cannabis, the active parent drug, Δ9-tetrahydrocannabinol (Δ9-THC), and its oxidized metabolite, 11-nor-9-carboxy-Δ9-THC (Δ9-THCCOOH), are attractive analytical targets to detect cannabis use. More recently, confirmation of these analytes may be hindered by a related interfering compound. Forensic toxicology laboratories attribute this phenomenon to an increase in cases containing Δ8-tetrahydrocannabinol (Δ8-THC) and 11-nor-9-carboxy-Δ8-THC (Δ8-THCCOOH). It is technically challenging to chromatographically resolve and accurately quantify Δ8- and Δ9-THC and THCCOOH in toxicology specimens due to their structural resemblance. This study describes a validated method to resolve and quantify active Δ8-THC and Δ9-THC in blood while qualitatively confirming the inactive metabolites Δ8-THCCOOH and Δ9-THCCOOH in blood and urine. Analytes are extracted and concentrated by solid-phase extraction and analyzed by liquid chromatography--electrospray ionization tandem mass spectrometry, which is amenable to modern toxicology laboratory routine workflows. This procedure offers a clear solution to untangling mixtures of these isomers, particularly in cases where Δ8-THC and its metabolite are the sole or dominant form. Introduction Over 100 cannabinoids have been identified in cannabis, with the main psychoactive component known as Δ9-tetrahydrocannabinol (Δ9-THC) (1, 2). Although Δ9-THC is federally illegal in the USA, cannabis use among adults has increased over the past several years (3). Products containing Δ9-THC became readily available in retail locations across the country following decriminalization efforts at the U.S. state level. Moreover, the U.S. Agriculture Improvement Act of 2018 (2018 Farm Bill) federally legalized cannabis material containing no more than 0.3% Δ9-THC on a dry weight basis and classified it as hemp. Hemp-derived products, particularly those marketed for their cannabidiol (CBD) content, became exceptionally popular following the passage of the bill. More recently, ambiguity within the 2018 Farm Bill resulted in numerous companies manufacturing Δ8-tetrahydrocannabinol (Δ8-THC) products. The naturally occurring source of Δ8-THC isolated from cannabis is typically <1% (4). However, CBD, a more abundant cannabinoid, can be isolated from hemp and cyclized under mild reaction conditions to generate Δ8-THC and Δ9-THC in various yields and ratios (5–8). Consumers can now effortlessly find commercially available products in stores or online that contain Δ8-THC in topical creams, vape cartridges and edible formulations such as gummies, cookies and snack chips. Δ8-THC is a positional isomer of Δ9-THC, which differs by the location of the double bond in the alicyclic ring. While it is known Δ8-THC is a partial agonist at CB1 and CB2 cannabinoid receptors, various sources report that CB1 receptor affinity is equivalent or perhaps diminished 3- to 4-fold lower than Δ9-THC (9–11). Likewise, Δ8-THC exhibits psychoactive properties qualitatively similar to Δ9-THC, although the Δ8-isomer shows lower potency ranging from 50% to 75% (12–14). Clinical studies in humans using Δ8-THC have not been as widely conducted as with Δ9-THC, but some trials have explored its potential to treat chemotherapy-induced nausea and glaucoma (15, 16). Once absorbed and distributed in the body, Δ9-THC metabolizes into active 11-hydroxy-Δ9-THC (11-OH-Δ9-THC), which further oxidizes into its most abundant metabolite, inactive 11-nor-9-carboxy-Δ9-THC (Δ9-THCCOOH) (17, 18). Much like Δ9-THC metabolism, 11-nor-9-carboxy-Δ8-THC (Δ8-THCCOOH) is the major metabolite of Δ8-THC, with 11-hydroxy-Δ8-THC (11-OH-Δ8-THC) found in lower concentrations (19). Forensic toxicologists are observing an increasing number of cases containing interferences produced by Δ8-THC and Δ8-THCCOOH isomers (20). Although most immunoassays are designed to target Δ9-THCCOOH, several exhibit substantial cross-reactivity between isomers (21), requiring a more targeted confirmation method to distinguish between the two. If Δ9-THC and its metabolites are analyzed by a method that does not fully resolve Δ8-isomer peaks, this may lead to multiple reaction monitoring (MRM) ratio failures, misidentifications and inaccurate concentration measurements. This manuscript presents a validated procedure for the separation and reporting of Δ8- and Δ9-THC and THCCOOH isomers, along with examples of authentic postmortem and human performance cases where the method enabled discrimination between these analytes. Materials Certified reference materials for Δ9-THC, Δ8-THC, Δ9-THCCOOH, Δ9-THCCOOH-glucuronide, Δ9-THC-d3 and Δ9-THCCOOH-d9 were purchased from Cerilliant (Round Rock, TX). The standard for Δ8-THCCOOH was available from Toronto Research Chemicals (Toronto, ON, Canada). Certified drug-free urine was obtained from UTAK Laboratories Inc. (Valencia, CA). Certified negative bovine blood was purchased from BioIVT (Westbury, NY). Acetonitrile, ammonium hydroxide (concentrated), ethyl acetate, glacial acetic acid, hexane, methanol and reagent alcohol were purchased from Fisher Scientific (Waltham, MA). An ELGA PURELAB flex purification system (High Wycombe, UK) was used to generate ultrapure water. Formic acid was obtained from Acros Organics (Fair Lawn, NJ), while concentrated potassium hydroxide was acquired from Sigma Aldrich (Darmstadt, Germany). Authentic negative human blood and urine specimens were forensic case specimens that were reported as negative and eligible for disposition. Working calibrator, control and internal standard solutions were prepared in reagent alcohol and stored in a freezer at −20°C. Methods Calibration curve and control preparation Sample preparation was conducted using 16 × 100-mm silanized glass test tubes (Fisher Scientific, Waltham, MA). Calibrators and low, mid and high positive blood controls were prepared in 1 mL blank bovine blood. Calibrators were fortified at final concentrations of 1, 3, 5, 10, 25 and 50 µg/L for Δ9-THC and Δ8-THC and 5, 15, 25, 50, 125 and 250 µg/L for Δ9-THCCOOH and Δ8-THCCOOH. Low positive controls were prepared at final concentrations of 2 µg/L for Δ9-THC and Δ8-THC and 10 µg/L for Δ9-THCCOOH and Δ8-THCCOOH. Mid positive controls were fortified at 20 µg/L for Δ9-THC and Δ8-THC and 100 µg/L for Δ9-THCCOOH and Δ8-THCCOOH. High positive controls contained final concentrations of 40 µg/L for Δ9-THC and Δ8-THC and 200 µg/L for Δ9-THCCOOH and Δ8-THCCOOH. A urine positive control was prepared in 1 mL blank urine at a final concentration of 25 µg/L for Δ9-THC and Δ8-THC and 125 µg/L for Δ9-THCCOOH and Δ8-THCCOOH, assuming 100% hydrolysis efficiency for the Δ9-THCCOOH glucuronide. Negative controls were prepared with 1 mL of blank matrix. Calibrators, controls and unknown specimens were fortified with 50 µL of internal standard for a final concentration of 5 µg/L Δ9-THC-d3 and 20 µg/L Δ9-THCCOOH-d9. Sample preparation Glucuronide conjugates were hydrolyzed in urine by adding 100 µL of 8.0 N potassium hydroxide, vortexing and incubating at 70°C for 15 min. Samples were cooled to room temperature and 50 µL of glacial acetic acid was used to neutralize the alkaline hydrolysis reaction. The samples were diluted with 2 mL of deionized water, gently mixed by hand and centrifuged at 3,000 rpm for 5 min. Blood samples were precipitated by adding 3.0 mL ice-cold acetonitrile in 0.5 mL increments while vortexing. Samples were vortexed an additional 5 sec after the last addition and centrifuged at 3,000 rpm for 10 min. Supernatants were decanted into fresh 16 × 100 mm silanized test tubes containing 5 mL of deionized water and were gently agitated by hand. Solid-phase extraction Solid-phase extraction columns (United Chemical Technologies, Inc, Bristol, PA; 10 mL Styre Screen® THC 60 mg) were conditioned with 1 mL of methanol and 2 mL of 2% ammonium hydroxide (v/v in deionized water). Samples were loaded onto the columns, washed with 2 mL of deionized water/acetonitrile/ammonium hydroxide (84:15:1 v/v) and dried under vacuum for 20 min. Samples were eluted with 3 mL of hexane/ethyl acetate/glacial acetic acid (49:49:2 v/v) into 16 × 100-mm silanized glass test tubes. Eluates were evaporated under nitrogen gas at 40°C. Extracts were reconstituted in 100 µL of 0.1% formic acid in water/0.1% formic acid in acetonitrile (60:40 v/v) and transferred to autosampler vials. LC–MS-MS analysis parameters A Shimadzu (Kyoto, Japan) Nexera liquid chromatograph (LC) with a LEAP Technologies (Carrboro, NC) PAL CTC autosampler was coupled with a Sciex (Framingham, MA) 3200 API mass spectrometer (MS) for analysis. An Agilent (Santa Clara, CA) Poroshell 120 EC-C18 column (100 × 2.1 mm, 2.7 μm) was held at 35°C in a column oven. A 10-µL injection volume and flow rate of 0.5 mL/min were utilized. Mobile phases were 0.1% formic acid in water (A) and 0.1% formic acid in acetonitrile (B). The gradient was held at 40% B for 0.8 min, increased to 55% B until 1.0 min and increased to 60% B until 4.5 min. The gradient then ramped to 70% B at 4.51 min, to 75% B until 9.0 min and finally to 95% B at 9.01 min and was held at 95% until 12 min. Re-equilibration was initiated by returning to 40% B conditions until 13 min. The mass spectrometer was operated in positive electrospray ionization (ESI) mode. Optimized source parameters were as follows: curtain gas 30 psi, collision gas 5, ion spray voltage 2,000 V, temperature 650°C, ion source gas 1 60 psi and ion source gas 2 40 psi. Data acquisition was carried out using scheduled MRM mode with compound-specific parameters listed in Supplemental Table SI. LC–MS-MS analysis parameters for the original laboratory Δ9-THC and metabolites method The same LC–MS-MS instrument, mobile phases, flow rate, injection volume and LC column were used for the standard panel analysis of Δ9-THC, 11-hydroxy-THC (11-OH-THC) and Δ9-THCCOOH. The column was maintained at 40°C in a column oven. Gradient elution began with an isocratic hold at 40% B for 0.5 min, increased to 95% B until 6.5 min and was held at 95% B until 9.5 min. The column was re-equilibrated at 40% B until the end of the run at 10.5 min. Positive ESI mode source parameters were as follows: curtain gas 45 psi, collision gas 5, ion spray voltage 4500 V, temperature 650°C, ion source gas 1 70 psi and ion source gas 2 60 psi. Method validation The isomeric differentiation method was validated according to the American Academy of Forensic Sciences Standards Board (ASB) Standard 036, Standard Practices for Method Validation in Forensic Toxicology (22). Validation parameters included selectivity, specificity, stable isotope internal standard interferences, calibration models, lower limit of quantitation (LLOQ), limit of detection (LOD), upper limit of quantitation (ULOQ), bias and precision, matrix effects, extract stability, dilution integrity and carryover. Qualitative acceptance criteria included signal-to-noise ≥3:1, Gaussian peak shape, retention time within 3% of the calibrator average and MRM ratios within 20% of the calibrator average. All calibrators and controls were prepared in negative bovine blood. Validation parameters such as LOD, LLOQ, ULOQ and matrix effects were performed in different authentic sources of human blood. Human urine was used throughout validation. Endogenous, exogenous and internal standard interferences were evaluated. Ten authentic negative urine and blood specimens were evaluated for selectivity without the addition of internal standard. Negative urine samples were fortified with 177 commonly encountered substances at 1,000 µg/L to assess method specificity. In addition, potential interferences from other THC isomers such as Δ6a,10a-THC, Δ10-THC and Δ9,11-THC (also referred to as “exo-THC”) were investigated. Potential matrix, drug and background interferences at the analyte or internal standard retention time were evaluated. Blank blood was fortified with internal standard and evaluated to determine if there was any contribution to the analyte signal. Potential analyte contribution to the internal standard signal was assessed by analyzing blank matrix fortified with analytes at the highest calibrator concentration. Suitable calibration models and weighting were determined for each analyte using standardized residual plots and relative error calculations. Six calibrators were analyzed in five separate extractions for a total of five replicates at each concentration. The calibration model was deemed valid if the mean was within ±20% of the theoretical concentration, the % coefficient of variation (%CV) was ≤10% and the r2 value was ≥0.9900. LOD and LOQ were established by fortifying authentic blood and urine samples in triplicate over three separate extractions. LOD was determined in both blood and urine, while LLOQ and ULOQ were determined in blood. LOD and LLOQ samples were fortified with 1 µg/L for Δ9-THC and Δ8-THC and 5 µg/L for Δ9-THCCOOH and Δ8-THCCOOH. ULOQ samples were fortified at 50 µg/L for Δ9-THC and Δ8-THC and 250 µg/L for Δ9-THCCOOH and Δ8-THCCOOH. LOD samples were required to meet qualitative acceptance criteria. In addition to meeting qualitative acceptance criteria, LLOQ and ULOQ samples were required to show limited bias within ±20% of the theoretical concentration and %CV ≤20%. Bias and precision were measured by evaluating controls in triplicate over five separate batches at the following concentrations: 2 and 10 µg/L for the low control, 20 and 100 µg/L for the mid control and 40 and 200 µg/L for the high controls for the THC and THCOOH isomers, respectively. Within-run and between-run precision and bias were assessed and required to meet bias within ±20% of its theoretical concentration and %CV ≤20%. Matrix effects were evaluated using post-extraction addition. Ten authentic negative blood and urine samples were extracted in duplicate. One set was resuspended in the reconstitution solvent fortified at the concentration of the low control and the other set dissolved in the reconstitution solvent fortified at the concentration of the high control. Three neat samples were prepared from both fortified reconstitution solvents and injected in duplicate for a total of six neat sample injections at each concentration. The average peak areas for the neat standards were compared to the average peak areas for the post-extraction fortified matrix samples to determine the ion suppression or enhancement. Average suppression/enhancement should not exceed ±25% and the %CV should not exceed 20%. Dilution integrity was evaluated by diluting a negative blood sample fortified at the highest calibrator at 2-fold and 5-fold dilution factors in triplicate. Dilution integrity samples were required to meet qualitative acceptance criteria and have a measured concentration within ±20% of the theoretical value for each replicate. Instrument carryover was evaluated by measuring the concentration of the analytes of interest in an extracted negative blood or urine sample directly following each of three injections of an extracted blood or urine fortified with the analytes at a high concentration. The blood carryover samples contained 100 µg/L Δ9-THC and Δ8-THC, and 500 µg/L Δ9-THCCOOH and Δ8-THCCOOH, whereas urine carryover was evaluated at 1,000 µg/L Δ9-THCCOOH and Δ8-THCCOOH. Extract autosampler stability was assessed by comparing the average peak area for each analyte in extracted blood and urine samples at set time points of 0, 24 and 48 h post-extraction. Stability was evaluated by re-injecting the calibrators, low, mid and high controls extracted for one of the bias and precision experiments. Blood extracts were no longer considered stable once the bias exceeded ±20%, CV ≥15%, the average peak area exceeded ±20% from time zero or the peak failed to meet qualitative acceptance criteria. Urine extracts were no longer considered stable once the average peak area exceeded ±20% from time zero or if the peak failed to meet qualitative acceptance criteria. Authentic case specimens All cases were screened either by an OraSure (Bethlehem, PA) Cannabinoids immunoassay (5 µg/L blood Δ9-THCCOOH cutoff) or Microgenics (Fremont, CA) DRI immunoassay (35 µg/L urine Δ9-THCCOOH cutoff). If the screen was presumptively positive, samples were sent for confirmation using a LC–MS-MS method, which included Δ9-THC, 11-OH-THC and Δ9-THCCOOH. If the presence of Δ8-THC or Δ8-THCCOOH was suspected due to co-eluting peaks or a retention time shift in the chromatograms generated with the original LC–MS-MS Δ9 method, samples were sent for analysis on the Δ8- and Δ9-isomeric differentiation method. Results Isomeric separation As new cases arrived containing various amounts of Δ8 isomers, the original LC–MS-MS Δ9 analysis method revealed convoluted chromatograms that would obscure confirmation of Δ9-THC and THCCOOH due to inadequate chromatographic resolution. Using the newly validated method, an improved resolution was achieved for confirming the individual isomers (Figure 1). Along with modifying the gradient, one of the key changes involved decreasing the column compartment temperature from 40°C to 35°C, which provided improved separation of the Δ8- and Δ9-isomers, while maintaining stable retention times. Figure 1. Open in new tabDownload slide Chromatography gradient settings with profiles and results. Extracted ion chromatograms demonstrate improvements in resolving isomer peaks when comparing the original laboratory method to the updated method. Figure 1. Open in new tabDownload slide Chromatography gradient settings with profiles and results. Extracted ion chromatograms demonstrate improvements in resolving isomer peaks when comparing the original laboratory method to the updated method. LC–MS-MS method validation A summary of the results from the validation experiments is shown in Supplemental Table SII. None of the exogenous, endogenous or internal standard interferences met the criteria for a positive identification for any of the analytes of interest. Regarding differentiation of the various THC isomers, the Δ6a,10a-THC and Δ10-THC forms did not co-elute with Δ8-THC and Δ9-THC in the enhanced method (Figure 2) or with Δ9-THC in the original cannabinoid LC–MS-MS panel. The Δ8- and Δ9-isomers of interest had retention times ranging from 8.4 to 8.6 min, whereas the Δ6a,10a- and Δ10-isomers eluted nearly 1 min later. However, only partial resolution was achieved between exo-THC and Δ9-THC in the isomeric differentiation method. Figure 2. Open in new tabDownload slide Potential interferences from additional THC isomers. An unscheduled MRM method was used to acquire the presented data. Figure 2. Open in new tabDownload slide Potential interferences from additional THC isomers. An unscheduled MRM method was used to acquire the presented data. All criteria were met for each analyte at the designated LOD/LLOQ of 1 µg/L for Δ9-THC and Δ8-THC and 5 µg/L for Δ9-THCCOOH and Δ8-THCCOOH in both blood and urine. Chromatograms for each analyte at the LOD are presented in Figure 3. ULOQ bias was within ±12% and CVs were 11% at most for Δ9-THC and Δ8-THC. However, bias at ULOQ exceeded 20% for both Δ9-THCCOOH and Δ8-THCCOOH. As is often seen with cannabinoids, matrix effects exceeded ±25% in both low and high blood quality control (QC) samples. When normalized against the internal standard, matrix effects were within ±12% at the low QC concentration and ±21% at the high QC concentration. Variations for the normalized QCs were all ≤5%CV. Due to the observed ion suppression, an additional LLOQ study was performed. This study analyzed the LLOQ in nine different authentic blood samples, as per 2019 ASB Guidelines, and found acceptable bias and precision for all analytes except Δ9-THCCOOH and Δ8-THCCOOH, as was seen with the ULOQ experiment. Figure 3. Open in new tabDownload slide LOD/LOQ MRM chromatograms from extracted blood fortified with 1 µg/L Δ8-THC and Δ9-THC and 5 µg/L Δ8-THCCOOH and Δ9-THCCOOH. Figure 3. Open in new tabDownload slide LOD/LOQ MRM chromatograms from extracted blood fortified with 1 µg/L Δ8-THC and Δ9-THC and 5 µg/L Δ8-THCCOOH and Δ9-THCCOOH. Authentic casework examples At the time of writing, over 40 investigative cases from locations across the USA were processed using the Δ8- and Δ9- isomeric differentiation method. These cases involved individuals suspected of driving under the influence and workplace incidents. Four cases are highlighted to demonstrate the value of adding this method to the laboratory’s scope. None of the examined casework has yet shown the presence of exo-THC among the Δ9- and Δ8-THC variants. Case 1: A 24-year-old male was under investigation for driving under the influence. His blood alcohol concentration was 0.069 g/dL and his blood also contained 1.3 µg/L Δ8-THC and Δ8-THCCOOH. Δ9-THC and its metabolite were not detected. Case 2: A 27-year-old was arrested under suspicion for driving under the influence. The suspect’s blood contained 1.9 µg/L Δ8-THC, 7.4 µg/L Δ9-THC, 2.8 µg/L 11-OH-THC, as well as Δ8-THCCOOH and Δ9-THCCOOH. Case 3: A 19-year-old male was presumed to be intoxicated while on duty in the workplace. Blood toxicology revealed 0.021 g/dL ethanol along with 1.1 µg/L Δ8-THC and Δ8-THCCOOH. Δ9-THC and its metabolite were not detected. Case 4: A second workplace incident was a fatality where no blood was available for analysis due to traumatic exsanguination. Analysis of the urine demonstrated the presence of Δ8-THCCOOH along with Δ9-THCCOOH and MDMB-4en-PINACA 3,3-dimethylbutanoic acid. In addition to the reported findings, Figure 4 demonstrates the differences in chromatography between two authentic blood samples analyzed under the original Δ9-THC and metabolites method versus the updated Δ8- and Δ9-isomer differentiation method. One case displayed in the figure contains both Δ8-THC and Δ9-THC and their metabolites. The second case displayed only contains reportable Δ8-THC and Δ8-THCCOOH. Figure 4. Open in new tabDownload slide Examples of isomer separation improvements in authentic casework. The top panel shows where all analytes were found above the limit of detection. The bottom panel highlights how the original laboratory method misidentified the Δ8-THC peak as Δ9-THC. When analyzed on the updated isomeric separation method, Δ8-THC was correctly identified as well as its corresponding metabolite, while Δ9-THCCOOH was determined to be below the limit of detection. Figure 4. Open in new tabDownload slide Examples of isomer separation improvements in authentic casework. The top panel shows where all analytes were found above the limit of detection. The bottom panel highlights how the original laboratory method misidentified the Δ8-THC peak as Δ9-THC. When analyzed on the updated isomeric separation method, Δ8-THC was correctly identified as well as its corresponding metabolite, while Δ9-THCCOOH was determined to be below the limit of detection. Discussion Chromatographic separation of Δ8- and Δ9-THC and THCCOOH isomers was achieved through adjustment of LC parameters. The most notable adjustment was the use of an unconventional multi-step gradient, which was shallow and nearly isocratic at times. The gradient featured abrupt increases from low organic to a higher organic mobile phase composition to maintain a reasonable run time and to prevent excessive peak broadening. The method has an extended hold at 95% organic to thoroughly wash the column of phospholipids, but can be decreased, if higher throughput efficiency is needed. Due to the increased prevalence of Δ8-THC, recently published manuscripts have included Δ8-THC and/or Δ8-THCCOOH in their analyses or investigated the potential for interferences (20, 23, 24). Chan-Hosokawa et al. (20) achieved baseline separation of Δ8- and Δ9-THC and THCCOOH, but matrix effects for Δ8-THC and Δ8-THCCOOH precluded addition of these analytes in their scope of analysis. Similarly, in the present study, Δ8-THCCOOH matrix effects resulted in unacceptable bias in some LLOQ and ULOQ replicates. Δ8-THCCOOH is currently reported as present if the analyte exceeds the analytical cutoff of 5 µg/L. Δ8-THC and Δ8-THCCOOH deuterated internal standards, while not available at the time of development, are now commercially produced and may help improve bias and linearity issues encountered due to matrix effects. While this method originally included 11-OH-Δ9-THC, a co-eluting peak was observed directly following 11-OH-Δ9-THC, which was most evident in MRM2 (331.2/193.3). This interference is most likely caused by 11-OH-Δ8-THC but requires further characterization, since a certified reference material for 11-OH-Δ8-THC was not available at the time this method was developed. Most cannabinoid analysis panels for Δ9-THC and metabolites do not provide enough separation between the isomers of 11-OH-THC; therefore, 11-OH-THC is currently reported without distinguishing the isomers, as long as all acceptance criteria are met to include proper Gaussian peak shape. In two of the four cases presented, Δ8-THC and Δ8-THCCOOH were present in blood, but without corresponding Δ9-isomers. Without further characterization of the Δ8-THC and Δ8-THCCOOH, these cases would have been reported as negative. This situation illustrates the importance of updating confirmatory assays to better serve clients in law enforcement and judicial systems. There is a possibility of misidentifying Δ8-THC and Δ8-THCCOOH as Δ9-THC and Δ9-THCCOOH if the concentration falls below the method detection limit, yet the retention time acceptance criteria are satisfied. Since the Δ8- and Δ9-THC and THCCOOH isomers share transitions and have similar relative abundances, it is important to employ analytical methods with adequate chromatographic separation to guarantee appropriate identification. Conclusion In the last several years, cannabis products became decriminalized in many U.S. states, and a proportional increase in recreational use was observed. The threat to public safety from THC-intoxicated drivers has grown (25), promoted by new offerings of more potent plant material, concentrated extracts and infused edibles. The rise of mainstream CBD use has encouraged its wide acceptance and the legalization of hemp farming provides a vast supply. By harvesting CBD and subjecting it to an acidic reaction, it is possible to produce various yields of Δ8- and Δ9-THC for consumer use (8). This generates yet another threat to public health and safety, since CBD use remains unregulated and uncharacterized (26), especially after it has been chemically altered. Recent trends point to a growing number of cannabinoid positive cases where Δ8-THC and Δ8-THCCOOH can interfere with the confirmation of the far more common Δ9-isomers. This may result in the failure of data to meet acceptance criteria, leading to the reporting of a negative or inconclusive result. In addition, laboratories unable to differentiate between isomers may issue a false-positive or inaccurate proficiency result. As with most drugs, it is difficult to reconcile patterns between dose, blood concentration and behavioral outcome from using THC; therefore, it is sufficient for laboratories to at least maintain the capability to qualitatively identify markers of cannabis use (27–29). This report outlines a method for distinguishing between the Δ8- and Δ9-isomers of THC and THCCOOH in routine forensic toxicology casework. The process consumes only 1 mL of blood or urine and is analyzed by LC–MS-MS in positive mode, which provided appropriate selectivity and sensitivity down to 1 µg/L for THC and 5 µg/L for THCCOOH isomers. The validation demonstrated it is possible to provide quantitative results for Δ8- and Δ9-THC, but attempts to measure the carboxylated metabolites produced unacceptably wide variations in accuracy. Until a deuterated form of Δ8-THCCOOH is more widely available, these circumstances can be mitigated by reporting qualitative data. In addition to disclosing a method for cannabinoid isomer analysis, this work also explored select forensic cases where Δ8-THC or its metabolite was a significant toxicology finding. While some cases displayed a mix of Δ8- and Δ9-THC and THCCOOH isomers, others contained Δ9-analytes below established limits of detection and would have been reported as negative without additional confirmatory analysis of the Δ8-isomers. This would be an unacceptable service to the U.S. military workforce, where there is zero tolerance for drug use due to adverse effects on safety and mission readiness. Likewise, stakeholders in the civilian sector would also benefit from this method to maintain accountability in the pursuit of justice and public safety. Supplementary data Supplementary data is available at Journal of Analytical Toxicology online. Acknowledgments The authors would like to acknowledge the Armed Forces Medical Examiner System Division of Forensic Toxicology staff and Dr. Eric Berg for their contributions. Funding This work was funded in part by SNA International, Alexandria, VA 22314. Disclaimer The opinions or assertions presented in this paper are the private views of the authors and should not be construed as official or as reflecting the views of the Department of Defense, its branches, the Defense Health Agency, or the Armed Forces Medical Examiner System. References 1. Elsohly M.A. , Radwan M.M., Gul W., Chandra S., Galal A. ( 2017 ) Phytochemistry of Cannabis sativa L . Progress in the Chemistry of Organic Natural Products , 103 , 1 – 36 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Huestis M.A. ( 2007 ) Human cannabinoid pharmacokinetics . Chemistry & Biodiversity , 4 , 1770 – 1804 . Google Scholar Crossref Search ADS WorldCat 3. National Survey on Drug Use and Health . 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This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Peters, Erica N; Mosesova, Irina; MacNair, Laura; Vandrey, Ryan; Land, M Hunter; Ware, Mark A; Turcotte, Cynthia; Bonn-Miller, Marcel O

doi: 10.1093/jat/bkab026pmid: 33710277

Abstract Due to a lack of published pharmacokinetic (PK) and/or pharmacodynamic (PD) data, decision-making surrounding appropriate dosing of cannabis used for medical purposes is limited. This multiple-dose study evaluated the safety, tolerability, PK and PD of Spectrum Yellow oil [20 mg/mL cannabidiol (CBD)/<1 mg/mL ∆9-tetrahydrocannabinol (THC)]. Participants (n = 43) were randomized to one of five groups: 120 mg CBD and 5.4 mg THC daily, 240 mg CBD and 10.8 mg THC daily, 360 mg CBD and 16.2 mg THC daily, 480 mg CBD and 21.6 mg THC daily or placebo. Study medication was administered every 12 h for 7 consecutive days. Treatment-emergent adverse events (TEAEs); plasma and urine concentrations of THC, CBD and metabolites; and self-reported subjective effects were collected. Nearly all TEAEs (44/45) were of mild or moderate severity; none was serious. The highest incidence of TEAEs (67%) was in the two higher-dose treatment groups. The highest number of TEAEs (17/45) occurred on the first treatment day. Steady-state plasma CBD concentrations were reached by Day 7. On Day 7, CBD exposure showed dose proportionality (AUC0–t slope = 1.03 [0.70, 1.36], Cmax slope = 0.92 [0.53, 1.31]). Most plasma THC concentrations were below the limit of quantification. Across Days 1 and 7, there were no consistent differences in subjective effects between placebo and active study medication. A prudent approach to improve tolerability with Spectrum Yellow oil might involve initial doses no higher than 240 mg total CBD and 10.8 mg total THC daily in divided doses, with titration upward over time as needed based on tolerability. Introduction ∆9-tetrahydrocannabinol (THC) and THC-like compounds have regulatory approval in a number of regions to treat anorexia associated with weight loss in patients with acquired immunodeficiency syndrome, nausea and vomiting associated with cancer chemotherapy, and neuropathic pain (1–3). Cannabidiol (CBD) is a non-intoxicating cannabinoid that has regulatory approval in the USA, the EU and Australia to treat rare seizure disorders including Dravet and Lennox–Gastaut syndromes (4) and has been investigated as a treatment for anxiety and mood disorders, psychosis, inflammatory disorders and chronic pain (5). Adverse events (AEs) associated with approved cannabinoid pharmaceutical medications are somnolence, decreased appetite and diarrhea for CBD (4) and abdominal pain, dizziness and euphoria for THC (6). Bioavailability of oral THC and CBD is generally low, highly variable and estimated to be ∼6% of dose delivered as a result of significant first-pass metabolism by the liver (7, 8) via cytochrome P450 isozymes CYP2C9, CYP2C19 and CYP3A4. THC is hydroxylated to pharmacologically active 11-hydroxy-THC (11-OH-THC) by CYP2C9, and its direct oxidation produces a pharmacologically inactive acid, 11-carboxy-THC (11-COOH-THC) (9). CBD is hydroxylated by CYP3A4 and CYP2C19 to pharmacologically active 7-hydroxy-CBD (7-OH-CBD), which is subsequently oxidized to pharmacologically inactive 7-carboxy-CBD (7-COOH-CBD) (10). Despite a growing body of literature surrounding the therapeutic use of cannabinoids, there is a paucity of data regarding the pharmacokinetic (PK) and pharmacodynamic (PD) profiles of non-pharmaceutical cannabis used for medical purposes. Two single-dose studies have compared the PK profiles of THC between oromucosal formulations with an approximate 1:1 ratio of THC to CBD and THC alone. One study found that there was a longer time to peak plasma concentration (tmax) for 11-OH-THC in the 1:1 THC to CBD group (10 mg THC; 10 mg CBD) compared to 10 mg THC (11). In the other study, there were no differences in PK profiles between low-dose 1:1 THC to CBD (5.4 mg THC; 5 mg CBD) and 5 mg THC or high-dose 1:1 THC to CBD (16.2 mg THC; 15 mg CBD) and 15 mg THC, although there was a trend toward decreases in mean 11-OH-THC time to maximum plasma concentration (Cmax) and area under the curve (AUC) after high-dose 1:1 THC to CBD vs. THC alone (12). In a single-dose study that compared the PK profiles of an oral formulation with a 2:1 ratio of THC to CBD (10 mg THC; 5.4 mg CBD) with 10 mg THC, there was a relative decrease in 11-OH-THC AUC in the 2:1 THC to CBD group (13). Although concurrently measured PD and PK data have not been collected for non-pharmaceutical cannabis used for medical purposes, the broader literature on the PD of THC and CBD can help show their expected acute effects. Subjective effects of oral THC include increased ratings of subjective “high,” increased hunger and alterations in mood, and at doses of 10 mg THC or higher, cognition and psychomotor functions are temporarily impaired; in contrast, oral administration of CBD typically does not produce interoceptive effects, impairment of cognitive or psychomotor function or significant abuse-related subjective response (14–16). In one study that examined the PD of combined THC and CBD, nabiximols (an oromucosal spray that contains THC and CBD in a 1:1 ratio) had a significant abuse potential at higher doses of 21.6 mg THC + 21 mg CBD and 43.2 mg THC + 40 mg CBD compared with placebo (17). A major limitation of this prior work is that the PD effects of both THC and CBD when orally administered have not been characterized in proportions other than an approximate 1:1 ratio. The lack of repeated- or multiple-dose PK data for non-pharmaceutical cannabis for medical purposes, coupled with a lack of PD data, leaves a gap in the literature related to cannabis used for medical purposes. Multiple-dose studies with a large dose range are needed to closely approximate real-world conditions in individuals who consume cannabis for medical purposes and to best inform physician and patient decision-making regarding safety and dosing. The aim of this study was to provide a thorough evaluation of the safety, tolerability, PK and PD of a cannabis product (Spectrum Yellow oil [20 mg/mL CBD and <1 mg/mL THC]) that is used for medical purposes in multiple countries. Methods Compliance with ethical standards This trial was conducted in accordance with consensus ethics principles, International Conference on Harmonization Good Clinical Practice guidelines, the Declaration of Helsinki and local Australian laws and regulations. The protocol was approved by the Alfred Hospital Ethics Committee (Project No. 591/19; approved 25 November 2019). Written informed consent was obtained from each participant before any trial-related procedures were performed. Participants Adults aged 18–55 years were eligible for the study if they were in good health as assessed by medical history, physical examination, 12-lead electrocardiogram (ECG) and clinical laboratory investigations; had ≥2 lifetime exposures to THC-containing cannabis products and had a body mass index (BMI) 18–30 kg/m2. Women of childbearing potential were required to have a negative pregnancy test at screening and at intake to the research facility. Exclusion criteria included women who were pregnant, lactating, breastfeeding or planning a pregnancy; women of childbearing potential or men who were sexually active with women of childbearing potential, who were unwilling or unable to use an acceptable method of contraception; use of tobacco/nicotine-containing products >5 occasions within 1 month of screening or during the study; use of prescription drugs or herbal supplements (except hormonal contraception) within 4 weeks of screening; use of any over-the-counter drugs, vitamins or supplements within 72 h prior to study treatment; a positive breath test for ethanol or positive urine drug screen at screening or prior to study treatment; a history of psychosis or schizophrenia, including first-degree relatives; use of any CBD- or THC-containing product within 8 weeks of screening or during the study; and a history of suicidal behavior or current suicidal ideation. Study design and treatment This Phase 1, randomized, double-blind, placebo-controlled, multiple-dose trial was conducted between November 2019 and December 2019 at one site in Australia. Spectrum Yellow is a commercially available cannabis-based product that was made with supercritical carbon dioxide extracted cannabis resin in medium-chain triglyceride (MCT) oil (Tweed Inc., Canopy Growth Corporation, Smiths Falls, ON, Canada). Analytical testing of the clinical batch detected a total terpene concentration <0.05%; the measured concentration of 0.9 mg/mL THC was used to estimate dosages of THC. Participants were randomly assigned to one of five groups in a 1:1:1:1:1 ratio: 120 mg CBD and 5.4 mg THC daily (3 mL, twice daily [Treatment A]); 240 mg CBD and 10.8 mg THC daily (6 mL, twice daily [Treatment B]); 360 mg CBD and 16.2 mg THC daily (9 mL, twice daily [Treatment C]); 480 mg CBD and 21.6 mg THC daily (12 mL, twice daily [Treatment D]); or placebo. Participants in the four active treatment groups received water in addition to study medication, coadministered with a dual syringe, to create equivalence across groups with respect to volume of liquid administered (18 mL, twice daily). Participants in the placebo group received a mixture of water and placebo (Tweed Inc., Canopy Growth Corporation, Smiths Falls, ON, Canada) coadministered with a dual syringe, in order to closely mimic the ratio of oil and water that participants in the active treatment groups received and thus preserve the blind. The placebo was made with MCT oil, coloring agents alfalfa extract and beta carotene extract, and natural cannabis terpenes for flavoring. Analytical testing of placebo confirmed the absence of cannabinoids and a total terpene content of 0.05%. Participants were confined to a residential research facility and received study medication twice daily after a standardized meal (e.g., for breakfast, 2 cups of cereal; 2 slices of toast; 2 servings of butter or margarine; 2 condiments; 250 mL of milk; 1 sugar sachet) for 6 days, plus a single dose in the morning of Day 7. Participants were discharged after a 32-h blood draw on Day 8 and returned to the facility on Days 9, 10, 11 and 13 for blood draws and study assessments. Safety assessments Safety measures included laboratory assessments (hematology, biochemistry and urinalysis), monitoring of vital signs and ECGs, assessment of suicidality (Columbia-Suicide Severity Rating Scale) and monitoring of treatment-emergent adverse events (TEAEs)/serious adverse events (SAEs). PK assessments Blood samples were collected in a 4-mL-draw heparin container prior to the morning dose and 1, 2, 4, 6, 8 and 12 h after the morning dose on Day 1; pre-morning dose on Days 2–7; prior to the morning dose and 1, 2, 4, 6, 8, 12 and 16 h after the morning dose on Day 7; and 24, 32, 48, 72, 96 and 144 h after the Day 7 morning dose. Immediately following collection, blood samples were placed on wet ice and centrifuged, and plasma was immediately frozen at −80°C until shipment to the bioanalytical laboratory (iC42 Clinical Research and Development, University of Colorado, Aurora, CO, USA) on dry ice. Samples were stored at the bioanalytical laboratory at −80°C for ∼2 weeks prior to analysis. Urine samples were collected prior to the morning dose on Days 1–6; and output (all samples provided) was collected between 00:00–12:00 and 12:00–24:00 intervals on Day 7. Urine samples were frozen on dry ice and then stored in a −80°C freezer until shipment to the bioanalytical laboratory (iC42 Clinical Research and Development, University of Colorado, Aurora, CO, USA) on dry ice. Samples were stored at the bioanalytical laboratory at −80°C for ∼2 weeks prior to analysis. All samples (plasma and urine) had undergone one freeze–thaw cycle at the time of analysis. Analytical methods Plasma and urine concentrations of CBD, THC and metabolites were quantified using a two-dimensional high-performance liquid chromatography tandem mass spectrometry (LC–LC–MS/MS) assay developed and validated by iC42 Clinical Research and Development (18), and study samples were analyzed in a CLIA (United States Clinical Laboratory Improvement Amendments)-certified laboratory environment accredited by the College of American Pathologists (Northfield, IL, USA). Plasma aliquots of 200 μL of the calibrator, quality control, blank and zero samples were transferred into 1.5-mL low-binding Eppendorf tubes (Eppendorf, Hamburg, Germany). Eight hundred microliters of a protein precipitation solution of 30% water containing 0.2 M ZnSO4/70% methanol (v/v) containing the appropriate isotope-labeled internal standards were added. After vortexing for 10 min and centrifugation (25,000×g, 4°C for 10 min), the supernatants were injected into the LC–LC system (1260 Infinity HPLC components, Agilent, Santa Clara, CA, USA) for online extraction (extraction column C8-material, 3.0·5 mm, 2.7 μm particle size, Advanced Materials Technology, Wilmington, DE, USA). After 1 min, the analytes were backflushed onto the analytical column (Ascentis Express RP-Amide, 3.0 × 150 mm, 2.7 µm particle size, Supelco, Bellefonte, PA, USA) and separated using a gradient of 0.04% formic acid in water (mobile phase A) and acetonitrile: methanol: isopropanol (3:1:1, v/v/v, mobile phase B). Analytes were quantified using an MS-MS detector (series 5500, Sciex, Concord, ON, Canada). MS-MS data were acquired after atmospheric pressure chemical ionization (APCI) in combination with multiple reaction monitoring (MRM) in positive ion mode. Calibration curves were constructed daily from peak area ratios of analytes to the internal standard. Calibrators were fitted using a quadratic equation in combination with 1/x weighting. Calculations were carried out using Sciex MultiQuant (version 3.0.2.). For details, please see the work by Sempio et al. (18). The assay had been developed and validated following the applicable Clinical Laboratory Standards Institute and United States Food and Drug Administration (FDA) guidelines (19, 20). Plasma and urine concentrations of the following, with lower limit of quantification (LLOQ) in parentheses, were analyzed: THC (0.780 ng/mL), 11-OH-THC (3.125 ng/mL), 11-COOH-THC (0.780 ng/mL), CBD (0.780 ng/mL), 7-hydroxy-CBD (7-OH-CBD; 1.560 ng/mL) and 7-carboxy-CBD (7-COOH-CBD; 1.560 ng/mL). The LLOQs in plasma and urine were both determined following the procedures as set forth in the applicable Clinical Laboratory Standards Institute guidelines (21) and were determined as the lowest concentration consistently achieving accuracy better than ±20% of the nominal concentration, with imprecision ≤20%. All concentrations reported as non-quantifiable were below the LLOQ. Urine concentrations of THC, CBD and metabolites were not normalized to creatinine. Urine samples were not hydrolyzed. The upper limits of quantification were between 100 and 2000 ng/mL. Inter-day analytical accuracy and imprecision ranged from 90.4% to 111% and from 3.1% to 17.4%, respectively. There were no significant matrix interferences and carryover. Sample stability exceeding the maximum storage time (at −80°C) and freeze–thaw cycles the study samples were exposed to were established (18). The calibration and quality control strategy during study sample analysis was in compliance with the applicable United States FDA guidance (20). PD assessments Subjective effects were self-reported using the Drug Effects Questionnaire (DEQ), administered prior to the morning dose and 1, 2, 4, 6, 8 and 12 h after the morning dose on Days 1, 3 and 7. Participants were instructed to rate how they were feeling “right now” on six items specifically related to the study product: feeling the effect, liking any of the effects, disliking any of the effects, feeling any good effects, feeling any bad effects and likelihood of taking the study product again. They also rated how much they were experiencing the following 14 adjectives: “sick,” “heart racing,” “anxious,” “relaxed,” “paranoid,” “tired/drowsy,” “alert,” “irritable,” “energetic,” “restless,” “hungry,” “dazed,” “distracted” and “euphoric/happy.” Items were rated on a 100-point visual analog scale, with anchors of “not at all” and “extremely.” Urine drug screens Urine drug screens (TOX/See; Bio-rad; Hercules, CA, USA) were collected at inpatient discharge on Day 8 and at outpatient visits on Days 9, 10, 11 and 13. Participants with positive screens for 11-COOH-THC (>50 ng/mL) were instructed to not drive a motor vehicle until a subsequent screen was negative. Statistical analyses AEs were tabulated and classified by System Organ Class (SOC) and preferred term using the Medical Dictionary for Regulatory Activities (version 22.1). Safety data were summarized using descriptive statistics. PK parameters for THC, CBD and metabolites were calculated using non-compartmental analysis (Phoenix 64 version 8.1, Pharsight, a Certara Company, USA). Individual PK parameters and plasma concentration over time were summarized using descriptive statistics. Pre-dose Ctrough plasma levels of CBD and THC at each dose were compared across Days 5–7 for assessment of steady state (where the contrast was not statistically significant, P < 0.05) using a mixed effect analysis of variance (ANOVA). On Days 1, 3 and 7, peak post-treatment value (Emax) for each DEQ item was analyzed using ANOVA, with treatment group as fixed effect and participant as random effect. Least square mean (LSmean) estimates and 95% confidence intervals (CIs) reported for each treatment group and for each paired difference between groups were adjusted with Tukey multiple comparison tests. Results Participant characteristics In total, 43 participants were enrolled and randomly assigned to one of five treatment groups (Treatment A, n = 9; Treatment B, n = 8; Treatment C, n = 9; Treatment D, n = 9; placebo, n = 8). Participants were, on average, 27.3 years old (standard deviation (SD) = 6.7) with a BMI of 24.3 (SD = 2.9), and approximately half (51.2%) were female; the majority of participants were White (86.0%) and not Hispanic or Latino (95.3%). All 43 participants were included in the safety and intent-to-treat populations. Three participants who withdrew from the study due to AEs and did not have sufficient PK data, plus the 8 participants in the placebo group, were not included in the PK population (n = 32). Safety and tolerability Overall, 49% of participants (21/43) experienced at least one TEAE (Table I). The most common TEAEs included dizziness, presyncope, insomnia, abdominal pain and diarrhea [each reported by three participants (7.0%)]. The number of TEAEs between Treatments A (4) and B (2) and placebo (3) were similar, while there were twice as many TEAEs in Treatments C (6) and D (6) than placebo. TEAEs in the psychiatric disorders SOC only affected participants taking higher doses [Treatments C (2) and D (4)]. The highest number of TEAEs (17/45; 37.8%) occurred on the first day of treatment (Figure 1). Table I. All-Causality Treatment-Emergent Adverse Events per Treatment Group, by MedDRA System Organ Class and Preferred Term (Safety Population) . . Treatmenta . SOC PT[n (%) E] . Overall (n = 43) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Placebo (n = 8) . Participants with at least one TEAE 21 (48.8) 45 4 (44.4) 7 2 (25.0) 4 6 (66.7) 13 6 (66.7) 14 3 (37.5) 7 Nervous system disorders 9 (20.9) 12 2 (22.2) 4 2 (25.0) 2 2 (22.2) 2 3 (33.3) 4 0 Dizziness 3 (7.0) 3 1 (11.1) 1 1 (12.5) 1 1 (11.1) 1 0 0 Presyncope 3 (7.0) 3 0 0 0 3 (33.3) 0 Headache 2 (4.7) 2 2 (22.2) 2 0 0 0 0 Somnolence 2 (4.7) 2 1 (11.1) 1 0 1 (11.1) 1 0 0 Amnesia 1 (2.3) 1 0 1 (12.5) 1 0 0 0 Lethargy 1 (2.3) 1 0 0 0 1 (11.1) 1 0 Psychiatric disorders 6 (14.0) 9 0 0 2 (22.2) 5 4 (44.4) 4 0 Insomnia 3 (7.0) 3 0 0 1 (11.1) 1 2 (22.2) 2 0 Anxiety 2 (4.7) 2 0 0 1 (11.1) 1 1 (11.1) 1 0 Paranoia 2 (4.7) 2 0 0 1 (11.1) 1 1 (11.1) 1 0 Hallucination 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Mood altered 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Gastrointestinal disorders 6 (14.0) 8 1 (11.1) 1 0 0 2 (22.2) 3 3 (37.5) 4 Abdominal pain 3 (7.0) 3 0 0 0 2 (22.2) 2 1 (12.5) 1 Diarrhea 3 (7.0) 3 0 0 0 1 (1.11) 1 2 (25.0) 2 Nausea 2 (4.7) 2 1 (11.1) 1 0 0 0 1 (12.5) 1 General disorders and administration site conditions 3 (7.0) 4 1 (11.1) 1 0 1 (11.1) 2 0 1 (12.5) 1 Discomfort 1 (2.3) 2 0 0 1 (11.1) 2 0 0 Eye complication associated with device 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Fatigue 1 (2.3) 1 1 (11.1) 1 0 0 0 0 Injury, poisoning and procedural complications 4 (9.3) 4 0 1 (12.5) 1 1 (11.1) 1 1 (11.1) 1 1 (12.5) 1 Ligament sprain 1 (2.3) 1 0 1 (12.5) 1 0 0 0 Vascular access site complication 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Vascular access site pain 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Vascular access site swelling 1 (2.3) 1 0 0 0 1 (11.1) 1 0 Cardiac disorders 2 (4.7) 2 1 (11.1) 1 0 1 (1.11) 1 0 0 Palpitations 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Ventricular extrasystoles 1 (2.3) 1 1 (11.1) 1 0 0 0 0 Infections and infestations 2 (4.7) 2 0 0 0 1 (11.1) 1 1 (12.5) 1 Upper respiratory tract infection 1 (2.3) 1 0 0 0 1 (11.1) 0 Viral upper respiratory tract infection 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Reproductive system and breast disorders 2 (4.7) 2 0 1 (12.5) 1 0 1 (11.1) 1 0 Dysmenorrhea 2 (4.7) 2 0 1 (12.5) 1 0 1 (11.1) 1 0 Investigations 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Sensory level abnormal 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Respiratory, thoracic and mediastinal disorders 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Nasal congestion 1 (2.3) 1 0 0 1 (11.1) 1 0 0 . . Treatmenta . SOC PT[n (%) E] . Overall (n = 43) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Placebo (n = 8) . Participants with at least one TEAE 21 (48.8) 45 4 (44.4) 7 2 (25.0) 4 6 (66.7) 13 6 (66.7) 14 3 (37.5) 7 Nervous system disorders 9 (20.9) 12 2 (22.2) 4 2 (25.0) 2 2 (22.2) 2 3 (33.3) 4 0 Dizziness 3 (7.0) 3 1 (11.1) 1 1 (12.5) 1 1 (11.1) 1 0 0 Presyncope 3 (7.0) 3 0 0 0 3 (33.3) 0 Headache 2 (4.7) 2 2 (22.2) 2 0 0 0 0 Somnolence 2 (4.7) 2 1 (11.1) 1 0 1 (11.1) 1 0 0 Amnesia 1 (2.3) 1 0 1 (12.5) 1 0 0 0 Lethargy 1 (2.3) 1 0 0 0 1 (11.1) 1 0 Psychiatric disorders 6 (14.0) 9 0 0 2 (22.2) 5 4 (44.4) 4 0 Insomnia 3 (7.0) 3 0 0 1 (11.1) 1 2 (22.2) 2 0 Anxiety 2 (4.7) 2 0 0 1 (11.1) 1 1 (11.1) 1 0 Paranoia 2 (4.7) 2 0 0 1 (11.1) 1 1 (11.1) 1 0 Hallucination 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Mood altered 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Gastrointestinal disorders 6 (14.0) 8 1 (11.1) 1 0 0 2 (22.2) 3 3 (37.5) 4 Abdominal pain 3 (7.0) 3 0 0 0 2 (22.2) 2 1 (12.5) 1 Diarrhea 3 (7.0) 3 0 0 0 1 (1.11) 1 2 (25.0) 2 Nausea 2 (4.7) 2 1 (11.1) 1 0 0 0 1 (12.5) 1 General disorders and administration site conditions 3 (7.0) 4 1 (11.1) 1 0 1 (11.1) 2 0 1 (12.5) 1 Discomfort 1 (2.3) 2 0 0 1 (11.1) 2 0 0 Eye complication associated with device 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Fatigue 1 (2.3) 1 1 (11.1) 1 0 0 0 0 Injury, poisoning and procedural complications 4 (9.3) 4 0 1 (12.5) 1 1 (11.1) 1 1 (11.1) 1 1 (12.5) 1 Ligament sprain 1 (2.3) 1 0 1 (12.5) 1 0 0 0 Vascular access site complication 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Vascular access site pain 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Vascular access site swelling 1 (2.3) 1 0 0 0 1 (11.1) 1 0 Cardiac disorders 2 (4.7) 2 1 (11.1) 1 0 1 (1.11) 1 0 0 Palpitations 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Ventricular extrasystoles 1 (2.3) 1 1 (11.1) 1 0 0 0 0 Infections and infestations 2 (4.7) 2 0 0 0 1 (11.1) 1 1 (12.5) 1 Upper respiratory tract infection 1 (2.3) 1 0 0 0 1 (11.1) 0 Viral upper respiratory tract infection 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Reproductive system and breast disorders 2 (4.7) 2 0 1 (12.5) 1 0 1 (11.1) 1 0 Dysmenorrhea 2 (4.7) 2 0 1 (12.5) 1 0 1 (11.1) 1 0 Investigations 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Sensory level abnormal 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Respiratory, thoracic and mediastinal disorders 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Nasal congestion 1 (2.3) 1 0 0 1 (11.1) 1 0 0 E = number of adverse events, MedDRA = Medical Dictionary for Regulatory Activities, n = number of participants with events, PT = preferred term, SOC = system organ class, TEAE = treatment-emergent adverse event. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. Open in new tab Table I. All-Causality Treatment-Emergent Adverse Events per Treatment Group, by MedDRA System Organ Class and Preferred Term (Safety Population) . . Treatmenta . SOC PT[n (%) E] . Overall (n = 43) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Placebo (n = 8) . Participants with at least one TEAE 21 (48.8) 45 4 (44.4) 7 2 (25.0) 4 6 (66.7) 13 6 (66.7) 14 3 (37.5) 7 Nervous system disorders 9 (20.9) 12 2 (22.2) 4 2 (25.0) 2 2 (22.2) 2 3 (33.3) 4 0 Dizziness 3 (7.0) 3 1 (11.1) 1 1 (12.5) 1 1 (11.1) 1 0 0 Presyncope 3 (7.0) 3 0 0 0 3 (33.3) 0 Headache 2 (4.7) 2 2 (22.2) 2 0 0 0 0 Somnolence 2 (4.7) 2 1 (11.1) 1 0 1 (11.1) 1 0 0 Amnesia 1 (2.3) 1 0 1 (12.5) 1 0 0 0 Lethargy 1 (2.3) 1 0 0 0 1 (11.1) 1 0 Psychiatric disorders 6 (14.0) 9 0 0 2 (22.2) 5 4 (44.4) 4 0 Insomnia 3 (7.0) 3 0 0 1 (11.1) 1 2 (22.2) 2 0 Anxiety 2 (4.7) 2 0 0 1 (11.1) 1 1 (11.1) 1 0 Paranoia 2 (4.7) 2 0 0 1 (11.1) 1 1 (11.1) 1 0 Hallucination 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Mood altered 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Gastrointestinal disorders 6 (14.0) 8 1 (11.1) 1 0 0 2 (22.2) 3 3 (37.5) 4 Abdominal pain 3 (7.0) 3 0 0 0 2 (22.2) 2 1 (12.5) 1 Diarrhea 3 (7.0) 3 0 0 0 1 (1.11) 1 2 (25.0) 2 Nausea 2 (4.7) 2 1 (11.1) 1 0 0 0 1 (12.5) 1 General disorders and administration site conditions 3 (7.0) 4 1 (11.1) 1 0 1 (11.1) 2 0 1 (12.5) 1 Discomfort 1 (2.3) 2 0 0 1 (11.1) 2 0 0 Eye complication associated with device 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Fatigue 1 (2.3) 1 1 (11.1) 1 0 0 0 0 Injury, poisoning and procedural complications 4 (9.3) 4 0 1 (12.5) 1 1 (11.1) 1 1 (11.1) 1 1 (12.5) 1 Ligament sprain 1 (2.3) 1 0 1 (12.5) 1 0 0 0 Vascular access site complication 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Vascular access site pain 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Vascular access site swelling 1 (2.3) 1 0 0 0 1 (11.1) 1 0 Cardiac disorders 2 (4.7) 2 1 (11.1) 1 0 1 (1.11) 1 0 0 Palpitations 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Ventricular extrasystoles 1 (2.3) 1 1 (11.1) 1 0 0 0 0 Infections and infestations 2 (4.7) 2 0 0 0 1 (11.1) 1 1 (12.5) 1 Upper respiratory tract infection 1 (2.3) 1 0 0 0 1 (11.1) 0 Viral upper respiratory tract infection 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Reproductive system and breast disorders 2 (4.7) 2 0 1 (12.5) 1 0 1 (11.1) 1 0 Dysmenorrhea 2 (4.7) 2 0 1 (12.5) 1 0 1 (11.1) 1 0 Investigations 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Sensory level abnormal 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Respiratory, thoracic and mediastinal disorders 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Nasal congestion 1 (2.3) 1 0 0 1 (11.1) 1 0 0 . . Treatmenta . SOC PT[n (%) E] . Overall (n = 43) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Placebo (n = 8) . Participants with at least one TEAE 21 (48.8) 45 4 (44.4) 7 2 (25.0) 4 6 (66.7) 13 6 (66.7) 14 3 (37.5) 7 Nervous system disorders 9 (20.9) 12 2 (22.2) 4 2 (25.0) 2 2 (22.2) 2 3 (33.3) 4 0 Dizziness 3 (7.0) 3 1 (11.1) 1 1 (12.5) 1 1 (11.1) 1 0 0 Presyncope 3 (7.0) 3 0 0 0 3 (33.3) 0 Headache 2 (4.7) 2 2 (22.2) 2 0 0 0 0 Somnolence 2 (4.7) 2 1 (11.1) 1 0 1 (11.1) 1 0 0 Amnesia 1 (2.3) 1 0 1 (12.5) 1 0 0 0 Lethargy 1 (2.3) 1 0 0 0 1 (11.1) 1 0 Psychiatric disorders 6 (14.0) 9 0 0 2 (22.2) 5 4 (44.4) 4 0 Insomnia 3 (7.0) 3 0 0 1 (11.1) 1 2 (22.2) 2 0 Anxiety 2 (4.7) 2 0 0 1 (11.1) 1 1 (11.1) 1 0 Paranoia 2 (4.7) 2 0 0 1 (11.1) 1 1 (11.1) 1 0 Hallucination 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Mood altered 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Gastrointestinal disorders 6 (14.0) 8 1 (11.1) 1 0 0 2 (22.2) 3 3 (37.5) 4 Abdominal pain 3 (7.0) 3 0 0 0 2 (22.2) 2 1 (12.5) 1 Diarrhea 3 (7.0) 3 0 0 0 1 (1.11) 1 2 (25.0) 2 Nausea 2 (4.7) 2 1 (11.1) 1 0 0 0 1 (12.5) 1 General disorders and administration site conditions 3 (7.0) 4 1 (11.1) 1 0 1 (11.1) 2 0 1 (12.5) 1 Discomfort 1 (2.3) 2 0 0 1 (11.1) 2 0 0 Eye complication associated with device 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Fatigue 1 (2.3) 1 1 (11.1) 1 0 0 0 0 Injury, poisoning and procedural complications 4 (9.3) 4 0 1 (12.5) 1 1 (11.1) 1 1 (11.1) 1 1 (12.5) 1 Ligament sprain 1 (2.3) 1 0 1 (12.5) 1 0 0 0 Vascular access site complication 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Vascular access site pain 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Vascular access site swelling 1 (2.3) 1 0 0 0 1 (11.1) 1 0 Cardiac disorders 2 (4.7) 2 1 (11.1) 1 0 1 (1.11) 1 0 0 Palpitations 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Ventricular extrasystoles 1 (2.3) 1 1 (11.1) 1 0 0 0 0 Infections and infestations 2 (4.7) 2 0 0 0 1 (11.1) 1 1 (12.5) 1 Upper respiratory tract infection 1 (2.3) 1 0 0 0 1 (11.1) 0 Viral upper respiratory tract infection 1 (2.3) 1 0 0 0 0 1 (12.5) 1 Reproductive system and breast disorders 2 (4.7) 2 0 1 (12.5) 1 0 1 (11.1) 1 0 Dysmenorrhea 2 (4.7) 2 0 1 (12.5) 1 0 1 (11.1) 1 0 Investigations 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Sensory level abnormal 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Respiratory, thoracic and mediastinal disorders 1 (2.3) 1 0 0 1 (11.1) 1 0 0 Nasal congestion 1 (2.3) 1 0 0 1 (11.1) 1 0 0 E = number of adverse events, MedDRA = Medical Dictionary for Regulatory Activities, n = number of participants with events, PT = preferred term, SOC = system organ class, TEAE = treatment-emergent adverse event. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. Open in new tab Figure 1. Open in new tabDownload slide (A) Total and (B) treatment-related treatment-emergent adverse events (TEAEs) by visit day. Figure 1. Open in new tabDownload slide (A) Total and (B) treatment-related treatment-emergent adverse events (TEAEs) by visit day. Almost all TEAEs were of mild (41/45 TEAEs) or moderate (3/45 TEAEs) severity. There was one severe TEAE: anxiety in Treatment D. All moderate and severe TEAEs were considered related to treatment except for ventricular extrasystoles (Treatment A). There were no SAEs, no life-threatening AEs and no deaths. Four participants experienced TEAEs that resulted in withdrawal from study treatment: two in Treatment A (in one participant, headache of moderate severity possibly related to study treatment, and fatigue and dizziness of mild severity and not related to study treatment; in another participant, ventricular extrasystoles of moderate severity and unlikely related to study treatment), one in Treatment C (anxiety, hallucination and paranoia, all of mild severity and definitely related to study treatment) and one in Treatment D (anxiety of severe severity and definitely related to study treatment). Three of these participants discontinued due to TEAEs: one each in Treatments A (Day 3), C (Day 4) and D (Day 2); one of these participants (Treatment A) discontinued treatment on Day 5 but did not withdraw from the study and completed outpatient visits. No clinically significant differences were observed between treatment groups with respect to clinical chemistry laboratory assessments (including no clinically significant changes in transaminases), vital signs, physical examinations, ECGs or suicidality. Pharmacokinetics Figure 2 shows the geometric mean plasma concentration–time profiles; Tables II and III summarize the plasma PK parameters, for CBD, THC and metabolites; Table IV summarizes the urinary PK parameters for CBD, THC and metabolites and Table V summarizes plasma THC concentrations. Figure 2. Open in new tabDownload slide Geometric mean (±standard deviation) plasma concentration–time profiles for cannabidiol (CBD), 7-hydroxy-cannabidiol (7-OH-CBD), 7-carboxy-cannabidiol (7-COOH-CBD), tetrahydrocannabinol (THC), 11-hydroxy-tetrahydrocannabinol (11-OH-THC) and 11-carboxy-tetrahydrocannabinol) (11-COOH-THC) on Day 1 and Day 7 for Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily (semi-logarithmic scale, pharmacokinetic population). Figure 2. Open in new tabDownload slide Geometric mean (±standard deviation) plasma concentration–time profiles for cannabidiol (CBD), 7-hydroxy-cannabidiol (7-OH-CBD), 7-carboxy-cannabidiol (7-COOH-CBD), tetrahydrocannabinol (THC), 11-hydroxy-tetrahydrocannabinol (11-OH-THC) and 11-carboxy-tetrahydrocannabinol) (11-COOH-THC) on Day 1 and Day 7 for Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily (semi-logarithmic scale, pharmacokinetic population). Table II. Plasma Pharmacokinetic Parameters for CBD, THC and Metabolites (Pharmacokinetic Population) Pharmacokinetic parameter (unit) . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . Day 1 . Day 7 . Day 1 . Day 7 . Day 1 . Day 7 . Day 1 . Day 7 . CBD Cmax (ng/mL)b 8.9 (69.6)e 9.6 (47.5)e 7.2 (142.1)e 18.3 (83.5) 10.9 (106.2) 23.9 (51.9) 23.3 (53.6) 36.3 (112.9) tmax (h)c 4.0 (1.0–6.0)e 4.0 (1.0–6.1)e 4.0 (4.0–6.0)e 4.0 (1.0–6.0) 6.0 (4.0–6.2) 4.0 (4.0–6.0) 5.0 (1.0–12.0) 5.0 (1.0–8.0) AUC0–12 (h × ng/mL)b 69.1 (-)g 54.1 (34.3)h 74.9 (6.7)i 100.8 (69.3) NE 153.2 (55.0) 125.9 (42.6)j 229.4 (79.5) AUC0–t (ng × h/mL)b 34.8 (77.0)e 62.2 (31.5)e 29.7 (138.6)e 110.2 (69.0) 51.6 (99.5) 175.8 (53.0) 117.5 (45.5) 263.3 (79.4) t1/2 (h)d – 4.7 (38.2) – 5.4 (23.3) – 5.2 (24.9) – 5.8 (28.7) CL/F (L/h)b – 2292.3 (18.6) – 2756.1 (43.8) – 1761.1 (39.6) – 1390.8 (52.5) Rac(AUC)b – 0.9 (-)g – 1.9 (35.0)i – NE – 2.3 (57.6)j 7-OH-CBD Cmax (ng/mL)b 6.4 (39.0)j 8.8 (41.1)h 16.1 (57.1)k 19.9 (78.0) 13.3 (57.5)e 23.8 (62.3) 20.7 (45.7) 32.7 (74.1) tmax (h)c 4.0 (4.0–6.0)j 5.0 (1.0–6.1)h 4.0 (4.0–4.0)k 4.0 (1.0–6.0) 4.0 (4.0–6.2)e 4.0 (4.0–6.0) 4.0 (4.0–12.0) 5.0 (1.0–6.0) AUC0–12 (h × ng/mL)b NE 70.2 (43.0)h 99.7 (12.2)f 140.3 (88.1) 110.4 (14.6)k 180.9 (57.8) 162.3 (32.1) 263.0 (67.7) AUC0–t (ng × h/mL)b 30.5 (30.4)j 78.5 (50.3)h 75.6 (59.9)k 156.2 (98.1) 64.0 (79.7)e 212.0 (55.5) 118.6 (57.9) 309.5 (71.0) t1/2 (h)d – 4.4 (-)g – 5.4 (0.2)i – 5.2 (15.8)f – 5.3 (4.1)f CL/F (L/h)b – 2022.8 (47.5)f – 2713.8 (48.8)k – 1263.7 (41.9)f – 1972.8 (112.8)f Rac(AUC)b – NE – 2.9 (62.3)f – 2.0 (50.4)k – 2.6 (40.8)k (M/P)AUC0–tb – 1.2 (24.9)j – 1.4 (44.8) – 1.2 (24.6) – 1.2 (30.5) 7-COOH-CBD Cmax (ng/mL)b 37.7 (100.7) 129.9 (69.8)e 99.8 (114.9) 343.9 (54.7) 105.3 (113.2) 671.2 (66.2) 233.8 (48.7) 1027.1 (58.8) tmax (h)c 5.0 (4.0–6.0) 8.0 (0.0–8.1)e 4.1 (4.0–12.0) 4.0 (4.0–12.0) 7.0 (4.0–12.0) 4.0 (4.0–8.0) 6.0 (4.0–12.0) 4.0 (4.0–8.0) AUC0–12 (h × ng/mL)b 318.5 (52.2)k 1160.4 (71.5)e 621.7 (66.0)j 3238.5 (57.8) 1487.8 (61.3)i 6471.9 (62.2) 2025.3 (58.4)k 9540.4 (63.3) AUC0–t (ng × h/mL)b 288.9 (86.6) 1486.7 (69.7)e 732.0 (101.9) 4059.8 (61.2) 731.6 (123.1) 8019.5 (59.8) 1747.2 (47.7) 11,766.7 (66.2) t1/2 (h)d – BLoQ – BLoQ – 6.3 (-)g – BLoQ CL/F (L/h)b – 99.7 (71.0)k – 69.7 (84.8)i – 58.8 (70.3)f – 32.3 (-)g Rac(AUC)b – 3.8 (30.5)f – 4.5 (23.5)j – 4.1 (20.8)i – 5.4 (44.3)k (M/P)AUC0–tb – 23.9 (81.1)h – 36.8 (83.9) – 45.6 (63.5) – 44.7 (47.3) THC Cmax (ng/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ tmax (h)c BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ AUC0–t (ng × h/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ AUC0–12 (h × ng/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ t1/2 (h)d – BLoQ – BLoQ – BLoQ – BLoQ CL/F (L/h)b – BLoQ – BLoQ – BLoQ – BLoQ Rac(AUC)b – BLoQ – BLoQ – BLoQ – BLoQ 11-OH-THC Cmax (ng/mL)b BLoQ BLoQ BLoQ 8.7 (107.3)i BLoQ 3.5 (56.3)f BLoQ 7.3 (40.3)j tmax (h)c BLoQ BLoQ BLoQ 4.0 (4.0–4.0)i BLoQ 4.0 (1.0–4.0)f BLoQ 6.0 (1.0–8.0)j AUC0–12 (h × ng/mL)b BLoQ BLoQ BLoQ 80.1 (-)g BLoQ 33.7 (-)g BLoQ 61.6 (17.1)f AUC0–t (ng × h/mL)b BLoQ BLoQ BLoQ 44.6 (99.3)i BLoQ 23.0 (70.4)f BLoQ 45.2 (57.8)j t1/2 (h)d – – – BLoQ – BLQ – BLoQ CL/F (L/h)b – – – – – – – 331.0 (19.7)i Rac(AUC)b – BLoQ – BLoQ – BLoQ – BLoQ (M/P)AUC0–tb – BLoQ – BLoQ – BLoQ – BLoQ 11-COOH-THC Cmax (ng/mL)b 4.5 (48.0)e 9.6 (38.3)e 11.4 (64.9e) 24.5 (62.7) 10.7 (124.6) 36.8 (53.7) 20.9 (53.9) 43.8 (68.4) tmax (h)c 4.0 (4.0–6.0)e 6.0 (1.0–8.0)e 4.0 (4.0–6.0)e 4.0 (4.0–6.0) 6.0 (4.0–11.9) 4.0 (4.0–6.0) 4.0 (4.0–12.0) 5.0 (4.0–8.0) AUC0–12 (h × ng/mL)b 32.5 (63.4)f 83.3 (35.8)e 74.3 (84.8)k 187.3 (71.9) 126.4 (65.9)f 307.8 (54.2) 141.5 (49.2)e 371.8 (64.5) AUC0–t (ng × h/mL)b 25.1 (52.3)e 103.7 (34.4)e 61.9 (74.9)e 210.9 (73.0) 62.0 (111.9) 362.7 (54.6) 130.3 (51.6) 436.8 (60.2) t1/2 (h)d – NE – NE – 5.6 (-)g – NE CL/F (L/h)b – 55.1 (22.4)e – 33.5 (-)g – 34.1(90.1)i – 28.7 (14.5)i Rac(AUC)b – 2.4 (15.3)f – 3.1 (19.1)k – 3.1 (14.0)f – 2.7 (42.0)e (M/P)AUC0–tb – BLoQ – BLoQ – BLoQ – BLoQ Pharmacokinetic parameter (unit) . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . Day 1 . Day 7 . Day 1 . Day 7 . Day 1 . Day 7 . Day 1 . Day 7 . CBD Cmax (ng/mL)b 8.9 (69.6)e 9.6 (47.5)e 7.2 (142.1)e 18.3 (83.5) 10.9 (106.2) 23.9 (51.9) 23.3 (53.6) 36.3 (112.9) tmax (h)c 4.0 (1.0–6.0)e 4.0 (1.0–6.1)e 4.0 (4.0–6.0)e 4.0 (1.0–6.0) 6.0 (4.0–6.2) 4.0 (4.0–6.0) 5.0 (1.0–12.0) 5.0 (1.0–8.0) AUC0–12 (h × ng/mL)b 69.1 (-)g 54.1 (34.3)h 74.9 (6.7)i 100.8 (69.3) NE 153.2 (55.0) 125.9 (42.6)j 229.4 (79.5) AUC0–t (ng × h/mL)b 34.8 (77.0)e 62.2 (31.5)e 29.7 (138.6)e 110.2 (69.0) 51.6 (99.5) 175.8 (53.0) 117.5 (45.5) 263.3 (79.4) t1/2 (h)d – 4.7 (38.2) – 5.4 (23.3) – 5.2 (24.9) – 5.8 (28.7) CL/F (L/h)b – 2292.3 (18.6) – 2756.1 (43.8) – 1761.1 (39.6) – 1390.8 (52.5) Rac(AUC)b – 0.9 (-)g – 1.9 (35.0)i – NE – 2.3 (57.6)j 7-OH-CBD Cmax (ng/mL)b 6.4 (39.0)j 8.8 (41.1)h 16.1 (57.1)k 19.9 (78.0) 13.3 (57.5)e 23.8 (62.3) 20.7 (45.7) 32.7 (74.1) tmax (h)c 4.0 (4.0–6.0)j 5.0 (1.0–6.1)h 4.0 (4.0–4.0)k 4.0 (1.0–6.0) 4.0 (4.0–6.2)e 4.0 (4.0–6.0) 4.0 (4.0–12.0) 5.0 (1.0–6.0) AUC0–12 (h × ng/mL)b NE 70.2 (43.0)h 99.7 (12.2)f 140.3 (88.1) 110.4 (14.6)k 180.9 (57.8) 162.3 (32.1) 263.0 (67.7) AUC0–t (ng × h/mL)b 30.5 (30.4)j 78.5 (50.3)h 75.6 (59.9)k 156.2 (98.1) 64.0 (79.7)e 212.0 (55.5) 118.6 (57.9) 309.5 (71.0) t1/2 (h)d – 4.4 (-)g – 5.4 (0.2)i – 5.2 (15.8)f – 5.3 (4.1)f CL/F (L/h)b – 2022.8 (47.5)f – 2713.8 (48.8)k – 1263.7 (41.9)f – 1972.8 (112.8)f Rac(AUC)b – NE – 2.9 (62.3)f – 2.0 (50.4)k – 2.6 (40.8)k (M/P)AUC0–tb – 1.2 (24.9)j – 1.4 (44.8) – 1.2 (24.6) – 1.2 (30.5) 7-COOH-CBD Cmax (ng/mL)b 37.7 (100.7) 129.9 (69.8)e 99.8 (114.9) 343.9 (54.7) 105.3 (113.2) 671.2 (66.2) 233.8 (48.7) 1027.1 (58.8) tmax (h)c 5.0 (4.0–6.0) 8.0 (0.0–8.1)e 4.1 (4.0–12.0) 4.0 (4.0–12.0) 7.0 (4.0–12.0) 4.0 (4.0–8.0) 6.0 (4.0–12.0) 4.0 (4.0–8.0) AUC0–12 (h × ng/mL)b 318.5 (52.2)k 1160.4 (71.5)e 621.7 (66.0)j 3238.5 (57.8) 1487.8 (61.3)i 6471.9 (62.2) 2025.3 (58.4)k 9540.4 (63.3) AUC0–t (ng × h/mL)b 288.9 (86.6) 1486.7 (69.7)e 732.0 (101.9) 4059.8 (61.2) 731.6 (123.1) 8019.5 (59.8) 1747.2 (47.7) 11,766.7 (66.2) t1/2 (h)d – BLoQ – BLoQ – 6.3 (-)g – BLoQ CL/F (L/h)b – 99.7 (71.0)k – 69.7 (84.8)i – 58.8 (70.3)f – 32.3 (-)g Rac(AUC)b – 3.8 (30.5)f – 4.5 (23.5)j – 4.1 (20.8)i – 5.4 (44.3)k (M/P)AUC0–tb – 23.9 (81.1)h – 36.8 (83.9) – 45.6 (63.5) – 44.7 (47.3) THC Cmax (ng/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ tmax (h)c BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ AUC0–t (ng × h/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ AUC0–12 (h × ng/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ t1/2 (h)d – BLoQ – BLoQ – BLoQ – BLoQ CL/F (L/h)b – BLoQ – BLoQ – BLoQ – BLoQ Rac(AUC)b – BLoQ – BLoQ – BLoQ – BLoQ 11-OH-THC Cmax (ng/mL)b BLoQ BLoQ BLoQ 8.7 (107.3)i BLoQ 3.5 (56.3)f BLoQ 7.3 (40.3)j tmax (h)c BLoQ BLoQ BLoQ 4.0 (4.0–4.0)i BLoQ 4.0 (1.0–4.0)f BLoQ 6.0 (1.0–8.0)j AUC0–12 (h × ng/mL)b BLoQ BLoQ BLoQ 80.1 (-)g BLoQ 33.7 (-)g BLoQ 61.6 (17.1)f AUC0–t (ng × h/mL)b BLoQ BLoQ BLoQ 44.6 (99.3)i BLoQ 23.0 (70.4)f BLoQ 45.2 (57.8)j t1/2 (h)d – – – BLoQ – BLQ – BLoQ CL/F (L/h)b – – – – – – – 331.0 (19.7)i Rac(AUC)b – BLoQ – BLoQ – BLoQ – BLoQ (M/P)AUC0–tb – BLoQ – BLoQ – BLoQ – BLoQ 11-COOH-THC Cmax (ng/mL)b 4.5 (48.0)e 9.6 (38.3)e 11.4 (64.9e) 24.5 (62.7) 10.7 (124.6) 36.8 (53.7) 20.9 (53.9) 43.8 (68.4) tmax (h)c 4.0 (4.0–6.0)e 6.0 (1.0–8.0)e 4.0 (4.0–6.0)e 4.0 (4.0–6.0) 6.0 (4.0–11.9) 4.0 (4.0–6.0) 4.0 (4.0–12.0) 5.0 (4.0–8.0) AUC0–12 (h × ng/mL)b 32.5 (63.4)f 83.3 (35.8)e 74.3 (84.8)k 187.3 (71.9) 126.4 (65.9)f 307.8 (54.2) 141.5 (49.2)e 371.8 (64.5) AUC0–t (ng × h/mL)b 25.1 (52.3)e 103.7 (34.4)e 61.9 (74.9)e 210.9 (73.0) 62.0 (111.9) 362.7 (54.6) 130.3 (51.6) 436.8 (60.2) t1/2 (h)d – NE – NE – 5.6 (-)g – NE CL/F (L/h)b – 55.1 (22.4)e – 33.5 (-)g – 34.1(90.1)i – 28.7 (14.5)i Rac(AUC)b – 2.4 (15.3)f – 3.1 (19.1)k – 3.1 (14.0)f – 2.7 (42.0)e (M/P)AUC0–tb – BLoQ – BLoQ – BLoQ – BLoQ AUC0–12 = area under the plasma concentration–time curve from 0 to 12 h time point, AUC0–t = area under the plasma concentration–time curve from 0 to the last quantifiable concentration, BLoQ = below limit of quantification, CL/F = oral clearance of drug from plasma, Cmax = maximum observed plasma concentration, (M/P)AUCτ = AUCτ metabolite/AUCτ parent, NE = not estimable, Rac(AUC) = accumulation ratio based on AUC, Rac(Cmax) = accumulation ratio based on Cmax, tmax = time to reach Cmax. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. b Geometric mean (geometric CV%). c Median (range). d Arithmetic mean (arithmetic CV%). e n = 7. f n = 3. g n = 1. h n = 6. i n = 2. j n = 5. k n = 4. Open in new tab Table II. Plasma Pharmacokinetic Parameters for CBD, THC and Metabolites (Pharmacokinetic Population) Pharmacokinetic parameter (unit) . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . Day 1 . Day 7 . Day 1 . Day 7 . Day 1 . Day 7 . Day 1 . Day 7 . CBD Cmax (ng/mL)b 8.9 (69.6)e 9.6 (47.5)e 7.2 (142.1)e 18.3 (83.5) 10.9 (106.2) 23.9 (51.9) 23.3 (53.6) 36.3 (112.9) tmax (h)c 4.0 (1.0–6.0)e 4.0 (1.0–6.1)e 4.0 (4.0–6.0)e 4.0 (1.0–6.0) 6.0 (4.0–6.2) 4.0 (4.0–6.0) 5.0 (1.0–12.0) 5.0 (1.0–8.0) AUC0–12 (h × ng/mL)b 69.1 (-)g 54.1 (34.3)h 74.9 (6.7)i 100.8 (69.3) NE 153.2 (55.0) 125.9 (42.6)j 229.4 (79.5) AUC0–t (ng × h/mL)b 34.8 (77.0)e 62.2 (31.5)e 29.7 (138.6)e 110.2 (69.0) 51.6 (99.5) 175.8 (53.0) 117.5 (45.5) 263.3 (79.4) t1/2 (h)d – 4.7 (38.2) – 5.4 (23.3) – 5.2 (24.9) – 5.8 (28.7) CL/F (L/h)b – 2292.3 (18.6) – 2756.1 (43.8) – 1761.1 (39.6) – 1390.8 (52.5) Rac(AUC)b – 0.9 (-)g – 1.9 (35.0)i – NE – 2.3 (57.6)j 7-OH-CBD Cmax (ng/mL)b 6.4 (39.0)j 8.8 (41.1)h 16.1 (57.1)k 19.9 (78.0) 13.3 (57.5)e 23.8 (62.3) 20.7 (45.7) 32.7 (74.1) tmax (h)c 4.0 (4.0–6.0)j 5.0 (1.0–6.1)h 4.0 (4.0–4.0)k 4.0 (1.0–6.0) 4.0 (4.0–6.2)e 4.0 (4.0–6.0) 4.0 (4.0–12.0) 5.0 (1.0–6.0) AUC0–12 (h × ng/mL)b NE 70.2 (43.0)h 99.7 (12.2)f 140.3 (88.1) 110.4 (14.6)k 180.9 (57.8) 162.3 (32.1) 263.0 (67.7) AUC0–t (ng × h/mL)b 30.5 (30.4)j 78.5 (50.3)h 75.6 (59.9)k 156.2 (98.1) 64.0 (79.7)e 212.0 (55.5) 118.6 (57.9) 309.5 (71.0) t1/2 (h)d – 4.4 (-)g – 5.4 (0.2)i – 5.2 (15.8)f – 5.3 (4.1)f CL/F (L/h)b – 2022.8 (47.5)f – 2713.8 (48.8)k – 1263.7 (41.9)f – 1972.8 (112.8)f Rac(AUC)b – NE – 2.9 (62.3)f – 2.0 (50.4)k – 2.6 (40.8)k (M/P)AUC0–tb – 1.2 (24.9)j – 1.4 (44.8) – 1.2 (24.6) – 1.2 (30.5) 7-COOH-CBD Cmax (ng/mL)b 37.7 (100.7) 129.9 (69.8)e 99.8 (114.9) 343.9 (54.7) 105.3 (113.2) 671.2 (66.2) 233.8 (48.7) 1027.1 (58.8) tmax (h)c 5.0 (4.0–6.0) 8.0 (0.0–8.1)e 4.1 (4.0–12.0) 4.0 (4.0–12.0) 7.0 (4.0–12.0) 4.0 (4.0–8.0) 6.0 (4.0–12.0) 4.0 (4.0–8.0) AUC0–12 (h × ng/mL)b 318.5 (52.2)k 1160.4 (71.5)e 621.7 (66.0)j 3238.5 (57.8) 1487.8 (61.3)i 6471.9 (62.2) 2025.3 (58.4)k 9540.4 (63.3) AUC0–t (ng × h/mL)b 288.9 (86.6) 1486.7 (69.7)e 732.0 (101.9) 4059.8 (61.2) 731.6 (123.1) 8019.5 (59.8) 1747.2 (47.7) 11,766.7 (66.2) t1/2 (h)d – BLoQ – BLoQ – 6.3 (-)g – BLoQ CL/F (L/h)b – 99.7 (71.0)k – 69.7 (84.8)i – 58.8 (70.3)f – 32.3 (-)g Rac(AUC)b – 3.8 (30.5)f – 4.5 (23.5)j – 4.1 (20.8)i – 5.4 (44.3)k (M/P)AUC0–tb – 23.9 (81.1)h – 36.8 (83.9) – 45.6 (63.5) – 44.7 (47.3) THC Cmax (ng/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ tmax (h)c BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ AUC0–t (ng × h/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ AUC0–12 (h × ng/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ t1/2 (h)d – BLoQ – BLoQ – BLoQ – BLoQ CL/F (L/h)b – BLoQ – BLoQ – BLoQ – BLoQ Rac(AUC)b – BLoQ – BLoQ – BLoQ – BLoQ 11-OH-THC Cmax (ng/mL)b BLoQ BLoQ BLoQ 8.7 (107.3)i BLoQ 3.5 (56.3)f BLoQ 7.3 (40.3)j tmax (h)c BLoQ BLoQ BLoQ 4.0 (4.0–4.0)i BLoQ 4.0 (1.0–4.0)f BLoQ 6.0 (1.0–8.0)j AUC0–12 (h × ng/mL)b BLoQ BLoQ BLoQ 80.1 (-)g BLoQ 33.7 (-)g BLoQ 61.6 (17.1)f AUC0–t (ng × h/mL)b BLoQ BLoQ BLoQ 44.6 (99.3)i BLoQ 23.0 (70.4)f BLoQ 45.2 (57.8)j t1/2 (h)d – – – BLoQ – BLQ – BLoQ CL/F (L/h)b – – – – – – – 331.0 (19.7)i Rac(AUC)b – BLoQ – BLoQ – BLoQ – BLoQ (M/P)AUC0–tb – BLoQ – BLoQ – BLoQ – BLoQ 11-COOH-THC Cmax (ng/mL)b 4.5 (48.0)e 9.6 (38.3)e 11.4 (64.9e) 24.5 (62.7) 10.7 (124.6) 36.8 (53.7) 20.9 (53.9) 43.8 (68.4) tmax (h)c 4.0 (4.0–6.0)e 6.0 (1.0–8.0)e 4.0 (4.0–6.0)e 4.0 (4.0–6.0) 6.0 (4.0–11.9) 4.0 (4.0–6.0) 4.0 (4.0–12.0) 5.0 (4.0–8.0) AUC0–12 (h × ng/mL)b 32.5 (63.4)f 83.3 (35.8)e 74.3 (84.8)k 187.3 (71.9) 126.4 (65.9)f 307.8 (54.2) 141.5 (49.2)e 371.8 (64.5) AUC0–t (ng × h/mL)b 25.1 (52.3)e 103.7 (34.4)e 61.9 (74.9)e 210.9 (73.0) 62.0 (111.9) 362.7 (54.6) 130.3 (51.6) 436.8 (60.2) t1/2 (h)d – NE – NE – 5.6 (-)g – NE CL/F (L/h)b – 55.1 (22.4)e – 33.5 (-)g – 34.1(90.1)i – 28.7 (14.5)i Rac(AUC)b – 2.4 (15.3)f – 3.1 (19.1)k – 3.1 (14.0)f – 2.7 (42.0)e (M/P)AUC0–tb – BLoQ – BLoQ – BLoQ – BLoQ Pharmacokinetic parameter (unit) . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . Day 1 . Day 7 . Day 1 . Day 7 . Day 1 . Day 7 . Day 1 . Day 7 . CBD Cmax (ng/mL)b 8.9 (69.6)e 9.6 (47.5)e 7.2 (142.1)e 18.3 (83.5) 10.9 (106.2) 23.9 (51.9) 23.3 (53.6) 36.3 (112.9) tmax (h)c 4.0 (1.0–6.0)e 4.0 (1.0–6.1)e 4.0 (4.0–6.0)e 4.0 (1.0–6.0) 6.0 (4.0–6.2) 4.0 (4.0–6.0) 5.0 (1.0–12.0) 5.0 (1.0–8.0) AUC0–12 (h × ng/mL)b 69.1 (-)g 54.1 (34.3)h 74.9 (6.7)i 100.8 (69.3) NE 153.2 (55.0) 125.9 (42.6)j 229.4 (79.5) AUC0–t (ng × h/mL)b 34.8 (77.0)e 62.2 (31.5)e 29.7 (138.6)e 110.2 (69.0) 51.6 (99.5) 175.8 (53.0) 117.5 (45.5) 263.3 (79.4) t1/2 (h)d – 4.7 (38.2) – 5.4 (23.3) – 5.2 (24.9) – 5.8 (28.7) CL/F (L/h)b – 2292.3 (18.6) – 2756.1 (43.8) – 1761.1 (39.6) – 1390.8 (52.5) Rac(AUC)b – 0.9 (-)g – 1.9 (35.0)i – NE – 2.3 (57.6)j 7-OH-CBD Cmax (ng/mL)b 6.4 (39.0)j 8.8 (41.1)h 16.1 (57.1)k 19.9 (78.0) 13.3 (57.5)e 23.8 (62.3) 20.7 (45.7) 32.7 (74.1) tmax (h)c 4.0 (4.0–6.0)j 5.0 (1.0–6.1)h 4.0 (4.0–4.0)k 4.0 (1.0–6.0) 4.0 (4.0–6.2)e 4.0 (4.0–6.0) 4.0 (4.0–12.0) 5.0 (1.0–6.0) AUC0–12 (h × ng/mL)b NE 70.2 (43.0)h 99.7 (12.2)f 140.3 (88.1) 110.4 (14.6)k 180.9 (57.8) 162.3 (32.1) 263.0 (67.7) AUC0–t (ng × h/mL)b 30.5 (30.4)j 78.5 (50.3)h 75.6 (59.9)k 156.2 (98.1) 64.0 (79.7)e 212.0 (55.5) 118.6 (57.9) 309.5 (71.0) t1/2 (h)d – 4.4 (-)g – 5.4 (0.2)i – 5.2 (15.8)f – 5.3 (4.1)f CL/F (L/h)b – 2022.8 (47.5)f – 2713.8 (48.8)k – 1263.7 (41.9)f – 1972.8 (112.8)f Rac(AUC)b – NE – 2.9 (62.3)f – 2.0 (50.4)k – 2.6 (40.8)k (M/P)AUC0–tb – 1.2 (24.9)j – 1.4 (44.8) – 1.2 (24.6) – 1.2 (30.5) 7-COOH-CBD Cmax (ng/mL)b 37.7 (100.7) 129.9 (69.8)e 99.8 (114.9) 343.9 (54.7) 105.3 (113.2) 671.2 (66.2) 233.8 (48.7) 1027.1 (58.8) tmax (h)c 5.0 (4.0–6.0) 8.0 (0.0–8.1)e 4.1 (4.0–12.0) 4.0 (4.0–12.0) 7.0 (4.0–12.0) 4.0 (4.0–8.0) 6.0 (4.0–12.0) 4.0 (4.0–8.0) AUC0–12 (h × ng/mL)b 318.5 (52.2)k 1160.4 (71.5)e 621.7 (66.0)j 3238.5 (57.8) 1487.8 (61.3)i 6471.9 (62.2) 2025.3 (58.4)k 9540.4 (63.3) AUC0–t (ng × h/mL)b 288.9 (86.6) 1486.7 (69.7)e 732.0 (101.9) 4059.8 (61.2) 731.6 (123.1) 8019.5 (59.8) 1747.2 (47.7) 11,766.7 (66.2) t1/2 (h)d – BLoQ – BLoQ – 6.3 (-)g – BLoQ CL/F (L/h)b – 99.7 (71.0)k – 69.7 (84.8)i – 58.8 (70.3)f – 32.3 (-)g Rac(AUC)b – 3.8 (30.5)f – 4.5 (23.5)j – 4.1 (20.8)i – 5.4 (44.3)k (M/P)AUC0–tb – 23.9 (81.1)h – 36.8 (83.9) – 45.6 (63.5) – 44.7 (47.3) THC Cmax (ng/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ tmax (h)c BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ AUC0–t (ng × h/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ AUC0–12 (h × ng/mL)b BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ BLoQ t1/2 (h)d – BLoQ – BLoQ – BLoQ – BLoQ CL/F (L/h)b – BLoQ – BLoQ – BLoQ – BLoQ Rac(AUC)b – BLoQ – BLoQ – BLoQ – BLoQ 11-OH-THC Cmax (ng/mL)b BLoQ BLoQ BLoQ 8.7 (107.3)i BLoQ 3.5 (56.3)f BLoQ 7.3 (40.3)j tmax (h)c BLoQ BLoQ BLoQ 4.0 (4.0–4.0)i BLoQ 4.0 (1.0–4.0)f BLoQ 6.0 (1.0–8.0)j AUC0–12 (h × ng/mL)b BLoQ BLoQ BLoQ 80.1 (-)g BLoQ 33.7 (-)g BLoQ 61.6 (17.1)f AUC0–t (ng × h/mL)b BLoQ BLoQ BLoQ 44.6 (99.3)i BLoQ 23.0 (70.4)f BLoQ 45.2 (57.8)j t1/2 (h)d – – – BLoQ – BLQ – BLoQ CL/F (L/h)b – – – – – – – 331.0 (19.7)i Rac(AUC)b – BLoQ – BLoQ – BLoQ – BLoQ (M/P)AUC0–tb – BLoQ – BLoQ – BLoQ – BLoQ 11-COOH-THC Cmax (ng/mL)b 4.5 (48.0)e 9.6 (38.3)e 11.4 (64.9e) 24.5 (62.7) 10.7 (124.6) 36.8 (53.7) 20.9 (53.9) 43.8 (68.4) tmax (h)c 4.0 (4.0–6.0)e 6.0 (1.0–8.0)e 4.0 (4.0–6.0)e 4.0 (4.0–6.0) 6.0 (4.0–11.9) 4.0 (4.0–6.0) 4.0 (4.0–12.0) 5.0 (4.0–8.0) AUC0–12 (h × ng/mL)b 32.5 (63.4)f 83.3 (35.8)e 74.3 (84.8)k 187.3 (71.9) 126.4 (65.9)f 307.8 (54.2) 141.5 (49.2)e 371.8 (64.5) AUC0–t (ng × h/mL)b 25.1 (52.3)e 103.7 (34.4)e 61.9 (74.9)e 210.9 (73.0) 62.0 (111.9) 362.7 (54.6) 130.3 (51.6) 436.8 (60.2) t1/2 (h)d – NE – NE – 5.6 (-)g – NE CL/F (L/h)b – 55.1 (22.4)e – 33.5 (-)g – 34.1(90.1)i – 28.7 (14.5)i Rac(AUC)b – 2.4 (15.3)f – 3.1 (19.1)k – 3.1 (14.0)f – 2.7 (42.0)e (M/P)AUC0–tb – BLoQ – BLoQ – BLoQ – BLoQ AUC0–12 = area under the plasma concentration–time curve from 0 to 12 h time point, AUC0–t = area under the plasma concentration–time curve from 0 to the last quantifiable concentration, BLoQ = below limit of quantification, CL/F = oral clearance of drug from plasma, Cmax = maximum observed plasma concentration, (M/P)AUCτ = AUCτ metabolite/AUCτ parent, NE = not estimable, Rac(AUC) = accumulation ratio based on AUC, Rac(Cmax) = accumulation ratio based on Cmax, tmax = time to reach Cmax. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. b Geometric mean (geometric CV%). c Median (range). d Arithmetic mean (arithmetic CV%). e n = 7. f n = 3. g n = 1. h n = 6. i n = 2. j n = 5. k n = 4. Open in new tab Table III. Pre-dose Plasma CBD Concentrations by Treatment Group, Days 2–6 (Pharmacokinetic Population) . Treatment Aa . Treatment Ba . Treatment Ca . Treatment Da . Day . (n = 8) . (n = 8) . (n = 8) . (n = 8) . Day 2 0.63 (1.06)b 1.79 (1.01)c 3.70 (2.48) 6.44 (3.61) Day 3 1.69 (0.96)c 2.96 (1.56) 5.50 (4.24) 9.80 (4.49) Day 4 1.75 (0.74)d 3.40 (2.07) 5.70 (3.38) 9.30 (4.95) Day 5 1.98 (1.15)e 4.33 (2.53) 6.75 (3.78) 9.73 (4.87) Day 6 2.25 (1.51)f 4.13 (2.09) 7.54 (3.99) 12.25 (7.13) . Treatment Aa . Treatment Ba . Treatment Ca . Treatment Da . Day . (n = 8) . (n = 8) . (n = 8) . (n = 8) . Day 2 0.63 (1.06)b 1.79 (1.01)c 3.70 (2.48) 6.44 (3.61) Day 3 1.69 (0.96)c 2.96 (1.56) 5.50 (4.24) 9.80 (4.49) Day 4 1.75 (0.74)d 3.40 (2.07) 5.70 (3.38) 9.30 (4.95) Day 5 1.98 (1.15)e 4.33 (2.53) 6.75 (3.78) 9.73 (4.87) Day 6 2.25 (1.51)f 4.13 (2.09) 7.54 (3.99) 12.25 (7.13) Mean values (standard deviation) in ng/mL are presented. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. b Five samples were below the lower limit of quantification (0.78 ng/mL) and were assigned as zero for analysis. c n = 7. d n = 6. e One sample was below the lower limit of quantification (0.78 ng/mL) and was assigned as zero for analysis. f n = 6; one sample was below the lower limit of quantification (0.78 ng/mL) and was assigned as zero for analysis. Open in new tab Table III. Pre-dose Plasma CBD Concentrations by Treatment Group, Days 2–6 (Pharmacokinetic Population) . Treatment Aa . Treatment Ba . Treatment Ca . Treatment Da . Day . (n = 8) . (n = 8) . (n = 8) . (n = 8) . Day 2 0.63 (1.06)b 1.79 (1.01)c 3.70 (2.48) 6.44 (3.61) Day 3 1.69 (0.96)c 2.96 (1.56) 5.50 (4.24) 9.80 (4.49) Day 4 1.75 (0.74)d 3.40 (2.07) 5.70 (3.38) 9.30 (4.95) Day 5 1.98 (1.15)e 4.33 (2.53) 6.75 (3.78) 9.73 (4.87) Day 6 2.25 (1.51)f 4.13 (2.09) 7.54 (3.99) 12.25 (7.13) . Treatment Aa . Treatment Ba . Treatment Ca . Treatment Da . Day . (n = 8) . (n = 8) . (n = 8) . (n = 8) . Day 2 0.63 (1.06)b 1.79 (1.01)c 3.70 (2.48) 6.44 (3.61) Day 3 1.69 (0.96)c 2.96 (1.56) 5.50 (4.24) 9.80 (4.49) Day 4 1.75 (0.74)d 3.40 (2.07) 5.70 (3.38) 9.30 (4.95) Day 5 1.98 (1.15)e 4.33 (2.53) 6.75 (3.78) 9.73 (4.87) Day 6 2.25 (1.51)f 4.13 (2.09) 7.54 (3.99) 12.25 (7.13) Mean values (standard deviation) in ng/mL are presented. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. b Five samples were below the lower limit of quantification (0.78 ng/mL) and were assigned as zero for analysis. c n = 7. d n = 6. e One sample was below the lower limit of quantification (0.78 ng/mL) and was assigned as zero for analysis. f n = 6; one sample was below the lower limit of quantification (0.78 ng/mL) and was assigned as zero for analysis. Open in new tab Table IV. Urine Pharmacokinetic Parameters of CBD, THC and Metabolites (Pharmacokinetic Population) Pharmacokinetic parameter (units)b . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . CBD Ae0–12 (mg) BLoQ 0.001 (-)c 0.001 (112.3)d BLoQ Ae12–24 (mg) BLoQ 0.000 (-)c BLoQ BLoQ Ae0–24 (mg) BLoQ 0.002 (-)c 0.001 (112.3)d BLoQ Fe0–12 BLoQ 6.02 (-)c 0.003 (NE)d BLoQ Fe12–24 BLoQ 0.000 (-)c BloQ BLoQ Fe0–24 BLoQ 0.000 (-)c 0.000 (112.3)d BLoQ CLR (L/h) BLoQ 2.16 (-)c 5.13 (29.2)d BLoQ 7-OH-CBD Ae0–12 (mg) 0.017 (73.3)e 0.040 (35.6) 0.056 (55.5) 0.024 (113.8) Ae12–24 (mg) 0.004 (93.0)e 0.007 (54.9)e 0.012 (39.7) 0.005 (141.3) Ae0–24 (mg) 0.021 (72.6)e 0.047 (36.4) 0.069 (51.2) 0.029 (116.6) Fe0–12 0.001 (NE)e 0.000 (35.6) 0.000 (55.5) 0.004 (NE) Fe12–24 0.004 (NE)e 0.004 (NE)e 0.193 (NE) 0.014 (NE) Fe0–24 0.000 (72.6)e 0.000 (36.4) 0.000 (51.2) 0.000 (116.6) CLR (L/h) 0.002 (71.3)f 0.001 (109.9) 0.001 (65.1) 0.003 (NE) THC Ae0–12 (mg) BLoQ BLoQ BLoQ BLoQ Ae12–24 (mg) BLoQ BLoQ BLoQ BLoQ Ae0–24 (mg) BLoQ BLoQ BLoQ BLoQ Fe0–12 (mg) BLoQ BLoQ BLoQ BLoQ Fe12–24 (mg) BLoQ BLoQ BLoQ BLoQ Fe0–24 (mg) BLoQ BLoQ BLoQ BLoQ CLR BLoQ BLoQ BLoQ BLoQ 11-COOH-THC Ae0–12 (mg) 0.002 (48.3)g 0.005 (58.3)e 0.006 (95.4)e 0.007 (114.6)h Ae12–24 (mg) 0.005 (218.2)d 0.004 (81.4)f 0.006 (110.2)e 0.001 (101.0)e Ae0–24 (mg) 0.003 (178.0)d 0.008 (81.6)e 0.010 (118.6) 0.004 (273.7) Fe0–12 0.000 (48.3)d 0.000 (58.3)e 0.000 (95.4)e 0.000 (114.6)h Fe12–24 0.001 (218.2)g 0.000 (81.4)f 0.002 (NE)e 1.2 (NE)e Fe0–24 0.001 (178.0)d 0.001 (81.6)e 0.001 (118.6) 0.000 (273.7) CLR (L/h) 0.003 (67.4)d 0.002 (77.0)e 0.001 (116.1)e 0.001 (202.3)h Pharmacokinetic parameter (units)b . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . CBD Ae0–12 (mg) BLoQ 0.001 (-)c 0.001 (112.3)d BLoQ Ae12–24 (mg) BLoQ 0.000 (-)c BLoQ BLoQ Ae0–24 (mg) BLoQ 0.002 (-)c 0.001 (112.3)d BLoQ Fe0–12 BLoQ 6.02 (-)c 0.003 (NE)d BLoQ Fe12–24 BLoQ 0.000 (-)c BloQ BLoQ Fe0–24 BLoQ 0.000 (-)c 0.000 (112.3)d BLoQ CLR (L/h) BLoQ 2.16 (-)c 5.13 (29.2)d BLoQ 7-OH-CBD Ae0–12 (mg) 0.017 (73.3)e 0.040 (35.6) 0.056 (55.5) 0.024 (113.8) Ae12–24 (mg) 0.004 (93.0)e 0.007 (54.9)e 0.012 (39.7) 0.005 (141.3) Ae0–24 (mg) 0.021 (72.6)e 0.047 (36.4) 0.069 (51.2) 0.029 (116.6) Fe0–12 0.001 (NE)e 0.000 (35.6) 0.000 (55.5) 0.004 (NE) Fe12–24 0.004 (NE)e 0.004 (NE)e 0.193 (NE) 0.014 (NE) Fe0–24 0.000 (72.6)e 0.000 (36.4) 0.000 (51.2) 0.000 (116.6) CLR (L/h) 0.002 (71.3)f 0.001 (109.9) 0.001 (65.1) 0.003 (NE) THC Ae0–12 (mg) BLoQ BLoQ BLoQ BLoQ Ae12–24 (mg) BLoQ BLoQ BLoQ BLoQ Ae0–24 (mg) BLoQ BLoQ BLoQ BLoQ Fe0–12 (mg) BLoQ BLoQ BLoQ BLoQ Fe12–24 (mg) BLoQ BLoQ BLoQ BLoQ Fe0–24 (mg) BLoQ BLoQ BLoQ BLoQ CLR BLoQ BLoQ BLoQ BLoQ 11-COOH-THC Ae0–12 (mg) 0.002 (48.3)g 0.005 (58.3)e 0.006 (95.4)e 0.007 (114.6)h Ae12–24 (mg) 0.005 (218.2)d 0.004 (81.4)f 0.006 (110.2)e 0.001 (101.0)e Ae0–24 (mg) 0.003 (178.0)d 0.008 (81.6)e 0.010 (118.6) 0.004 (273.7) Fe0–12 0.000 (48.3)d 0.000 (58.3)e 0.000 (95.4)e 0.000 (114.6)h Fe12–24 0.001 (218.2)g 0.000 (81.4)f 0.002 (NE)e 1.2 (NE)e Fe0–24 0.001 (178.0)d 0.001 (81.6)e 0.001 (118.6) 0.000 (273.7) CLR (L/h) 0.003 (67.4)d 0.002 (77.0)e 0.001 (116.1)e 0.001 (202.3)h 7-COOH-CBD and 11-OH-THC were not measured in urine. Ae0–12 = amount of drug eliminated between 0 and 12 h, Ae12–24 = amount of drug eliminated between 12 and 24 h, Ae0–24 = amount of drug eliminated between 0 and 24 h, BLoQ = below limit of quantification, CLR = renal clearance, Fe0–12 = fraction of administered dose excreted in urine between 0 and 12 h, Fe12–24 = fraction of administered dose excreted in urine between 12 and 24 h, Fe12–24 = fraction of administered dose excreted in urine between 0 and 24 h, NE = not estimable. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. b Geometric mean (geometric mean CV%). c n = 1. d n = 2. e n = 7. f n = 6. g n = 4. h n = 5. Open in new tab Table IV. Urine Pharmacokinetic Parameters of CBD, THC and Metabolites (Pharmacokinetic Population) Pharmacokinetic parameter (units)b . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . CBD Ae0–12 (mg) BLoQ 0.001 (-)c 0.001 (112.3)d BLoQ Ae12–24 (mg) BLoQ 0.000 (-)c BLoQ BLoQ Ae0–24 (mg) BLoQ 0.002 (-)c 0.001 (112.3)d BLoQ Fe0–12 BLoQ 6.02 (-)c 0.003 (NE)d BLoQ Fe12–24 BLoQ 0.000 (-)c BloQ BLoQ Fe0–24 BLoQ 0.000 (-)c 0.000 (112.3)d BLoQ CLR (L/h) BLoQ 2.16 (-)c 5.13 (29.2)d BLoQ 7-OH-CBD Ae0–12 (mg) 0.017 (73.3)e 0.040 (35.6) 0.056 (55.5) 0.024 (113.8) Ae12–24 (mg) 0.004 (93.0)e 0.007 (54.9)e 0.012 (39.7) 0.005 (141.3) Ae0–24 (mg) 0.021 (72.6)e 0.047 (36.4) 0.069 (51.2) 0.029 (116.6) Fe0–12 0.001 (NE)e 0.000 (35.6) 0.000 (55.5) 0.004 (NE) Fe12–24 0.004 (NE)e 0.004 (NE)e 0.193 (NE) 0.014 (NE) Fe0–24 0.000 (72.6)e 0.000 (36.4) 0.000 (51.2) 0.000 (116.6) CLR (L/h) 0.002 (71.3)f 0.001 (109.9) 0.001 (65.1) 0.003 (NE) THC Ae0–12 (mg) BLoQ BLoQ BLoQ BLoQ Ae12–24 (mg) BLoQ BLoQ BLoQ BLoQ Ae0–24 (mg) BLoQ BLoQ BLoQ BLoQ Fe0–12 (mg) BLoQ BLoQ BLoQ BLoQ Fe12–24 (mg) BLoQ BLoQ BLoQ BLoQ Fe0–24 (mg) BLoQ BLoQ BLoQ BLoQ CLR BLoQ BLoQ BLoQ BLoQ 11-COOH-THC Ae0–12 (mg) 0.002 (48.3)g 0.005 (58.3)e 0.006 (95.4)e 0.007 (114.6)h Ae12–24 (mg) 0.005 (218.2)d 0.004 (81.4)f 0.006 (110.2)e 0.001 (101.0)e Ae0–24 (mg) 0.003 (178.0)d 0.008 (81.6)e 0.010 (118.6) 0.004 (273.7) Fe0–12 0.000 (48.3)d 0.000 (58.3)e 0.000 (95.4)e 0.000 (114.6)h Fe12–24 0.001 (218.2)g 0.000 (81.4)f 0.002 (NE)e 1.2 (NE)e Fe0–24 0.001 (178.0)d 0.001 (81.6)e 0.001 (118.6) 0.000 (273.7) CLR (L/h) 0.003 (67.4)d 0.002 (77.0)e 0.001 (116.1)e 0.001 (202.3)h Pharmacokinetic parameter (units)b . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . CBD Ae0–12 (mg) BLoQ 0.001 (-)c 0.001 (112.3)d BLoQ Ae12–24 (mg) BLoQ 0.000 (-)c BLoQ BLoQ Ae0–24 (mg) BLoQ 0.002 (-)c 0.001 (112.3)d BLoQ Fe0–12 BLoQ 6.02 (-)c 0.003 (NE)d BLoQ Fe12–24 BLoQ 0.000 (-)c BloQ BLoQ Fe0–24 BLoQ 0.000 (-)c 0.000 (112.3)d BLoQ CLR (L/h) BLoQ 2.16 (-)c 5.13 (29.2)d BLoQ 7-OH-CBD Ae0–12 (mg) 0.017 (73.3)e 0.040 (35.6) 0.056 (55.5) 0.024 (113.8) Ae12–24 (mg) 0.004 (93.0)e 0.007 (54.9)e 0.012 (39.7) 0.005 (141.3) Ae0–24 (mg) 0.021 (72.6)e 0.047 (36.4) 0.069 (51.2) 0.029 (116.6) Fe0–12 0.001 (NE)e 0.000 (35.6) 0.000 (55.5) 0.004 (NE) Fe12–24 0.004 (NE)e 0.004 (NE)e 0.193 (NE) 0.014 (NE) Fe0–24 0.000 (72.6)e 0.000 (36.4) 0.000 (51.2) 0.000 (116.6) CLR (L/h) 0.002 (71.3)f 0.001 (109.9) 0.001 (65.1) 0.003 (NE) THC Ae0–12 (mg) BLoQ BLoQ BLoQ BLoQ Ae12–24 (mg) BLoQ BLoQ BLoQ BLoQ Ae0–24 (mg) BLoQ BLoQ BLoQ BLoQ Fe0–12 (mg) BLoQ BLoQ BLoQ BLoQ Fe12–24 (mg) BLoQ BLoQ BLoQ BLoQ Fe0–24 (mg) BLoQ BLoQ BLoQ BLoQ CLR BLoQ BLoQ BLoQ BLoQ 11-COOH-THC Ae0–12 (mg) 0.002 (48.3)g 0.005 (58.3)e 0.006 (95.4)e 0.007 (114.6)h Ae12–24 (mg) 0.005 (218.2)d 0.004 (81.4)f 0.006 (110.2)e 0.001 (101.0)e Ae0–24 (mg) 0.003 (178.0)d 0.008 (81.6)e 0.010 (118.6) 0.004 (273.7) Fe0–12 0.000 (48.3)d 0.000 (58.3)e 0.000 (95.4)e 0.000 (114.6)h Fe12–24 0.001 (218.2)g 0.000 (81.4)f 0.002 (NE)e 1.2 (NE)e Fe0–24 0.001 (178.0)d 0.001 (81.6)e 0.001 (118.6) 0.000 (273.7) CLR (L/h) 0.003 (67.4)d 0.002 (77.0)e 0.001 (116.1)e 0.001 (202.3)h 7-COOH-CBD and 11-OH-THC were not measured in urine. Ae0–12 = amount of drug eliminated between 0 and 12 h, Ae12–24 = amount of drug eliminated between 12 and 24 h, Ae0–24 = amount of drug eliminated between 0 and 24 h, BLoQ = below limit of quantification, CLR = renal clearance, Fe0–12 = fraction of administered dose excreted in urine between 0 and 12 h, Fe12–24 = fraction of administered dose excreted in urine between 12 and 24 h, Fe12–24 = fraction of administered dose excreted in urine between 0 and 24 h, NE = not estimable. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. b Geometric mean (geometric mean CV%). c n = 1. d n = 2. e n = 7. f n = 6. g n = 4. h n = 5. Open in new tab CBD and metabolites On Day 1, after a single dose of study medication, CBD exposure showed dose proportionality; however, the wide CIs surrounding slope estimates indicate large variability in estimates (AUC0–t slope = 0.81 [0.32, 1.30]; Cmax slope = 0.62 [0.13, 1.12]). The Cmax for 7-OH-CBD increased by 2.5- and 1.3-fold with a doubling in dose between Treatments A and B and Treatments B and D, respectively. The AUC0–12 for 7-OH-CBD in Treatment A was not estimable; therefore, dose proportionality was undetermined. Exposure to 7-COOH-CBD approximately doubled to tripled with each 2-fold increase in dose, where Cmax increased by 2.6- and 2.3-fold, and AUC0–12 increased by 1.9- and 3.2-fold between Treatments A and B and Treatments B and D, respectively. The median tmax for CBD, 7-OH-CBD and 7-COOH-CBD ranged from 4 to 7 h across treatments. Ctrough data showed that steady-state plasma CBD concentrations were reached by Day 7 for all treatment groups (Treatment A: LSmean Day 5 [2.02 ng/mL] vs. remaining days [2.18 ng/mL] = −0.1, P = 0.51; Treatment B: LSmean Day 5 [4.32 ng/mL] vs. remaining days [4.32 ng/mL] = −0.006, P = 0.99; Treatment C: LSmean Day 6 [7.54 ng/mL] vs. Day 7 [7.65 ng/mL] = −0.11, P = 0.80; Treatment D: LSmean Day 6 [12.25 ng/mL] vs. Day 7 [11.78 ng/mL] = 0.47, P = 0.71) (also see Table III for mean pre-dose plasma CBD concentrations for Days 2–6). On Day 7, CBD exposure showed dose proportionality (AUC0–t slope = 1.03 [0.70, 1.36], Cmax slope = 0.92 [0.53, 1.31]). By Day 7, there was an almost doubling in exposure of 7-OH-CBD for a 2-fold increase in dose; the Cmax increased by 2.3- and 1.6-fold and the AUC0–12 increased by 2.0- and 1.9-fold between Treatments A and B and Treatments B and D, respectively. For 7-COOH-CBD, there was a tripling in exposure for each 2-fold increase in dose, where the Cmax increased by 2.6- and 3.0-fold, and the AUC0–12 increased by 2.8- and 2.9-fold between Treatments A and B and Treatments B and D, respectively. On Day 7, the median tmax of CBD and 7-OH-CBD ranged from 4 to 5 h, independent of dose, although for 7-COOH-CBD, the median tmax was halved from Treatment A to Treatments B, C and D from ∼8 to ∼4 h, respectively. On Day 7, the mean plasma terminal elimination half-life, t1/2, ranged from 4.7–5.8 to 4.4–5.4 h for CBD and 7-OH-CBD, respectively. Apparent clearance (CL/F) slightly decreased with increasing dose of CBD and 7-OH-CBD, while clearance of 7-COOH-CBD decreased more rapidly with increasing doses. On Day 7, compared with Day 1, the accumulation ratio based on AUC (Rac (AUC)) for CBD was 0.9- to 2.3-fold (except Rac (AUC) for Treatment C, which was below the limit of quantification [BLoQ]); for 7-OH-CBD, it was 2.0- to 2.6-fold (except Rac(AUC) for Treatment A, which was [BLoQ]) and for 7-COOH-CBD, it was 3.8- to 5.4-fold. On Day 7, 7-COOH-CBD was the major circulating product (23.9-, 36.8-, 45.6- and 44.7-fold higher than CBD for Treatments A, B, C, and D, respectively) followed by 7-OH-CBD (1.2-, 1.4-, 1.2- and 1.2-fold higher than CBD for Treatments A, B, C and D, respectively) and then parent CBD. On Day 7, urinary CBD was detected in one participant in Treatment B and two in Treatment C but was BLoQ for Treatments A and D. THC and metabolites All plasma concentrations for THC on Days 1 and 7 in Treatment A were BLoQ, and the majority of plasma concentrations for THC on Days 1 and 7 in Treatments B, C and D were BLoQ (Table V). Because no participant had more than two quantifiable concentrations of THC on either Day 1 or 7, PK parameters for THC were not calculated for any treatment group. No participant in any treatment group had more than two quantifiable concentrations of 11-OH-THC on Day 1, and no participant in Treatment A had more than two quantifiable concentrations of 11-OH-THC on Day 7. Table V. Summary of Plasma THC Concentrations (ng/mL) by Treatment Group (Pharmacokinetic Population) Timepoint . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . Day 1 Pre-dose 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 1 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.13 (0.35) 2 h 8 (8) 0 (0) 6 (8) 0.44 (0.93) 6 (7) 0.16 (0.42) 5 (6) 0.23 (0.65) 4 h 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.10 (0.28) 7 (7) 0 (0) 6 h 8 (8) 0 (0) 8 (8) 0 (0) 7 (7) 0 (0) 6 (6) 0 (0) 8 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 12 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (7) 0 (0) Day 7 Pre-dose 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 1 h 6 (6) 0 (0) 7 (8) 0.13 (0.35) 8 (8) 0 (0) 6 (7) 0.11 (0.30) 2 h 7 (7) 0 (0) 5 (8) 0.69 (1.01) 6 (8) 0.44 (0.90) 5 (8) 0.70 (1.05) 4 h 7 (7) 0 (0) 6 (7) 0.13 (0.34) 5 (7) 0.61 (1.31) 6 (8) 0.51 (1.05) 6 h 7 (7) 0 (0) 8 (8) 0 (0) 7 (8) 0.19 (0.53) 4 (7) 1.57 (2.76) 8 h 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.33 (0.92) 12 h 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) Timepoint . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . Day 1 Pre-dose 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 1 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.13 (0.35) 2 h 8 (8) 0 (0) 6 (8) 0.44 (0.93) 6 (7) 0.16 (0.42) 5 (6) 0.23 (0.65) 4 h 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.10 (0.28) 7 (7) 0 (0) 6 h 8 (8) 0 (0) 8 (8) 0 (0) 7 (7) 0 (0) 6 (6) 0 (0) 8 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 12 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (7) 0 (0) Day 7 Pre-dose 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 1 h 6 (6) 0 (0) 7 (8) 0.13 (0.35) 8 (8) 0 (0) 6 (7) 0.11 (0.30) 2 h 7 (7) 0 (0) 5 (8) 0.69 (1.01) 6 (8) 0.44 (0.90) 5 (8) 0.70 (1.05) 4 h 7 (7) 0 (0) 6 (7) 0.13 (0.34) 5 (7) 0.61 (1.31) 6 (8) 0.51 (1.05) 6 h 7 (7) 0 (0) 8 (8) 0 (0) 7 (8) 0.19 (0.53) 4 (7) 1.57 (2.76) 8 h 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.33 (0.92) 12 h 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) Timepoints are in relation to the morning dose. Concentrations that were BLQ were assigned as zero for analysis. n = number, BLoQ = below limit of quantitation; lower limit of quantification of THC is 0.78 ng/mL; SD = standard deviation. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. Open in new tab Table V. Summary of Plasma THC Concentrations (ng/mL) by Treatment Group (Pharmacokinetic Population) Timepoint . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . Day 1 Pre-dose 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 1 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.13 (0.35) 2 h 8 (8) 0 (0) 6 (8) 0.44 (0.93) 6 (7) 0.16 (0.42) 5 (6) 0.23 (0.65) 4 h 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.10 (0.28) 7 (7) 0 (0) 6 h 8 (8) 0 (0) 8 (8) 0 (0) 7 (7) 0 (0) 6 (6) 0 (0) 8 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 12 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (7) 0 (0) Day 7 Pre-dose 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 1 h 6 (6) 0 (0) 7 (8) 0.13 (0.35) 8 (8) 0 (0) 6 (7) 0.11 (0.30) 2 h 7 (7) 0 (0) 5 (8) 0.69 (1.01) 6 (8) 0.44 (0.90) 5 (8) 0.70 (1.05) 4 h 7 (7) 0 (0) 6 (7) 0.13 (0.34) 5 (7) 0.61 (1.31) 6 (8) 0.51 (1.05) 6 h 7 (7) 0 (0) 8 (8) 0 (0) 7 (8) 0.19 (0.53) 4 (7) 1.57 (2.76) 8 h 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.33 (0.92) 12 h 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) Timepoint . Treatment Aa (n = 8) . Treatment Ba (n = 8) . Treatment Ca (n = 8) . Treatment Da (n = 8) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . BLoQ (n) . Mean (SD) . Day 1 Pre-dose 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 1 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.13 (0.35) 2 h 8 (8) 0 (0) 6 (8) 0.44 (0.93) 6 (7) 0.16 (0.42) 5 (6) 0.23 (0.65) 4 h 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.10 (0.28) 7 (7) 0 (0) 6 h 8 (8) 0 (0) 8 (8) 0 (0) 7 (7) 0 (0) 6 (6) 0 (0) 8 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 12 h 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (7) 0 (0) Day 7 Pre-dose 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 1 h 6 (6) 0 (0) 7 (8) 0.13 (0.35) 8 (8) 0 (0) 6 (7) 0.11 (0.30) 2 h 7 (7) 0 (0) 5 (8) 0.69 (1.01) 6 (8) 0.44 (0.90) 5 (8) 0.70 (1.05) 4 h 7 (7) 0 (0) 6 (7) 0.13 (0.34) 5 (7) 0.61 (1.31) 6 (8) 0.51 (1.05) 6 h 7 (7) 0 (0) 8 (8) 0 (0) 7 (8) 0.19 (0.53) 4 (7) 1.57 (2.76) 8 h 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 7 (8) 0.33 (0.92) 12 h 7 (7) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) 8 (8) 0 (0) Timepoints are in relation to the morning dose. Concentrations that were BLQ were assigned as zero for analysis. n = number, BLoQ = below limit of quantitation; lower limit of quantification of THC is 0.78 ng/mL; SD = standard deviation. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. Open in new tab On Day 7, Cmax, tmax and AUC0–12 of 11-OH-THC for Treatments B, C and D appeared to be dose independent. On Day 1, 11-COOH-THC was readily detected in plasma with a median tmax of 4–6 h. On Day 7, 11-COOH-THC Cmax increased by 2.6- and 1.8-fold as the dose doubled between Treatments A and B and Treatments B and D, respectively. A similar apparent increase was observed for 11-COOH-THC AUC0–12 on Day 7, where it increased by 2.3- and 2.0-fold as the dose doubled between Treatments A and B and Treatments B and D, respectively. CL/F slightly decreased with increasing doses. On Day 7, the Rac (AUC) for 11-COOH-THC was 2.4–3.1-fold for all treatment groups. Urinary THC concentrations were BLoQ for all treatments at 0–12 and 12–24 h on Day 7. Pharmacodynamics Mean post-treatment peak ratings of most negative effects (dislike, bad effects, heart racing, anxious, paranoid, tired/drowsy, irritable, restless, dazed and distracted) were low on Days 1, 3 and 7 (Table VI). Mean post-treatment peak ratings of “restless” on Day 1 were higher for Treatment D relative to Treatments A, B and C; on Day 3, they were higher for Treatment D relative to Treatment A and on Day 7, they were higher for D relative to placebo and lower for A relative to B and D. Across treatment groups, the median time to post-treatment peak ratings of “restless” occurred at 4.5 h on Days 1 (Q1 = 1.7, Q3 = 8.7), 3 (Q1 = 1.8, Q3 = 8.4) and 7 (Q1 = 2.5, Q3 = 8.6). Mean post-treatment peak ratings of “distracted” on Day 1 were higher for Treatment D relative to placebo and Treatments A and B, and on Days 3 and 7, they were higher for Treatment D relative to B. Across treatment groups, the median time to post-treatment peak ratings of “distracted” occurred at 2.7 h (Q1 = 1.7, Q3 = 8.5) on Day 1, at 4.5 h on Day 3 (Q1 = 1.7, Q3 = 8.3) and at 3.4 h (Q1 = 1.6, Q3 = 6.5) on Day 7. Mean post-treatment peak ratings of other negative effects differed between active study medication and placebo (e.g., “bad effects” on Day 7) and between the three lower-dose treatment groups relative to the highest-dose treatment group (e.g., “dazed” on Day 1; “dislike the effects” on Day 3); however, these other between-group differences were not consistent across Days 1, 3 and 7. Mean post-treatment peak ratings of “take study product again” appeared to differ in Treatments A and B vs. placebo on Days 1 and 7; however, high mean pre-treatment ratings of this item on both days in Treatments A and B (e.g., on Day 7, Treatment A: M = 81.1, Treatment B: M = 70.8, placebo: M = 33.9) suggest that post-treatment between-group differences on this item may simply be due to high pre-treatment ratings in active vs. placebo treatment groups. Table VI. Mean Peak Post-treatment Value on Drug Effects Questionnaire (Intent-to-Treat Population) . Treatmenta . . Day 1 . Day 3 . DEQ, LSmean (SE) . Placebo (n = 8) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Placebo (n = 8) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Feelings 34.5 (9.6) 24.7 (9.0)b 32.4 (9.6) 41.4 (9.0) 51.2 (9.0)b 42.1 (9.6) 35.1 (9.0) 42.2 (9.6) 47.1 (9.0) 44.9 (9.0) Dislike 18.4 (6.9) 5.8 (6.5)b 12.3 (6.9) 15.4 (6.5) 30.9 (6.5)b 19.5 (6.9) 3.3 (6.5)b 5.0 (6.9)g 7.3 (6.5)f 26.4 (6.5)b,g,f Like 39.6 (10.2) 42.0 (9.6) 50.1 (10.2) 49.4 (9.6) 45.3 (9.6) 44.6 (10.2) 39.0 (9.9) 49.6 (10.2) 43.2 (9.6) 31.33 (9.6) Good effects 42.6 (10.9) 36.9 (10.3) 48.5 (10.9) 45.7 (10.3) 46.3 (10.3) 40.2 (10.9) 37.9 (10.2) 50.1 (10.9) 37.3 (10.2) 35.4 (10.2) Bad effects 19.5 (7.1) 8.3 (6.7) 11.5 (7.1) 14.4 (6.7) 27.0 (6.7) 22.4 (7.1) 8.9 (6.7)b 5.6 (7.1)g 9.4 (6.7) 28.1 (6.7)b,g Take study product again 43.0 (10.9)c,d 79.7 (10.3)d 78.3 (10.9)c 64.7 (10.3) 66.9 (10.5) 52.2 (10.9) 72.0 (10.3) 73.6 (10.9) 55.9 (10.3) 53.6 (10.3) Sick 22.0 (6.7)d 2.9 (6.3)d 7.4 (6.7) 9.8 (6.3) 20.3 (6.3) 22.0 (6.7)d 1.7 (6.3)d 7.6 (6.7) 7.3 (6.3) 7.3 (6.3) Heart racing 4.4 (3.7) 1.8 (3.5)b 5.5 (3.7) 1.4 (3.5)f 11.7 (3.5)b,f 5.7 (3.7) 3.7 (3.5) 3.2 (3.7) 1.8 (3.5) 7.4 (3.5) Anxious 15.4 (4.4)d 2.2 (4.2)b,d 4.5 (4.4)g 8.8 (4.2) 18.1 (4.2)b,g 8.0 (4.4) 4.01 (4.2) 3.5 (4.4) 4.9 (4.2) 14.0 (4.2) Relaxed 61.5 (9.1) 61.4 (8.6) 71.4 (9.1) 64.3 (8.6) 72.1 (8.6) 56.4 (9.1) 60.3 (8.6) 67.4 (9.1) 65.3 (8.6) 68.3 (8.6) Paranoid 9.5 (3.6) 4.0 (3.4) 1.4 (3.7)g 10.4 (3.4) 12.4 (3.4)g 9.4 (3.7) 1.9 (3.4)b 0.9 (3.7)g 3.9 (3.4) 12.4 (3.4)b,g Tired/drowsy 50.6 (9.0) 58.9 (8.5) 54.5 (9.0) 51.7 (8.5) 70.9 (8.5) 57.1 (9.0) 57.9 (8.7) 44.0 (9.0)g 51.8 (8.7) 72.4 (8.5)g Alert 39.7 (10.4) 41.9 (9.8) 30.9 (10.4) 44.4 (9.8) 42.2 (9.8) 37.7 (10.4) 33.7 (10.1) 30.5 (10.4) 38.4 (10.1) 21.6 (9.8) Irritable 3.3 (5.0) 3.8 (4.7) 3.6 (5.1) 11.7 (4.8) 16.3 (4.8) 15.4 (5.1) 9.1 (4.9) 3.1 (5.1) 6.4 (4.9) 12.22 (4.8) Energetic 40.1 (9.2) 34.8 (8.6) 39.1 (9.2) 32.1 (8.6) 37.9 (8.6) 45.1 (9.2) 30.5 (8.8) 31.5 (9.2) 37.6 (8.8) 33.9 (8.6) Restless 19.6 (7.2) 10.7 (6.8)b 16.6 (7.2)g 19.3 (6.8)f 40.2 (6.8)b,g,f 20.6 (7.2) 5.01 (7.2)b 14.7 (7.2) 21.0 (7.2) 33.2 (6.8)b Hungry 48.8 (10.6) 40.1 (10.0) 65.9 (10.6) 45.7 (10.0) 61.4 (10.0) 42.1 (10.6) 45.1 (10.4) 63.2 (10.6) 33.9 (10.4) 47.2 (10.0) Dazed 22.0 (9.2)i 20.8 (8.6)b 14.3 (9.2)g 25.2 (8.6)f 57.8 (8.6)b,f,g,i 29.4 (9.1) 27.3 (8.8)b 12.9 (9.1)g 31.7 (8.8) 53.9 (8.6)b,g Distracted 14.0 (8.0)i 18.6 (7.5)b 11.0 (8.0)g 30.0 (7.5) 45.9 (7.5)b,g,i 19.4 (8.0) 24.5 (7.7) 3.0 (8.0)g 23.4 (7.7) 38.9 (7.5)g Euphoric/happy 39.0 (10.3) 37.8 (9.7) 51.6 (10.3) 50.8 (9.7) 59.3 (9.7) 36.7 (10.3) 34.2 (9.7) 43.2 (10.3) 46.3 (9.7) 51.6 (9.7) Feelings 30.8 (9.6) 23.9 (9.4) 41.4 (9.6) 48.2 (9.4) 41.1 (9.4) Dislike 23.6 (6.9)c 14.2 (6.9) 1.8 (6.9)c 13.8 (6.9) 19.9 (6.9) Like 33.4 (10.2) 42.1 (9.9) 43.1 (10.2) 42.8 (9.9) 30.9 (9.9) Good effects 31.9 (10.9) 37.7 (10.5) 44.4 (10.9) 41.1 (10.5) 31.4 (10.5) Bad effects 23.3 (7.1)c 11.4 (7.0) 1.0 (7.1)c 13.4 (7.0) 19.5 (7.0) Take study product again 45.0 (10.9)c,d 85.0 (10.5)d,e 76.3 (10.9)c 49.5 (10.5)e 63.7 (10.5) Sick 19.6 (6.7) 11.5 (6.6) 0.9 (6.7) 4.1 (6.6) 12.1 (6.6) Heart racing 9.8 (3.7) 1.6 (3.7) 0.9 (3.7) 5.6 (3.7) 5.6 (3.7) Anxious 8.1 (4.4) 2.3 (4.4) 1.8 (4.4) 5.8 (4.4) 5.8 (4.4) Relaxed 53.1 (9.1) 59.5 (8.9) 59.5 (9.1) 55.9 (8.9) 67.8 (8.9) Paranoid 3.5 (3.7) 3.1 (3.6) 2.0 (3.7) 3.1 (3.6) 3.7 (3.6) Tired/drowsy 43.8 (9.00) 62.0 (8.8) 41.6 (9.0) 46.9 (8.8) 60.0 (8.8) Alert 36.8 (10.42) 41.2 (10.1) 26.8 (10.4) 37.7 (10.1) 28.6 (10.1) Irritable 11.0 (5.1) 7.5 (4.9) 9.6 (5.1) 9.3 (4.9) 20.4 (4.9) Energetic 39.8 (9.2) 35.1 (8.8) 22.1 (9.2) 29.0 (8.8) 41.5 (8.8) Restless 15.6 (7.2)i 4.2 (7.2)b,h 28.8 (7.3)h 21.9 (7.2) 38.2 (7.2)b,i Hungry 46.3 (10.6) 46.4 (10.4) 49.5 (10.6) 42.9 (10.4) 58.3 (10.4) Dazed 20.4 (9.2) 22.1 (8.8) 12.0 (9.2)g,j 37.5 (8.8)j 43.7 (8.8)g Distracted 14.9 (8.0) 24.5 (7.7) 10.4 (8.00)g 30.8 (7.7) 40.9 (7.7)g Euphoric/happy 35.0 (10.3) 36.2 (9.9) 47.9 (10.3) 47.6 (9.9) 56.0 (9.9) . Treatmenta . . Day 1 . Day 3 . DEQ, LSmean (SE) . Placebo (n = 8) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Placebo (n = 8) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Feelings 34.5 (9.6) 24.7 (9.0)b 32.4 (9.6) 41.4 (9.0) 51.2 (9.0)b 42.1 (9.6) 35.1 (9.0) 42.2 (9.6) 47.1 (9.0) 44.9 (9.0) Dislike 18.4 (6.9) 5.8 (6.5)b 12.3 (6.9) 15.4 (6.5) 30.9 (6.5)b 19.5 (6.9) 3.3 (6.5)b 5.0 (6.9)g 7.3 (6.5)f 26.4 (6.5)b,g,f Like 39.6 (10.2) 42.0 (9.6) 50.1 (10.2) 49.4 (9.6) 45.3 (9.6) 44.6 (10.2) 39.0 (9.9) 49.6 (10.2) 43.2 (9.6) 31.33 (9.6) Good effects 42.6 (10.9) 36.9 (10.3) 48.5 (10.9) 45.7 (10.3) 46.3 (10.3) 40.2 (10.9) 37.9 (10.2) 50.1 (10.9) 37.3 (10.2) 35.4 (10.2) Bad effects 19.5 (7.1) 8.3 (6.7) 11.5 (7.1) 14.4 (6.7) 27.0 (6.7) 22.4 (7.1) 8.9 (6.7)b 5.6 (7.1)g 9.4 (6.7) 28.1 (6.7)b,g Take study product again 43.0 (10.9)c,d 79.7 (10.3)d 78.3 (10.9)c 64.7 (10.3) 66.9 (10.5) 52.2 (10.9) 72.0 (10.3) 73.6 (10.9) 55.9 (10.3) 53.6 (10.3) Sick 22.0 (6.7)d 2.9 (6.3)d 7.4 (6.7) 9.8 (6.3) 20.3 (6.3) 22.0 (6.7)d 1.7 (6.3)d 7.6 (6.7) 7.3 (6.3) 7.3 (6.3) Heart racing 4.4 (3.7) 1.8 (3.5)b 5.5 (3.7) 1.4 (3.5)f 11.7 (3.5)b,f 5.7 (3.7) 3.7 (3.5) 3.2 (3.7) 1.8 (3.5) 7.4 (3.5) Anxious 15.4 (4.4)d 2.2 (4.2)b,d 4.5 (4.4)g 8.8 (4.2) 18.1 (4.2)b,g 8.0 (4.4) 4.01 (4.2) 3.5 (4.4) 4.9 (4.2) 14.0 (4.2) Relaxed 61.5 (9.1) 61.4 (8.6) 71.4 (9.1) 64.3 (8.6) 72.1 (8.6) 56.4 (9.1) 60.3 (8.6) 67.4 (9.1) 65.3 (8.6) 68.3 (8.6) Paranoid 9.5 (3.6) 4.0 (3.4) 1.4 (3.7)g 10.4 (3.4) 12.4 (3.4)g 9.4 (3.7) 1.9 (3.4)b 0.9 (3.7)g 3.9 (3.4) 12.4 (3.4)b,g Tired/drowsy 50.6 (9.0) 58.9 (8.5) 54.5 (9.0) 51.7 (8.5) 70.9 (8.5) 57.1 (9.0) 57.9 (8.7) 44.0 (9.0)g 51.8 (8.7) 72.4 (8.5)g Alert 39.7 (10.4) 41.9 (9.8) 30.9 (10.4) 44.4 (9.8) 42.2 (9.8) 37.7 (10.4) 33.7 (10.1) 30.5 (10.4) 38.4 (10.1) 21.6 (9.8) Irritable 3.3 (5.0) 3.8 (4.7) 3.6 (5.1) 11.7 (4.8) 16.3 (4.8) 15.4 (5.1) 9.1 (4.9) 3.1 (5.1) 6.4 (4.9) 12.22 (4.8) Energetic 40.1 (9.2) 34.8 (8.6) 39.1 (9.2) 32.1 (8.6) 37.9 (8.6) 45.1 (9.2) 30.5 (8.8) 31.5 (9.2) 37.6 (8.8) 33.9 (8.6) Restless 19.6 (7.2) 10.7 (6.8)b 16.6 (7.2)g 19.3 (6.8)f 40.2 (6.8)b,g,f 20.6 (7.2) 5.01 (7.2)b 14.7 (7.2) 21.0 (7.2) 33.2 (6.8)b Hungry 48.8 (10.6) 40.1 (10.0) 65.9 (10.6) 45.7 (10.0) 61.4 (10.0) 42.1 (10.6) 45.1 (10.4) 63.2 (10.6) 33.9 (10.4) 47.2 (10.0) Dazed 22.0 (9.2)i 20.8 (8.6)b 14.3 (9.2)g 25.2 (8.6)f 57.8 (8.6)b,f,g,i 29.4 (9.1) 27.3 (8.8)b 12.9 (9.1)g 31.7 (8.8) 53.9 (8.6)b,g Distracted 14.0 (8.0)i 18.6 (7.5)b 11.0 (8.0)g 30.0 (7.5) 45.9 (7.5)b,g,i 19.4 (8.0) 24.5 (7.7) 3.0 (8.0)g 23.4 (7.7) 38.9 (7.5)g Euphoric/happy 39.0 (10.3) 37.8 (9.7) 51.6 (10.3) 50.8 (9.7) 59.3 (9.7) 36.7 (10.3) 34.2 (9.7) 43.2 (10.3) 46.3 (9.7) 51.6 (9.7) Feelings 30.8 (9.6) 23.9 (9.4) 41.4 (9.6) 48.2 (9.4) 41.1 (9.4) Dislike 23.6 (6.9)c 14.2 (6.9) 1.8 (6.9)c 13.8 (6.9) 19.9 (6.9) Like 33.4 (10.2) 42.1 (9.9) 43.1 (10.2) 42.8 (9.9) 30.9 (9.9) Good effects 31.9 (10.9) 37.7 (10.5) 44.4 (10.9) 41.1 (10.5) 31.4 (10.5) Bad effects 23.3 (7.1)c 11.4 (7.0) 1.0 (7.1)c 13.4 (7.0) 19.5 (7.0) Take study product again 45.0 (10.9)c,d 85.0 (10.5)d,e 76.3 (10.9)c 49.5 (10.5)e 63.7 (10.5) Sick 19.6 (6.7) 11.5 (6.6) 0.9 (6.7) 4.1 (6.6) 12.1 (6.6) Heart racing 9.8 (3.7) 1.6 (3.7) 0.9 (3.7) 5.6 (3.7) 5.6 (3.7) Anxious 8.1 (4.4) 2.3 (4.4) 1.8 (4.4) 5.8 (4.4) 5.8 (4.4) Relaxed 53.1 (9.1) 59.5 (8.9) 59.5 (9.1) 55.9 (8.9) 67.8 (8.9) Paranoid 3.5 (3.7) 3.1 (3.6) 2.0 (3.7) 3.1 (3.6) 3.7 (3.6) Tired/drowsy 43.8 (9.00) 62.0 (8.8) 41.6 (9.0) 46.9 (8.8) 60.0 (8.8) Alert 36.8 (10.42) 41.2 (10.1) 26.8 (10.4) 37.7 (10.1) 28.6 (10.1) Irritable 11.0 (5.1) 7.5 (4.9) 9.6 (5.1) 9.3 (4.9) 20.4 (4.9) Energetic 39.8 (9.2) 35.1 (8.8) 22.1 (9.2) 29.0 (8.8) 41.5 (8.8) Restless 15.6 (7.2)i 4.2 (7.2)b,h 28.8 (7.3)h 21.9 (7.2) 38.2 (7.2)b,i Hungry 46.3 (10.6) 46.4 (10.4) 49.5 (10.6) 42.9 (10.4) 58.3 (10.4) Dazed 20.4 (9.2) 22.1 (8.8) 12.0 (9.2)g,j 37.5 (8.8)j 43.7 (8.8)g Distracted 14.9 (8.0) 24.5 (7.7) 10.4 (8.00)g 30.8 (7.7) 40.9 (7.7)g Euphoric/happy 35.0 (10.3) 36.2 (9.9) 47.9 (10.3) 47.6 (9.9) 56.0 (9.9) Items were rated on a 100-point visual analog scale. DEQ = Drug Effects Questionnaire, LSmean = least square mean, SE = standard error. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. b A vs. D (P < 0.05). c B vs. placebo (P < 0.05). d A vs. placebo (P < 0.05). e A vs. C (P < 0.05). f C vs. D (P < 0.05). g B vs. D (P < 0.05). h A vs. B (P < 0.05). i D vs. placebo (P < 0.05). j B vs. C (P < 0.05). Open in new tab Table VI. Mean Peak Post-treatment Value on Drug Effects Questionnaire (Intent-to-Treat Population) . Treatmenta . . Day 1 . Day 3 . DEQ, LSmean (SE) . Placebo (n = 8) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Placebo (n = 8) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Feelings 34.5 (9.6) 24.7 (9.0)b 32.4 (9.6) 41.4 (9.0) 51.2 (9.0)b 42.1 (9.6) 35.1 (9.0) 42.2 (9.6) 47.1 (9.0) 44.9 (9.0) Dislike 18.4 (6.9) 5.8 (6.5)b 12.3 (6.9) 15.4 (6.5) 30.9 (6.5)b 19.5 (6.9) 3.3 (6.5)b 5.0 (6.9)g 7.3 (6.5)f 26.4 (6.5)b,g,f Like 39.6 (10.2) 42.0 (9.6) 50.1 (10.2) 49.4 (9.6) 45.3 (9.6) 44.6 (10.2) 39.0 (9.9) 49.6 (10.2) 43.2 (9.6) 31.33 (9.6) Good effects 42.6 (10.9) 36.9 (10.3) 48.5 (10.9) 45.7 (10.3) 46.3 (10.3) 40.2 (10.9) 37.9 (10.2) 50.1 (10.9) 37.3 (10.2) 35.4 (10.2) Bad effects 19.5 (7.1) 8.3 (6.7) 11.5 (7.1) 14.4 (6.7) 27.0 (6.7) 22.4 (7.1) 8.9 (6.7)b 5.6 (7.1)g 9.4 (6.7) 28.1 (6.7)b,g Take study product again 43.0 (10.9)c,d 79.7 (10.3)d 78.3 (10.9)c 64.7 (10.3) 66.9 (10.5) 52.2 (10.9) 72.0 (10.3) 73.6 (10.9) 55.9 (10.3) 53.6 (10.3) Sick 22.0 (6.7)d 2.9 (6.3)d 7.4 (6.7) 9.8 (6.3) 20.3 (6.3) 22.0 (6.7)d 1.7 (6.3)d 7.6 (6.7) 7.3 (6.3) 7.3 (6.3) Heart racing 4.4 (3.7) 1.8 (3.5)b 5.5 (3.7) 1.4 (3.5)f 11.7 (3.5)b,f 5.7 (3.7) 3.7 (3.5) 3.2 (3.7) 1.8 (3.5) 7.4 (3.5) Anxious 15.4 (4.4)d 2.2 (4.2)b,d 4.5 (4.4)g 8.8 (4.2) 18.1 (4.2)b,g 8.0 (4.4) 4.01 (4.2) 3.5 (4.4) 4.9 (4.2) 14.0 (4.2) Relaxed 61.5 (9.1) 61.4 (8.6) 71.4 (9.1) 64.3 (8.6) 72.1 (8.6) 56.4 (9.1) 60.3 (8.6) 67.4 (9.1) 65.3 (8.6) 68.3 (8.6) Paranoid 9.5 (3.6) 4.0 (3.4) 1.4 (3.7)g 10.4 (3.4) 12.4 (3.4)g 9.4 (3.7) 1.9 (3.4)b 0.9 (3.7)g 3.9 (3.4) 12.4 (3.4)b,g Tired/drowsy 50.6 (9.0) 58.9 (8.5) 54.5 (9.0) 51.7 (8.5) 70.9 (8.5) 57.1 (9.0) 57.9 (8.7) 44.0 (9.0)g 51.8 (8.7) 72.4 (8.5)g Alert 39.7 (10.4) 41.9 (9.8) 30.9 (10.4) 44.4 (9.8) 42.2 (9.8) 37.7 (10.4) 33.7 (10.1) 30.5 (10.4) 38.4 (10.1) 21.6 (9.8) Irritable 3.3 (5.0) 3.8 (4.7) 3.6 (5.1) 11.7 (4.8) 16.3 (4.8) 15.4 (5.1) 9.1 (4.9) 3.1 (5.1) 6.4 (4.9) 12.22 (4.8) Energetic 40.1 (9.2) 34.8 (8.6) 39.1 (9.2) 32.1 (8.6) 37.9 (8.6) 45.1 (9.2) 30.5 (8.8) 31.5 (9.2) 37.6 (8.8) 33.9 (8.6) Restless 19.6 (7.2) 10.7 (6.8)b 16.6 (7.2)g 19.3 (6.8)f 40.2 (6.8)b,g,f 20.6 (7.2) 5.01 (7.2)b 14.7 (7.2) 21.0 (7.2) 33.2 (6.8)b Hungry 48.8 (10.6) 40.1 (10.0) 65.9 (10.6) 45.7 (10.0) 61.4 (10.0) 42.1 (10.6) 45.1 (10.4) 63.2 (10.6) 33.9 (10.4) 47.2 (10.0) Dazed 22.0 (9.2)i 20.8 (8.6)b 14.3 (9.2)g 25.2 (8.6)f 57.8 (8.6)b,f,g,i 29.4 (9.1) 27.3 (8.8)b 12.9 (9.1)g 31.7 (8.8) 53.9 (8.6)b,g Distracted 14.0 (8.0)i 18.6 (7.5)b 11.0 (8.0)g 30.0 (7.5) 45.9 (7.5)b,g,i 19.4 (8.0) 24.5 (7.7) 3.0 (8.0)g 23.4 (7.7) 38.9 (7.5)g Euphoric/happy 39.0 (10.3) 37.8 (9.7) 51.6 (10.3) 50.8 (9.7) 59.3 (9.7) 36.7 (10.3) 34.2 (9.7) 43.2 (10.3) 46.3 (9.7) 51.6 (9.7) Feelings 30.8 (9.6) 23.9 (9.4) 41.4 (9.6) 48.2 (9.4) 41.1 (9.4) Dislike 23.6 (6.9)c 14.2 (6.9) 1.8 (6.9)c 13.8 (6.9) 19.9 (6.9) Like 33.4 (10.2) 42.1 (9.9) 43.1 (10.2) 42.8 (9.9) 30.9 (9.9) Good effects 31.9 (10.9) 37.7 (10.5) 44.4 (10.9) 41.1 (10.5) 31.4 (10.5) Bad effects 23.3 (7.1)c 11.4 (7.0) 1.0 (7.1)c 13.4 (7.0) 19.5 (7.0) Take study product again 45.0 (10.9)c,d 85.0 (10.5)d,e 76.3 (10.9)c 49.5 (10.5)e 63.7 (10.5) Sick 19.6 (6.7) 11.5 (6.6) 0.9 (6.7) 4.1 (6.6) 12.1 (6.6) Heart racing 9.8 (3.7) 1.6 (3.7) 0.9 (3.7) 5.6 (3.7) 5.6 (3.7) Anxious 8.1 (4.4) 2.3 (4.4) 1.8 (4.4) 5.8 (4.4) 5.8 (4.4) Relaxed 53.1 (9.1) 59.5 (8.9) 59.5 (9.1) 55.9 (8.9) 67.8 (8.9) Paranoid 3.5 (3.7) 3.1 (3.6) 2.0 (3.7) 3.1 (3.6) 3.7 (3.6) Tired/drowsy 43.8 (9.00) 62.0 (8.8) 41.6 (9.0) 46.9 (8.8) 60.0 (8.8) Alert 36.8 (10.42) 41.2 (10.1) 26.8 (10.4) 37.7 (10.1) 28.6 (10.1) Irritable 11.0 (5.1) 7.5 (4.9) 9.6 (5.1) 9.3 (4.9) 20.4 (4.9) Energetic 39.8 (9.2) 35.1 (8.8) 22.1 (9.2) 29.0 (8.8) 41.5 (8.8) Restless 15.6 (7.2)i 4.2 (7.2)b,h 28.8 (7.3)h 21.9 (7.2) 38.2 (7.2)b,i Hungry 46.3 (10.6) 46.4 (10.4) 49.5 (10.6) 42.9 (10.4) 58.3 (10.4) Dazed 20.4 (9.2) 22.1 (8.8) 12.0 (9.2)g,j 37.5 (8.8)j 43.7 (8.8)g Distracted 14.9 (8.0) 24.5 (7.7) 10.4 (8.00)g 30.8 (7.7) 40.9 (7.7)g Euphoric/happy 35.0 (10.3) 36.2 (9.9) 47.9 (10.3) 47.6 (9.9) 56.0 (9.9) . Treatmenta . . Day 1 . Day 3 . DEQ, LSmean (SE) . Placebo (n = 8) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Placebo (n = 8) . A (n = 9) . B (n = 8) . C (n = 9) . D (n = 9) . Feelings 34.5 (9.6) 24.7 (9.0)b 32.4 (9.6) 41.4 (9.0) 51.2 (9.0)b 42.1 (9.6) 35.1 (9.0) 42.2 (9.6) 47.1 (9.0) 44.9 (9.0) Dislike 18.4 (6.9) 5.8 (6.5)b 12.3 (6.9) 15.4 (6.5) 30.9 (6.5)b 19.5 (6.9) 3.3 (6.5)b 5.0 (6.9)g 7.3 (6.5)f 26.4 (6.5)b,g,f Like 39.6 (10.2) 42.0 (9.6) 50.1 (10.2) 49.4 (9.6) 45.3 (9.6) 44.6 (10.2) 39.0 (9.9) 49.6 (10.2) 43.2 (9.6) 31.33 (9.6) Good effects 42.6 (10.9) 36.9 (10.3) 48.5 (10.9) 45.7 (10.3) 46.3 (10.3) 40.2 (10.9) 37.9 (10.2) 50.1 (10.9) 37.3 (10.2) 35.4 (10.2) Bad effects 19.5 (7.1) 8.3 (6.7) 11.5 (7.1) 14.4 (6.7) 27.0 (6.7) 22.4 (7.1) 8.9 (6.7)b 5.6 (7.1)g 9.4 (6.7) 28.1 (6.7)b,g Take study product again 43.0 (10.9)c,d 79.7 (10.3)d 78.3 (10.9)c 64.7 (10.3) 66.9 (10.5) 52.2 (10.9) 72.0 (10.3) 73.6 (10.9) 55.9 (10.3) 53.6 (10.3) Sick 22.0 (6.7)d 2.9 (6.3)d 7.4 (6.7) 9.8 (6.3) 20.3 (6.3) 22.0 (6.7)d 1.7 (6.3)d 7.6 (6.7) 7.3 (6.3) 7.3 (6.3) Heart racing 4.4 (3.7) 1.8 (3.5)b 5.5 (3.7) 1.4 (3.5)f 11.7 (3.5)b,f 5.7 (3.7) 3.7 (3.5) 3.2 (3.7) 1.8 (3.5) 7.4 (3.5) Anxious 15.4 (4.4)d 2.2 (4.2)b,d 4.5 (4.4)g 8.8 (4.2) 18.1 (4.2)b,g 8.0 (4.4) 4.01 (4.2) 3.5 (4.4) 4.9 (4.2) 14.0 (4.2) Relaxed 61.5 (9.1) 61.4 (8.6) 71.4 (9.1) 64.3 (8.6) 72.1 (8.6) 56.4 (9.1) 60.3 (8.6) 67.4 (9.1) 65.3 (8.6) 68.3 (8.6) Paranoid 9.5 (3.6) 4.0 (3.4) 1.4 (3.7)g 10.4 (3.4) 12.4 (3.4)g 9.4 (3.7) 1.9 (3.4)b 0.9 (3.7)g 3.9 (3.4) 12.4 (3.4)b,g Tired/drowsy 50.6 (9.0) 58.9 (8.5) 54.5 (9.0) 51.7 (8.5) 70.9 (8.5) 57.1 (9.0) 57.9 (8.7) 44.0 (9.0)g 51.8 (8.7) 72.4 (8.5)g Alert 39.7 (10.4) 41.9 (9.8) 30.9 (10.4) 44.4 (9.8) 42.2 (9.8) 37.7 (10.4) 33.7 (10.1) 30.5 (10.4) 38.4 (10.1) 21.6 (9.8) Irritable 3.3 (5.0) 3.8 (4.7) 3.6 (5.1) 11.7 (4.8) 16.3 (4.8) 15.4 (5.1) 9.1 (4.9) 3.1 (5.1) 6.4 (4.9) 12.22 (4.8) Energetic 40.1 (9.2) 34.8 (8.6) 39.1 (9.2) 32.1 (8.6) 37.9 (8.6) 45.1 (9.2) 30.5 (8.8) 31.5 (9.2) 37.6 (8.8) 33.9 (8.6) Restless 19.6 (7.2) 10.7 (6.8)b 16.6 (7.2)g 19.3 (6.8)f 40.2 (6.8)b,g,f 20.6 (7.2) 5.01 (7.2)b 14.7 (7.2) 21.0 (7.2) 33.2 (6.8)b Hungry 48.8 (10.6) 40.1 (10.0) 65.9 (10.6) 45.7 (10.0) 61.4 (10.0) 42.1 (10.6) 45.1 (10.4) 63.2 (10.6) 33.9 (10.4) 47.2 (10.0) Dazed 22.0 (9.2)i 20.8 (8.6)b 14.3 (9.2)g 25.2 (8.6)f 57.8 (8.6)b,f,g,i 29.4 (9.1) 27.3 (8.8)b 12.9 (9.1)g 31.7 (8.8) 53.9 (8.6)b,g Distracted 14.0 (8.0)i 18.6 (7.5)b 11.0 (8.0)g 30.0 (7.5) 45.9 (7.5)b,g,i 19.4 (8.0) 24.5 (7.7) 3.0 (8.0)g 23.4 (7.7) 38.9 (7.5)g Euphoric/happy 39.0 (10.3) 37.8 (9.7) 51.6 (10.3) 50.8 (9.7) 59.3 (9.7) 36.7 (10.3) 34.2 (9.7) 43.2 (10.3) 46.3 (9.7) 51.6 (9.7) Feelings 30.8 (9.6) 23.9 (9.4) 41.4 (9.6) 48.2 (9.4) 41.1 (9.4) Dislike 23.6 (6.9)c 14.2 (6.9) 1.8 (6.9)c 13.8 (6.9) 19.9 (6.9) Like 33.4 (10.2) 42.1 (9.9) 43.1 (10.2) 42.8 (9.9) 30.9 (9.9) Good effects 31.9 (10.9) 37.7 (10.5) 44.4 (10.9) 41.1 (10.5) 31.4 (10.5) Bad effects 23.3 (7.1)c 11.4 (7.0) 1.0 (7.1)c 13.4 (7.0) 19.5 (7.0) Take study product again 45.0 (10.9)c,d 85.0 (10.5)d,e 76.3 (10.9)c 49.5 (10.5)e 63.7 (10.5) Sick 19.6 (6.7) 11.5 (6.6) 0.9 (6.7) 4.1 (6.6) 12.1 (6.6) Heart racing 9.8 (3.7) 1.6 (3.7) 0.9 (3.7) 5.6 (3.7) 5.6 (3.7) Anxious 8.1 (4.4) 2.3 (4.4) 1.8 (4.4) 5.8 (4.4) 5.8 (4.4) Relaxed 53.1 (9.1) 59.5 (8.9) 59.5 (9.1) 55.9 (8.9) 67.8 (8.9) Paranoid 3.5 (3.7) 3.1 (3.6) 2.0 (3.7) 3.1 (3.6) 3.7 (3.6) Tired/drowsy 43.8 (9.00) 62.0 (8.8) 41.6 (9.0) 46.9 (8.8) 60.0 (8.8) Alert 36.8 (10.42) 41.2 (10.1) 26.8 (10.4) 37.7 (10.1) 28.6 (10.1) Irritable 11.0 (5.1) 7.5 (4.9) 9.6 (5.1) 9.3 (4.9) 20.4 (4.9) Energetic 39.8 (9.2) 35.1 (8.8) 22.1 (9.2) 29.0 (8.8) 41.5 (8.8) Restless 15.6 (7.2)i 4.2 (7.2)b,h 28.8 (7.3)h 21.9 (7.2) 38.2 (7.2)b,i Hungry 46.3 (10.6) 46.4 (10.4) 49.5 (10.6) 42.9 (10.4) 58.3 (10.4) Dazed 20.4 (9.2) 22.1 (8.8) 12.0 (9.2)g,j 37.5 (8.8)j 43.7 (8.8)g Distracted 14.9 (8.0) 24.5 (7.7) 10.4 (8.00)g 30.8 (7.7) 40.9 (7.7)g Euphoric/happy 35.0 (10.3) 36.2 (9.9) 47.9 (10.3) 47.6 (9.9) 56.0 (9.9) Items were rated on a 100-point visual analog scale. DEQ = Drug Effects Questionnaire, LSmean = least square mean, SE = standard error. a Treatment A: 120 mg total CBD and 5.4 mg THC daily; B: 240 mg total CBD and 10.8 mg total THC daily; C: 360 mg total CBD and 16.2 mg total THC daily; D: 480 mg total CBD and 21.6 mg total THC daily. b A vs. D (P < 0.05). c B vs. placebo (P < 0.05). d A vs. placebo (P < 0.05). e A vs. C (P < 0.05). f C vs. D (P < 0.05). g B vs. D (P < 0.05). h A vs. B (P < 0.05). i D vs. placebo (P < 0.05). j B vs. C (P < 0.05). Open in new tab Urine drug screens At least one participant in each treatment group had a positive urine drug screen for 11-COOH-THC through 72 h after the final dose of study medication (Figure 3). One participant in Treatment B, and two participants in Treatment D had a positive urine drug screen for 11-COOH-THC 144 h after the final dose. Figure 3. Open in new tabDownload slide Percentage of urine drug screens positive for 11-carboxy-tetrahydrocannabinol (11-COOH-THC) (>50 ng/mL) in each treatment group. Treatment A: 120 mg total CBD and 5.4 mg THC daily (n = 8); B: 240 mg total CBD and 10.8 mg total THC daily (n = 8); C: 360 mg total CBD and 16.2 mg total THC daily (n = 8); D: 480 mg total CBD and 21.6 mg total THC daily (n = 8). Figure 3. Open in new tabDownload slide Percentage of urine drug screens positive for 11-carboxy-tetrahydrocannabinol (11-COOH-THC) (>50 ng/mL) in each treatment group. Treatment A: 120 mg total CBD and 5.4 mg THC daily (n = 8); B: 240 mg total CBD and 10.8 mg total THC daily (n = 8); C: 360 mg total CBD and 16.2 mg total THC daily (n = 8); D: 480 mg total CBD and 21.6 mg total THC daily (n = 8). Discussion Safety and tolerability Given that almost all TEAEs were mild or moderate in severity and there were no SAEs, doses of Spectrum Yellow oil ranging from 120 mg CBD and 5.4 mg THC to 480 mg CBD and 21.6 mg THC were well-tolerated. Fewer AEs were reported on Days 2 through 13 relative to Day 1, indicating increased tolerability with repeated dosing. Notably, 3 of the 43 enrolled participants (7%) discontinued study treatment for TEAEs definitely or possibly related to treatment. The finding that CBD and THC were well-tolerated is consistent with conclusions of systematic reviews of medical cannabis and cannabinoids (22) and of CBD (5). The most frequently reported TEAEs of dizziness, presyncope, insomnia, abdominal pain and diarrhea are similar to the TEAEs reported in studies of approved cannabinoid pharmaceutical products (Marinol®, Sativex® and Epidiolex®) (23–25). Participants in Treatments C and D reported the highest incidence of TEAEs, suggesting dose dependence in the incidence of TEAEs. Some TEAEs associated with Epidiolex® appear to similarly be dose-dependent (4), but other approved cannabinoid pharmaceutical products have not reported on the dose dependence of TEAEs. Pharmacokinetics After both single and multiple doses of Spectrum Yellow oil, CBD exposure showed dose proportionality; steady-state conditions were achieved within 7 days. After 7 days of dosing, there was no to moderate accumulation of CBD, moderate accumulation for 7-OH-CBD and 11-COOH-THC and higher accumulation for 7-COOH-CBD; a multiple-dose PK study of Epidiolex® also reported higher accumulation of 7-COOH-CBD than accumulation of CBD and 7-OH-CBD (23). 7-COOH-CBD is not pharmacologically active and has not shown an anticonvulsant effect in mice (26). The majority of plasma THC concentrations were below the limit of quantification of 0.78 ng/mL. Plasma concentrations of CBD, THC and metabolites were lower in this study than has been reported in systematic reviews of the PK profiles of oral CBD (5) and THC (27). Although participants in this study consumed study medication 1 h after a meal, higher-fat content foods in the pre-dose meals could have improved PK profiles, as high-fat food increases CBD and THC exposure by as much as 3–5 times relative to fasted conditions (e.g., 28, 29). Nonetheless, the notable percentage of urine drug screens positive for 11-COOH-THC through 144 h after the final dose of Spectrum Yellow oil suggests accumulation of THC and metabolites in tissues and relatively slow urinary excretion. Overall, our results are consistent with the prevailing notion that oral delivery of cannabinoids is characterized by low and variable absorption. Because previous PK studies have examined cannabinoid formulations with a 1:1 or 2:1 ratio of THC to CBD, additional research is needed to further explore the impact of high levels of CBD concomitantly administered with low levels of THC, such as those studied here, on bioavailability. Pharmacodynamics Across Days 1 and 7, there were no consistent differences in subjective effects between placebo and Spectrum Yellow oil. There were no between-group differences on items that typically indicate abuse liability, such as “like the effects” and “good effects,” and the magnitude of post-treatment peak ratings of negative effects was low. Negative subjective effects in the two lower-dose treatment groups did not differ from those in the placebo group, and there were some differences in negative effects between the three lower-dose treatment groups relative to the highest-dose treatment group, such as on items of “restless” and “distracted,” which generally peaked 2.5–4.5 h post-treatment. The lack of between-group differences in subjective effects may be because subjective effects are typically observed at higher doses of THC and CBD (14, 16, 30). However, the small number of participants in each group and the wide variability surrounding estimates of between-group differences suggest that PD results should be interpreted with caution. Clinical implications Taken together, these safety, tolerability, PK and PD data support a “start low and go slow” approach, with initial doses of Spectrum Yellow oil similar to those in Treatments A and B and titration upward over time based on tolerability. However, research with individuals with various medical conditions is needed before formal condition-specific dosing guidelines can be promulgated. Individuals who elect to use Spectrum Yellow oil for medical purposes may consider the duration for which urine drug screens showed positive (>50 ng/mL) results for 11-COOH-THC at the studied THC total daily doses ranging from 5.4 to 21.6 mg, as urine drug screens could be used to evaluate driving or workplace impairment. Trial limitations This trial is limited by its focus on healthy adults; future studies are needed to characterize Spectrum Yellow oil in patient populations. Sample sizes in each treatment group were small, yielding imprecise estimates of dose proportionality and between-group differences in PD. The measure of PD was designed for substances with abuse potential, not for non-intoxicating substances such as CBD. Conclusion Over a week of twice-daily dosing, daily doses of CBD up to 480 mg and of THC up to 21.6 mg were generally safe and became better tolerated after the first day of treatment. Steady-state conditions for CBD were achieved within 7 days, but quantifiable plasma THC concentrations were sporadic. A prudent approach to improve tolerability with Spectrum Yellow oil might involve initial doses no higher than 240 mg total CBD and 10.8 mg total THC daily in divided doses, with titration upward over time as needed based on tolerability. Acknowledgments We acknowledge Clinical Network Services and Nucleus Network for collecting study data; Roland Jbeily, Justin Verwoert and Ryan Yablonsky for facilitating shipment of study products; staff at iC42 Clinical Research and Development for analyzing blood and urine samples; staff at Nuventra for helping interpret PK results; Aleksandra Trajkovic for assisting with study operations; Scott Young for testing study syringes and Stephanie Louis for reviewing an earlier version of the manuscript. Funding This study was funded by Canopy Growth Corporation. Conflict of Interest The product investigated in this study is part of the Spectrum Therapeutics line of medical cannabis products, and Spectrum Therapeutics is a wholly owned subsidiary of Canopy Growth Corporation. Canopy Growth Corporation funded the study, provided the study products, designed the study, and interpreted the findings. An external contract research organization, in collaboration with an Australian Phase 1 unit, executed the study; more specifically, the external organization obtained Ethics approval, led participant recruitment, and collected, managed, and analyzed all study data. All biological samples were shipped to the University of Colorado for independent analysis of cannabinoids and associated metabolites. Dr. Peters is an employee of Canopy Growth Corporation, during which time she has received stock options. She also serves as a consultant to Battelle. Ms. Mosesova is an employee of Canopy Growth Corporation, during which time she has received stock options. Dr. MacNair is an employee of Canopy Growth Corporation, during which time she has received stock options. Dr. Vandrey has received consulting fees or honoraria from Canopy Growth Corporation, MyMD Pharmaceuticals Inc., FSD Pharma, and Present Life Corporation. Mr. Land is an employee of Canopy Growth Corporation, during which time he has received stock options, and was a prior employee of GW Pharmaceuticals. Dr. Ware is an employee of Canopy Growth Corporation, during which time he has received stock options. Ms. Turcotte is an employee of Canopy Growth Corporation, during which time she has received stock options. Dr. Bonn-Miller is an employee of Canopy Growth Corporation, during which time he has received stock options. 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JAMA Network Open , 1 , e184841.doi: 10.1001/jamanetworkopen.2018.4841 . Google Scholar OpenURL Placeholder Text WorldCat Crossref © The Author(s) 2021. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] © The Author(s) 2021. Published by Oxford University Press.