ORIGINAL ARTICLE
Honey Oil Burns: A Growing Problem Guy Jensen, MD, Robert Bertelotti, MD, FACS, David Greenhalgh, MD, FACS, Tina Palmieri, MD, FACS, FCCM, Pirko Maguina, MD
There is an emerging mechanism of burn injury as a result of the ignition of butane, during the manufacture of a tetrahydrocannabinol concentrate known as butane honey oil. The authors report of a series of patients who presented with this mechanism of injury and a description of the process that causes these burns. Patient data were gathered from the medical records of eight patients treated at the University of California Davis Medical Center and Shriners Hospital of Northern California. Information on the manufacturing process of butane honey oil was gathered from Internet searches and published literature on the topic. The burns witnessed at the abovementioned institutions ranged from 16 to 95% TBSA, with an average of 49.9%. The average length of stay for the patients was 118.3 hospital days and 114.4 intensive care unit days, with an average of 43.8 days spent on mechanical ventilation. The average age of patients was 22 years, with only one patient above the age of 30 years. Accidents during honey oil production have resulted in a surge of burn injuries in our community during the past year. The manufacture of this product, which involves the use of volatile butane gas, is gaining in popularity. Although considered to be safer than previous methods, multiple casualties with extensive burn injuries have resulted from this process. Associated injuries from blast trauma or chemical burns are not likely to occur in these types of explosions and have not been observed in the series reported in this article. In light of the increasing popularity of honey oil, it is important for burn care providers to gain awareness and understanding of this problem and its growing presence in the community. (J Burn Care Res 2015;36:e34–e37)
Burns resulting from accidents during the manufacturing process of illegal drugs have burdened our community for many years, most commonly related to crystal meth laboratory explosions. Marijuana and other tetrahydrocannabinol (THC)-containing derivatives are the most widely used category of illicit drugs worldwide.1 While the majority of THC is consumed as the less potent but easier-to-obtain plant matter, a small percentage is consumed as concentrated oil known as “hash oil” or “honey oil.” Honey oil is the most potent of the commonly confiscated cannabis products.2 During the past year, we have started to see patients with severe burn injuries secondary to accidents during manufacturing of honey oil. This illegal drug is made in clandestine distilleries using highly From the University of California Davis Sacramento. Address correspondence to Pirko Maguina, MD, Department of Surgery, 2425 Stockton Boulevard, Sacramento, CA 95817. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000067
e34
flammable agents such as pressurized butane or isopropyl alcohol. In view of the sudden surge of honey oil burns, we decided to review our institution’s experience. This case series explores the injuries sustained by patients involved in honey oil distillation and reviews the manufacturing process in order to explain the patterns of injuries that can be expected with these patients.
METHODS A retrospective study was performed to review all cases of burns related to the making of honey oil, treated at the burn units of the University of California Davis Medical Center and Shriners Hospitals for Children Northern California between September 2011 and September 2012. The patient chart review was approved by the University of California Institutional Review Board. Data collection included patient age, sex, extent and pattern of burns, as well as review of all patient photographs from the medical records. Information regarding the manufacturing process of honey oil was obtained, by entering the
Journal of Burn Care & Research Volume 36, Number 2
Jensen et al e35
working in groups of two or three people at the time. As a result, in most of these cases multiple patients had to be evaluated simultaneously. Only two of the eight patients presented without other accompanying burn victims. All patients sustained burns to the anterior chest wall, at least one upper extremity, and the face. Variations from this injury pattern included the three patients who sustained burns to their back and four patients with burns to the lower extremities. Emergency escharotomies were required in four patients and one required decompressive laparotomy for treatment of abdominal compartment syndrome. Nonthermal injuries from the explosions were not seen. There were no instances of penetrating injuries or ocular injuries as a result of the explosions. Of the eight patients in our series, five required intubation for airway protection and ventilator support. None of the patients reported prolonged exposure to smoke or presented with clinical signs suggestive of inhalation injury. Bronchoscopies were therefore not performed in this series of patients for evaluation of airway injuries. Only one patient (with 95% burns) had a bronchoscopy later for evaluation of persistent pneumonia. The average length of time on ventilators was 43.75 days (SD 94.49, range 0–275). The review of Internet searches for “honey oil manufacturing” revealed that there are several available options. Isopropyl alcohol has historically been the more commonly used method. This chemical boils at 82.5°C, releasing flammable vapors. Boiling the alcohol reduces the mixture to produce the concentrated oil form, colloquially dubbed “hash” or “honey” oil. Explosions can occur from ignition
search terms “manufacture of hash oil” and “manufacturing of honey oil” into the Google search engine. Further information was obtained through review of published literature regarding illicit and medical cannabis use.1–6 Data analysis was performed using the Microsoft®Excel 2010 function calculator (Microsoft Corporation, Redmond WA).
RESULTS Eight patients were admitted with burns sustained during the manufacturing of honey oil during the duration of the study. Burn size ranged from 16 to 96% of TBSA, with a mean of 49.9% (28.3% SD). All patients survived their injuries. The average intensive care unit stay was 114.4 days (SD 164.6). The average overall stay was 118.3 days (SD 165.1 days). Six of the eight patients (75%) in this series required excision and grafting of burns. All patients were very young: the average age of our patients was 22 years (range 17–33), with only one burn victim being above the age of 30 years. The patients were almost exclusively men, with only one woman admitted during the study period (Table 1). The injuries sustained were primarily caused by explosion of butane gas and by ignition of clothing after the explosion. Only one patient admitted to honey oil manufacturing at the time of the initial admission history; in all other cases this information was obtained later during the hospitalization. All patients came to our institution immediately after their accidents, either directly or as a transfer from a referring emergency room. Most of the patients were Table 1. Honey oil burn patients Sex
Age
Degree
TBSA
Hospital Days
ICU Days
Ventilator Days
TBSA Autografted
M
33
2nd/3rd
96%
472
467
275
F
21
2nd/3rd
85%
263
257
44
M
23
3rd
25%
24
23
11
M
23
3rd
32%
38
35
6
M
18
3rd
50%
67
67
3
M
18
2nd/3rd
56%
60
52
9
M M
17 23
2nd 2nd
39% 16%
15 5
8 4
0 2
96% (excess skin graft area due to grafts for contracture release) 85% TBSA (abdomen, posterior torso, face, bilateral upper and lower extremities) 11% TBSA (bilateral hands and right arm) 29% TBSA (bilateral hands, posterior trunk, buttocks, and bilateral lower extremities) 50% TBSA (bilateral upper extremities, anterior and posterior trunk) 39% TBSA (bilateral hands, bilateral lower extremities) No autografting required No autografting required
ICU, intensive care unit.
e36 Jensen et al
of the boiling alcohol or the residual fumes.3,6,7 Increasingly common is a method using butane that is considered to be safer, as well as more efficient.8 Butane evaporates at around −0.5°C, and therefore requires no heat source in order to obtain the gas, which forms at room temperature. The making of butane honey oil, is accomplished by forcing pressurized liquid butane through a cylinder full of cannabis plant matter.7 This results in a mix of oil and butane dripping out the tube and collected onto a plate. This mixture can then be heated to expedite the evaporation of the butane and obtain the purified honey oil.
DISCUSSION Manufacturing of honey oil is a dangerous process. It carries risk of severe burn injuries, as evidenced by the patients in our series. The patients tended to present in groups. It is our impression that the manufacturing of honey oil is a process that can be performed by an individual, but most often is completed in small groups. This is notable, because the simultaneous arrival of multiple severely burned patients has the potential to stretch the resources of many medical systems. Our 1-year experience showed no associated traumatic injuries resulting from honey oil laboratory explosions. Despite the common concerns associated with evaluating patients after explosions, the pattern of injuries seen to date is more consistent with flash burns. Honey oil is manufactured both for its mindaltering properties as well as for the potential to obtain financial gain. While the process is not new, it seems to have gained sudden popularity in our community, as reflected by the sudden spike of accidents. It is unclear to us what has caused this increase in honey oil burns in California over the past year, but we hypothesize that it may be related to new barriers to access THC products legally. The possession or manufacture of cannabis concentrates, like honey oil, remains criminalized in California.9 In contrast, plant matter cannabis was legalized for medical use in 1996.10 Under this ruling, medical marijuana became widely available, with certain neighborhoods reporting more dispensaries than Starbucks coffee shops.11 This changed in 2012 when the Federal government began to shut down dispensaries that had previously been permitted by the state. While official numbers have not yet been made available, 500 to 650 of the state’s estimated 1400 dispensaries were ordered to shut down during the first 8 months of 2012.12 As barriers to obtaining legal marijuana have increased, it seems to have
Journal of Burn Care & Research March/April 2015
reopened a market for illegal products. The diminished access to legal THC products may explain the surge in accidents resulting from the manufacturing of honey oil. Oil production is especially attractive when legal marijuana growth is limited, as the distillation process of honey oil can use “shake” or left-over plant matter deemed unfit for smoking. Honey oil can either be smoked or ingested in raw form or after using it as an ingredient for baked goods. While the sudden surge of injuries from honey oil manufacturing has brought this process to our attention, the fraction of marijuana trafficked in oil form has been on the rise for several years. Between 2000 and 2007 the percentage of marijuana samples in oil form confiscated and sent to the National Center for Natural Products Research at the University of Mississippi has more than doubled from 0.2 to 0.6% of all THC products seized.4 Overall, cannabis products seem to be gaining a newfound popularity over other drugs: the share of cannabis product seizures by the Drug Enforcement Agency and other law-enforcement agencies had declined between 1980 and 1999 but has been on the rise since.2,4 Honey oil contains up to 22% THC vs a maximum of 4% in the more common plant matter marijuana form.2,4 While all marijuana compounds have been increasing in potency in the United States, hash or honey oil has demonstrated the largest increase in potency of any THC products.2,4,5 The available literature regarding injuries from honey oil manufacturing is limited. While there are studies of burns resulting from hash oil production from New Zealand and Jamaica,6 we could not identify any American case reports. Porter and Armstrong3 in New Zealand described their experience with burns from illegal drug manufacturing in 2004. They included a series of nine patients burned during the production of honey oil. Six of these nine patients required skin grafting, with burns ranging from 5 to 50% TBSA. None of their patients died. Hospital stay for the patients who underwent skin grafting ranged from 17 to 57 days. The authors were able to discuss the mechanism of burns with several patients, and reported that the burns occurred during the heating of isopropyl alcohol in the extraction of THC. Butane gas is now the preferred manufacturing agent. It is easy to obtain and relatively inexpensive. It is commonly sold for the purpose of refueling cigarette lighters. The butane sold for use in camp stoves is not routinely favored because of the added odorants included to aid in detection of leaks.8 Butane gas is heavier than air and can therefore collect in poorly ventilated rooms. As a result the risk for ignition persists even after the manufacturing is completed. The
Journal of Burn Care & Research Volume 36, Number 2
illicit nature of the process increases the likelihood of taking place in clandestine, poorly ventilated indoor areas. The manufacturing process does not seem to result in blast injuries involving shrapnel, rather the gas appears to fill the work area, engulfing the patients at the time of the explosion, leading to flash burn injuries and ignition of clothing. This would explain how some patients sustained deep burns that included their backs, which were facing away from the gas source. Also, reviewing the manufacturing process has allowed us to understand how—unlike the frequently reported chemical eye injuries sustained during methamphetamine production—such eye injuries are not likely to result during the manufacturing of honey oil.13,14 Butane honey oil’s rise in popularity is reflected in publications touting its benefits, such as the October 2012 cover of High Times (the largest cannabis culture magazine in circulation worldwide).8 While the media covers the “benefits” of honey oil, more education about the risks involved in its manufacture is needed. Increased risk awareness may help prevent future burn accidents like the ones seen this year at our institution.
CONCLUSIONS Honey oil production accidents have resulted in a surge of burn injuries in our community during the past year. Although the manufacturing process now has moved from using isopropyl alcohol to butane gas, which is generally considered safer, accidents still result from ignition of the gas in poorly ventilated rooms. They often result in multiple casualties with extensive burns. Associated injuries from blast trauma or chemical burns are not likely to occur in these types of explosions and have not been observed in our series. With increasing popularity of honey oil,
Jensen et al e37
it is important for the burn care providers to gain awareness and understanding of this problem. REFERENCES 1. Bogdanoski T. Accommodating the medical use of marijuana: surveying the differing legal approaches in Australia, the United States and Canada. J Law Med 2010;17:508–31. 2. ElSohly MA, Ross SA, Mehmedic Z, Arafat R, Yi B, Banahan BF III. Potency trends of delta9-THC and other cannabinoids in confiscated marijuana from 1980-1997. J Forensic Sci 2000;45:24–30. 3. Porter CJ, Armstrong JR. Burns from illegal drug manufacture: case series and management. J Burn Care Rehabil 2004;25:314–8. 4. Mehmedic Z, Chandra S, Slade D, et al. Potency trends of Δ9-THC and other cannabinoids in confiscated cannabis preparations from 1993 to 2008. J Forensic Sci 2010;55:1209–17. 5. Castle D, Murray RM, D’Souza C. Marijuana and madness. 2nd ed. New York: Cambridge University Press; 2012. p. 35–37. 6. Williams GD. Hash-oil manufacture: an important factor in the occurrence of adult burns in Jamaica. West Indian Med J 1988;37:210–4. 7. Alvarado, A. Butane Hash Oil: The Future of Pot. Miami New Times. 2013; available from http://www.miaminew times.com/2013-10-24/news/bho-butane-hash-oil/; accessed November 1, 2013. 8. Black, B. To dab or not to dab? exploring the pros, cons, and dangers of butane hash oil. High Times 2012: October; 72–82. 9. California Health and Safety code 11018, Section 11357 part a. 10. Compassionate Use Act 1996, Cal Health & Safety Code Ann § 11362.5 11. Gonzales, R. Pot friendly California: Amsterdam In America? NPR. 2009; available from http://www.npr.org/ templates/story/story.php?storyId=111784495; accessed March 4, 2013. 12. Onishi, N. Cities balk as federal law on marijuana is enforced. New York Times; 30 June 2012. 13. Chan AY, Storck SA, Stone DU. Ocular injuries from shake and bake methamphetamine labs. J Okla State Med Assoc 2011;104 409–12. 14. Charukamnoetkanok P, Wagoner MD. Facial and ocular injuries associated with methamphetamine production accidents. Am J Ophthalmol 2004;138:875–6.
Honey Oil Burns: A Growing Problem Guy Jensen, MD, Robert Bertelotti, MD, FACS, David Greenhalgh, MD, FACS, Tina Palmieri, MD, FACS, FCCM, Pirko Maguina, MD
There is an emerging mechanism of burn injury as a result of the ignition of butane, during the manufacture of a tetrahydrocannabinol concentrate known as butane honey oil. The authors report of a series of patients who presented with this mechanism of injury and a description of the process that causes these burns. Patient data were gathered from the medical records of eight patients treated at the University of California Davis Medical Center and Shriners Hospital of Northern California. Information on the manufacturing process of butane honey oil was gathered from Internet searches and published literature on the topic. The burns witnessed at the abovementioned institutions ranged from 16 to 95% TBSA, with an average of 49.9%. The average length of stay for the patients was 118.3 hospital days and 114.4 intensive care unit days, with an average of 43.8 days spent on mechanical ventilation. The average age of patients was 22 years, with only one patient above the age of 30 years. Accidents during honey oil production have resulted in a surge of burn injuries in our community during the past year. The manufacture of this product, which involves the use of volatile butane gas, is gaining in popularity. Although considered to be safer than previous methods, multiple casualties with extensive burn injuries have resulted from this process. Associated injuries from blast trauma or chemical burns are not likely to occur in these types of explosions and have not been observed in the series reported in this article. In light of the increasing popularity of honey oil, it is important for burn care providers to gain awareness and understanding of this problem and its growing presence in the community. (J Burn Care Res 2015;36:e34–e37)
Burns resulting from accidents during the manufacturing process of illegal drugs have burdened our community for many years, most commonly related to crystal meth laboratory explosions. Marijuana and other tetrahydrocannabinol (THC)-containing derivatives are the most widely used category of illicit drugs worldwide.1 While the majority of THC is consumed as the less potent but easier-to-obtain plant matter, a small percentage is consumed as concentrated oil known as “hash oil” or “honey oil.” Honey oil is the most potent of the commonly confiscated cannabis products.2 During the past year, we have started to see patients with severe burn injuries secondary to accidents during manufacturing of honey oil. This illegal drug is made in clandestine distilleries using highly From the University of California Davis Sacramento. Address correspondence to Pirko Maguina, MD, Department of Surgery, 2425 Stockton Boulevard, Sacramento, CA 95817. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000067
e34
flammable agents such as pressurized butane or isopropyl alcohol. In view of the sudden surge of honey oil burns, we decided to review our institution’s experience. This case series explores the injuries sustained by patients involved in honey oil distillation and reviews the manufacturing process in order to explain the patterns of injuries that can be expected with these patients.
METHODS A retrospective study was performed to review all cases of burns related to the making of honey oil, treated at the burn units of the University of California Davis Medical Center and Shriners Hospitals for Children Northern California between September 2011 and September 2012. The patient chart review was approved by the University of California Institutional Review Board. Data collection included patient age, sex, extent and pattern of burns, as well as review of all patient photographs from the medical records. Information regarding the manufacturing process of honey oil was obtained, by entering the
Journal of Burn Care & Research Volume 36, Number 2
Jensen et al e35
working in groups of two or three people at the time. As a result, in most of these cases multiple patients had to be evaluated simultaneously. Only two of the eight patients presented without other accompanying burn victims. All patients sustained burns to the anterior chest wall, at least one upper extremity, and the face. Variations from this injury pattern included the three patients who sustained burns to their back and four patients with burns to the lower extremities. Emergency escharotomies were required in four patients and one required decompressive laparotomy for treatment of abdominal compartment syndrome. Nonthermal injuries from the explosions were not seen. There were no instances of penetrating injuries or ocular injuries as a result of the explosions. Of the eight patients in our series, five required intubation for airway protection and ventilator support. None of the patients reported prolonged exposure to smoke or presented with clinical signs suggestive of inhalation injury. Bronchoscopies were therefore not performed in this series of patients for evaluation of airway injuries. Only one patient (with 95% burns) had a bronchoscopy later for evaluation of persistent pneumonia. The average length of time on ventilators was 43.75 days (SD 94.49, range 0–275). The review of Internet searches for “honey oil manufacturing” revealed that there are several available options. Isopropyl alcohol has historically been the more commonly used method. This chemical boils at 82.5°C, releasing flammable vapors. Boiling the alcohol reduces the mixture to produce the concentrated oil form, colloquially dubbed “hash” or “honey” oil. Explosions can occur from ignition
search terms “manufacture of hash oil” and “manufacturing of honey oil” into the Google search engine. Further information was obtained through review of published literature regarding illicit and medical cannabis use.1–6 Data analysis was performed using the Microsoft®Excel 2010 function calculator (Microsoft Corporation, Redmond WA).
RESULTS Eight patients were admitted with burns sustained during the manufacturing of honey oil during the duration of the study. Burn size ranged from 16 to 96% of TBSA, with a mean of 49.9% (28.3% SD). All patients survived their injuries. The average intensive care unit stay was 114.4 days (SD 164.6). The average overall stay was 118.3 days (SD 165.1 days). Six of the eight patients (75%) in this series required excision and grafting of burns. All patients were very young: the average age of our patients was 22 years (range 17–33), with only one burn victim being above the age of 30 years. The patients were almost exclusively men, with only one woman admitted during the study period (Table 1). The injuries sustained were primarily caused by explosion of butane gas and by ignition of clothing after the explosion. Only one patient admitted to honey oil manufacturing at the time of the initial admission history; in all other cases this information was obtained later during the hospitalization. All patients came to our institution immediately after their accidents, either directly or as a transfer from a referring emergency room. Most of the patients were Table 1. Honey oil burn patients Sex
Age
Degree
TBSA
Hospital Days
ICU Days
Ventilator Days
TBSA Autografted
M
33
2nd/3rd
96%
472
467
275
F
21
2nd/3rd
85%
263
257
44
M
23
3rd
25%
24
23
11
M
23
3rd
32%
38
35
6
M
18
3rd
50%
67
67
3
M
18
2nd/3rd
56%
60
52
9
M M
17 23
2nd 2nd
39% 16%
15 5
8 4
0 2
96% (excess skin graft area due to grafts for contracture release) 85% TBSA (abdomen, posterior torso, face, bilateral upper and lower extremities) 11% TBSA (bilateral hands and right arm) 29% TBSA (bilateral hands, posterior trunk, buttocks, and bilateral lower extremities) 50% TBSA (bilateral upper extremities, anterior and posterior trunk) 39% TBSA (bilateral hands, bilateral lower extremities) No autografting required No autografting required
ICU, intensive care unit.
e36 Jensen et al
of the boiling alcohol or the residual fumes.3,6,7 Increasingly common is a method using butane that is considered to be safer, as well as more efficient.8 Butane evaporates at around −0.5°C, and therefore requires no heat source in order to obtain the gas, which forms at room temperature. The making of butane honey oil, is accomplished by forcing pressurized liquid butane through a cylinder full of cannabis plant matter.7 This results in a mix of oil and butane dripping out the tube and collected onto a plate. This mixture can then be heated to expedite the evaporation of the butane and obtain the purified honey oil.
DISCUSSION Manufacturing of honey oil is a dangerous process. It carries risk of severe burn injuries, as evidenced by the patients in our series. The patients tended to present in groups. It is our impression that the manufacturing of honey oil is a process that can be performed by an individual, but most often is completed in small groups. This is notable, because the simultaneous arrival of multiple severely burned patients has the potential to stretch the resources of many medical systems. Our 1-year experience showed no associated traumatic injuries resulting from honey oil laboratory explosions. Despite the common concerns associated with evaluating patients after explosions, the pattern of injuries seen to date is more consistent with flash burns. Honey oil is manufactured both for its mindaltering properties as well as for the potential to obtain financial gain. While the process is not new, it seems to have gained sudden popularity in our community, as reflected by the sudden spike of accidents. It is unclear to us what has caused this increase in honey oil burns in California over the past year, but we hypothesize that it may be related to new barriers to access THC products legally. The possession or manufacture of cannabis concentrates, like honey oil, remains criminalized in California.9 In contrast, plant matter cannabis was legalized for medical use in 1996.10 Under this ruling, medical marijuana became widely available, with certain neighborhoods reporting more dispensaries than Starbucks coffee shops.11 This changed in 2012 when the Federal government began to shut down dispensaries that had previously been permitted by the state. While official numbers have not yet been made available, 500 to 650 of the state’s estimated 1400 dispensaries were ordered to shut down during the first 8 months of 2012.12 As barriers to obtaining legal marijuana have increased, it seems to have
Journal of Burn Care & Research March/April 2015
reopened a market for illegal products. The diminished access to legal THC products may explain the surge in accidents resulting from the manufacturing of honey oil. Oil production is especially attractive when legal marijuana growth is limited, as the distillation process of honey oil can use “shake” or left-over plant matter deemed unfit for smoking. Honey oil can either be smoked or ingested in raw form or after using it as an ingredient for baked goods. While the sudden surge of injuries from honey oil manufacturing has brought this process to our attention, the fraction of marijuana trafficked in oil form has been on the rise for several years. Between 2000 and 2007 the percentage of marijuana samples in oil form confiscated and sent to the National Center for Natural Products Research at the University of Mississippi has more than doubled from 0.2 to 0.6% of all THC products seized.4 Overall, cannabis products seem to be gaining a newfound popularity over other drugs: the share of cannabis product seizures by the Drug Enforcement Agency and other law-enforcement agencies had declined between 1980 and 1999 but has been on the rise since.2,4 Honey oil contains up to 22% THC vs a maximum of 4% in the more common plant matter marijuana form.2,4 While all marijuana compounds have been increasing in potency in the United States, hash or honey oil has demonstrated the largest increase in potency of any THC products.2,4,5 The available literature regarding injuries from honey oil manufacturing is limited. While there are studies of burns resulting from hash oil production from New Zealand and Jamaica,6 we could not identify any American case reports. Porter and Armstrong3 in New Zealand described their experience with burns from illegal drug manufacturing in 2004. They included a series of nine patients burned during the production of honey oil. Six of these nine patients required skin grafting, with burns ranging from 5 to 50% TBSA. None of their patients died. Hospital stay for the patients who underwent skin grafting ranged from 17 to 57 days. The authors were able to discuss the mechanism of burns with several patients, and reported that the burns occurred during the heating of isopropyl alcohol in the extraction of THC. Butane gas is now the preferred manufacturing agent. It is easy to obtain and relatively inexpensive. It is commonly sold for the purpose of refueling cigarette lighters. The butane sold for use in camp stoves is not routinely favored because of the added odorants included to aid in detection of leaks.8 Butane gas is heavier than air and can therefore collect in poorly ventilated rooms. As a result the risk for ignition persists even after the manufacturing is completed. The
Journal of Burn Care & Research Volume 36, Number 2
illicit nature of the process increases the likelihood of taking place in clandestine, poorly ventilated indoor areas. The manufacturing process does not seem to result in blast injuries involving shrapnel, rather the gas appears to fill the work area, engulfing the patients at the time of the explosion, leading to flash burn injuries and ignition of clothing. This would explain how some patients sustained deep burns that included their backs, which were facing away from the gas source. Also, reviewing the manufacturing process has allowed us to understand how—unlike the frequently reported chemical eye injuries sustained during methamphetamine production—such eye injuries are not likely to result during the manufacturing of honey oil.13,14 Butane honey oil’s rise in popularity is reflected in publications touting its benefits, such as the October 2012 cover of High Times (the largest cannabis culture magazine in circulation worldwide).8 While the media covers the “benefits” of honey oil, more education about the risks involved in its manufacture is needed. Increased risk awareness may help prevent future burn accidents like the ones seen this year at our institution.
CONCLUSIONS Honey oil production accidents have resulted in a surge of burn injuries in our community during the past year. Although the manufacturing process now has moved from using isopropyl alcohol to butane gas, which is generally considered safer, accidents still result from ignition of the gas in poorly ventilated rooms. They often result in multiple casualties with extensive burns. Associated injuries from blast trauma or chemical burns are not likely to occur in these types of explosions and have not been observed in our series. With increasing popularity of honey oil,
Jensen et al e37
it is important for the burn care providers to gain awareness and understanding of this problem. REFERENCES 1. Bogdanoski T. Accommodating the medical use of marijuana: surveying the differing legal approaches in Australia, the United States and Canada. J Law Med 2010;17:508–31. 2. ElSohly MA, Ross SA, Mehmedic Z, Arafat R, Yi B, Banahan BF III. Potency trends of delta9-THC and other cannabinoids in confiscated marijuana from 1980-1997. J Forensic Sci 2000;45:24–30. 3. Porter CJ, Armstrong JR. Burns from illegal drug manufacture: case series and management. J Burn Care Rehabil 2004;25:314–8. 4. Mehmedic Z, Chandra S, Slade D, et al. Potency trends of Δ9-THC and other cannabinoids in confiscated cannabis preparations from 1993 to 2008. J Forensic Sci 2010;55:1209–17. 5. Castle D, Murray RM, D’Souza C. Marijuana and madness. 2nd ed. New York: Cambridge University Press; 2012. p. 35–37. 6. Williams GD. Hash-oil manufacture: an important factor in the occurrence of adult burns in Jamaica. West Indian Med J 1988;37:210–4. 7. Alvarado, A. Butane Hash Oil: The Future of Pot. Miami New Times. 2013; available from http://www.miaminew times.com/2013-10-24/news/bho-butane-hash-oil/; accessed November 1, 2013. 8. Black, B. To dab or not to dab? exploring the pros, cons, and dangers of butane hash oil. High Times 2012: October; 72–82. 9. California Health and Safety code 11018, Section 11357 part a. 10. Compassionate Use Act 1996, Cal Health & Safety Code Ann § 11362.5 11. Gonzales, R. Pot friendly California: Amsterdam In America? NPR. 2009; available from http://www.npr.org/ templates/story/story.php?storyId=111784495; accessed March 4, 2013. 12. Onishi, N. Cities balk as federal law on marijuana is enforced. New York Times; 30 June 2012. 13. Chan AY, Storck SA, Stone DU. Ocular injuries from shake and bake methamphetamine labs. J Okla State Med Assoc 2011;104 409–12. 14. Charukamnoetkanok P, Wagoner MD. Facial and ocular injuries associated with methamphetamine production accidents. Am J Ophthalmol 2004;138:875–6.
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