<p class="frontmatter-fieldnotes disclaimernew" style="margin-bottom:15px;">This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s <a href="/pages/termsofuse.aspx" target="_blank">Terms & Conditions</a>.</p>
<div id="_idContainer000">
<p class="ltrs-br-ltr-br-title"><span class="bold"><a id="_idTextAnchor000"></a>I Use “Wax” Because It Makes Me Calmer, But Now I Am Seeing 3D Images</span></p>
<p class="ltrs-br-ltr-br-body-text">To the Editor: Use of high-potency cannabis derivatives has become increasingly popular over the past few years; however, their effects are not fully known. Here, we present the case of a woman who experienced hallucinations after using “wax.” </p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Case report.</span> A 39-year-old single white woman with a past psychiatric history of posttraumatic stress disorder and cannabis use disorder presented for a follow-up appointment. She was seen in the psychiatry clinic earlier than originally scheduled because she was experiencing new auditory and visual hallucinations. She described her visual hallucinations as seeing 3D images and lights. At this appointment, she was diagnosed with unspecified psychosis (<span class="italic">DSM-5</span> criteria).</p>
<p class="ltrs-br-ltr-br-body-text">Further questioning at follow-up appointments revealed the patient was producing and using a concentrated form of marijuana that she was calling wax. She described in detail how to prepare the wax. She would place marijuana leaves and lighter fluid in a glass bowl and then heat the substance until the mixture became a greenish-yellow, thick, waxy consistency. She would then cool the substance and store it in a contact lens holder. She would place the wax in a vaporizer and use it when she was feeling anxious. She stated that this improved her anxiety and made her feel calm. However, although her anxiety was improved, she was now having hallucinations that were scaring her.</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text">Wax is a form of cannabis. <span class="italic">Butane hash oil</span>, <span class="italic">shatter</span>, <span class="italic">budder</span>, <span class="italic">ear wax</span>, and <span class="italic">honeycomb</span> are some of the other colloquial terms used by patients to describe this concentrated tetrahydrocannabinol (THC) product. The inhalation of concentrated THC through butane extraction is called dabbing.<span class="htm-cite"><a href="#ref1">1</a></span> Modification of cannabis using butane is popularly called wax in the southwest United States. Wax production at home requires few resources, with free instructional videos available on social media. The production of wax at home is called “blasting.” This process involves passing butane through a glass tube packed with cannabis trimmings. The THC dissolves within butane, and the combination passes through the tube and is collected on a tray. The volatile butane gas then evaporates and leaves a greenish-colored resin that can have THC concentrations of up to 70%–80%.<span class="htm-cite"><a href="#ref1">1</a></span></p>
<p class="ltrs-br-ltr-br-body-text">Butane hash oil burns are another growing problem that has been mentioned in various case series.<span class="htm-cite"><a href="#ref2">2</a></span> According to these reports,<span class="htm-cite"><a href="#ref2">2</a></span> the injuries were sustained during the production of these concentrates, with burn sizes ranging from 16% to 96% of the total body surface area as butane is extremely flammable.</p>
<p class="ltrs-br-ltr-br-body-text">Cannabis-induced psychosis and its related development of a schizophrenia spectrum disorder or other severe psychopathology is a rising concern.<span class="htm-cite"><a href="#ref3">3</a>,<a href="#ref4">4</a></span> The use of high-potency cannabis derivatives may have a more detrimental effect on mental health than the use of lower-potency cannabis.<span class="htm-cite"><a href="#ref5">5</a></span> The increased prevalence and potency of marijuana derivatives like wax warrants further research.</p>
<p class="references_references-heading"><span class="bold">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a><span class="htm-ref"> 1.	</span>Stogner JM, Miller BL. Assessing the dangers of “dabbing”: mere marijuana or harmful new trend? <span class="italic">Pediatrics</span>. 2015;136(1):1–3. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=26077476&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1542/peds.2015-0454"><span class="pubmed-crossref">doi:10.1542/peds.2015-0454</span></a></p>
<p class="references-references-text-1-9"><a name="ref2"></a><span class="htm-ref"> 2.	</span>Jensen G, Bertelotti R, Greenhalgh D, et al. Honey oil burns: a growing problem. <span class="italic">J Burn Care Res</span>. 2015;36(2):e34–e37. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=24823328&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1097/BCR.0000000000000067"><span class="pubmed-crossref">doi:10.1097/BCR.0000000000000067</span></a></p>
<p class="references-references-text-1-9"><a name="ref3"></a><span class="htm-ref"> 3.	</span>Arendt M, Rosenberg R, Foldager L, et al. Cannabis-induced psychosis and subsequent schizophrenia-spectrum disorders: follow-up study of 535 incident cases. <span class="italic">Br J Psychiatry</span>. 2005;187(6):510–515. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16319402&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1192/bjp.187.6.510"><span class="pubmed-crossref">doi:10.1192/bjp.187.6.510</span></a></p>
<p class="references-references-text-1-9"><a name="ref4"></a><span class="htm-ref"> 4.	</span>Moore TH, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. <span class="italic">Lancet</span>. 2007;370(9584):319–328. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=17662880&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1016/S0140-6736(07)61162-3"><span class="pubmed-crossref">doi:10.1016/S0140-6736(07)61162-3</span></a></p>
<p class="references-references-text-1-9"><a name="ref5"></a><span class="htm-ref"> 5.	</span>Di Forti M, Marconi A, Carra E, et al. Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis: a case-control study. <span class="italic">Lancet Psychiatry</span>. 2015;2(3):233–238. <a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=26359901&dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="
http://dx.doi.org/10.1016/S2215-0366(14)00117-5"><span class="pubmed-crossref">doi:10.1016/S2215-0366(14)00117-5</span></a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Roopa Sethi, MD</span><span class="superscript">a</span></p>
<p class="ltrs-br-ltr-br-author"><a href="
mailto:roopasethimd@gmail.com">
roopasethimd@gmail.com</a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Dominic DiPrinzo, MD</span><span class="superscript">b</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Ryan McAllister, DO</span><span class="superscript">b</span></p>
<p class="end-matter"><span class="superscript">a</span>Department of Psychiatry, Kansas University Medical Center, Kansas City, Kansas</p>
<p class="end-matter"><span class="superscript">b</span>Arizona College of Osteopathic Medicine, Midwestern University, Glendale, Arizona</p>
<p class="end-matter"><span class="bold-italic">Potential conflicts of interest: </span>None.</p>
<p class="end-matter"><span class="bold-italic">Funding/support:</span> None.</p>
<p class="end-matter"><span class="bold-italic">Patient consent:</span> The patient provided consent to publish this case, and information has been de-identified to protect anonymity. </p>
<p class="end-matter"><span class="bold-italic">Published online:</span> June 21, 2018.</p>
<p class="front-matter-rule"><span class="bold-italic">To cite:</span> Sethi R, DiPrinzo D, McAllister R. I use “wax” because it makes me calmer, but now I am seeing 3D images. <span class="italic">Prim Care Companion CNS Disord. </span>2018;20(3):15l01868.</p>
<p class="doi-line"><span class="bold-italic">To share:</span><span class="italic"> </span>
https://doi.org/<span class="doi">10.4088/PCC.15l01868</span></p>
<p class="end-matter"><span class="italic">© Copyright 2018 Physicians Postgraduate Press, Inc.</span></p>
</div>