medical cannabis: a guide for healthcare professionals
TRANSCRIPT
Medical Cannabis:
A Guide for Healthcare Professionals
Table of Contents02 Cannabis, Cannabinoids, and
the Endocannabinoid System
08 The SpectrumTM
11 Methods of Administration
14 How Do Oil and Softgels Differ from Dried Flowers?
16 Dosing Guidance for Oil and Softgels
22 How to Authorize Medical Cannabis
26 Why Choose Spectrum Therapeutics?
28 References
This guide provides you with information to make informed decisions about how to incorporate medical cannabis into your practice. It covers terminology, choosing a product, administration, dosing guidance, and how to authorize medical cannabis.
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Cannabis, Cannabinoids, and the Endocannabinoid System
Medical cannabis refers to the use of cannabis and its cannabinoid constituents—primarily THC and CBD—as therapy to treat or alleviate symptoms, particularly for chronic pain.
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CannabisCannabis contains more than 500 chemical compounds. Bioactive compounds are produced in high concentration in the glandular trichomes, which are hair-like, resin-secreting glands found on the surface of the female cannabis flower.
CannabinoidsThere are more than 100 cannabinoids in cannabis, which interact with the body’s cannabinoid receptors.
w Endocannabinoids – naturally produced in the body
w Phytocannabinoids – found in many plants, but in highest concentrations in cannabis
w Synthetic cannabinoids – includes pharmaceuticals that have the same chemical structure as THC (e.g., dronabinol), or are analogues of THC (e.g., nabilone)
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Activation of cannabinoidsInactive ∆9-tetrahydrocannabinolic acid (THCA) and cannabidiolic acid (CBDA) in the raw plant must be decarboxylated to the neutral phenols (THC and CBD) to interact with the endocannabinoid system.
This occurs when dried cannabis flowers are heated, either by vapourizing, smoking, baking, or cooking. Many commercially available oils are decarboxylated to provide consistent and precise dosing.
Terpenes and flavonoidsThese are responsible for the variety of scents and flavours of different cannabis varieties. Terpenes may have direct physiologic effects as well as interacting with cannabinoids to create the unique properties of individual cannabis varieties.
This is known as the entourage effect, a theory that describes the potential interactions between major cannabinoids, minor cannabinoids, terpenes, and other plant constituents.
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Δ9-tetrahydrocannabinol (THC)THC interacts with cannabinoid receptors and has these effects (Howlett et al. 2002; Grotenhermen and Müller-Vahl 2012; Health Canada 2018):
w analgesic
w antispasmodic
w reduces chemotherapy-induced nausea and vomiting
w stimulates appetite
w decreases intestinal motility
THC also has psychotropic effects, and varieties with high concentrations of THC can cause anxiety, disorientation, and intoxication in some patients.
Cannabidiol (CBD)CBD has these effects (Izzo et al. 2009; Parker et al. 2011; Health Canada 2018):
w anti-inflammatory
w analgesic
w antiemetic
w antipsychotic
w anxiolytic
w anti-seizure
CBD lacks the intoxicating, euphoric effects of THC, although it has potential benefit as a treatment for anxiety disorders (Blessing et al. 2015).
OHH
H
O
THC
OH
HOH
H
CBD
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The Endocannabinoid SystemThe endocannabinoid system (ECS) is a lipid signaling system that plays an important role in the regulation of homeostasis throughout the human body.
It has been implicated in neural development, immune function, inflammation, appetite, metabolism and energy homeostasis, cardiovascular function, digestion, bone development and bone density, synaptic plasticity and learning, pain, reproduction, psychiatric disease, psychomotor behaviour, memory, wake/sleep cycles, and the regulation of stress and emotional state (Health Canada 2018).
The ECS consists of the CB1 and CB2 receptors, two endogenous agonists (or endocannabinoids), and endocannabinoid synthesizing and degrading enzymes. CB1 receptors are found in highest concentration in the central and peripheral nervous system and in the gastrointestinal tract. CB2 receptors are found primarily in the immune system, including the tonsils, spleen, lymph nodes, and in circulating lymphocytes and neutrophils.
While present throughout the CNS, the concentration of cannabinoid receptors is low in the brainstem, specifically the area responsible for cardiorespiratory drive (Aggarwal 2013). Thus, it is almost impossible to cause cardiorespiratory depression and death using cannabinoids, in contrast to opioids (ElSohly 2002).
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The SpectrumThe Spectrum is a straightforward colour-coding system that simplifies the understanding of medical cannabis. This helps healthcare professionals and patients communicate clearly about product selection.
Each colour represents a category of products based on THC and CBD content. Depending on your patient’s needs, you may recommend that they take a product containing THC, CBD, or a mixture of both.
Red represents products that are THC-dominant with little-to-no CBD.
Blue represents products that have a more balanced ratio of THC and CBD.
Yellow represents products that are CBD-dominant with little-to-no THC.
All Spectrum Therapeutics™ products, which are available at SpectrumTherapeutics.com, can be categorized by The Spectrum, making it easier to select the right product for your patients.
Indica and SativaIndica and sativa are used in plant taxonomy as species names, though there is disagreement about the validity of these distinctions. Even if C. indica and C. sativa are two distinct species, it would be rare to find a pure indica or sativa variety due to centuries of cross-breeding. Instead, the majority of cannabis varieties today are hybrids, created by crossbreeding two varieties, that may be indica or sativa dominant.
Some medical cannabis users believe that sativa varieties tend to be energizing and indica more sedating. When someone asks if a variety is sativa or indica, they want to know if the product will make them feel energized, and therefore good for daytime use, or sleepy, and therefore more suited to evening use.
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The Spectrum
CB
DTH
C
ORANGE PURPLE
BLUE GREEN YELLOW
RED
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Methods of Administration
InhalationVapourizingVapourizing is a way to inhale the bioactive components of medical cannabis without burning the plant material. Cannabis is heated to a temperature that volatilizes, without combusting, the cannabinoids and other plant constituents, substantially reducing toxic by-products. It reduces the harms associated with smoking, is a more efficient way of extracting chemically active constituents, and reduces the loss of cannabinoids in sidestream smoke, which leads to substantial cost saving over smoking.
Ground cannabis flower is placed into a chamber where it is progressively heated past the boiling points of the bioactive compounds, but not high enough to cause combustion. The vapours are either collected in a secondary chamber or directly inhaled.
Vapourizers vary in size, portability, battery life, warranty, and customizability of temperature settings and mouthpieces. Because we believe patients need options to consume cannabis with the least potential harm, we offer registered patients vapourizers in our online store, including two that have been approved by Health Canada as class II medical devices (the Mighty Medic and the Volcano).
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IngestionMany patients choose to ingest their medical cannabis as oil or softgels.
OilConcentrated resin, containing cannabinoids and other bioactive compounds, is extracted from cannabis flowers that have undergone thermal decarboxylation. The resin is diluted with a food-grade oil to make a finished cannabis oil product that has a defined concentration of cannabinoids and terpenes and to facilitate oral administration. We use supercritical fluid CO2 extraction to produce a high-purity, solvent-free cannabis resin.
This environmentally friendly alternative to hydrocarbon-based solvent extraction techniques leaves no residual solvents and is commonly used in the beverage industry to decaffeinate coffee and tea.
Cannabis oil is for oral consumption and is neither meant to be vapourized, combusted, nor is it designed for sublingual administration.
SoftgelsSoftgels consist of two hermetically sealed halves filled with cannabis resin dissolved in food-grade oil to form a single, highly durable capsule. This provides superior dosage uniformity when compared to other delivery methods (e.g., oil measured with a dropper). Softgels provide patients with a convenient and discreet option for their medication while avoiding the taste of the cannabis oil.
Spectrum Therapeutics sells an extensive line of cannabis oil and softgels at SpectrumTherapeutics.com.
There are significant differences between ingesting and inhaling medical cannabis. When cannabis is ingested, the onset of effect is delayed and may last longer compared to inhalation. See infographic on page 15 for a full comparison of the differences between inhalation and ingestion.
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How Do Oil and Softgels Differ from Dried Flowers?
There are important differences between ingestion and inhalation. Often, patients will benefit from the use of more than one type of product to address different therapeutic needs.
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up to 12 hours,or longer*
up to 6 hours,or longer*
2.5 mg of THCand equalamount CBD
1 inhalation
from the GI tract andmetabolized in the liver before entering the bloodstream
through the lungs directly into the
bloodstream
30 minutes–1.5 hours, or longer
seconds to minutes
DURATION
STARTING DOSE
HOW IT’S ABSORBED
ONSET
Inhaled Ingested
*Health Canada cautions that some effects could last as long as 24 hours.
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Dosing Guidance for Oil and Softgels
The patient does NOT need to experience euphoria for cannabis to provide therapeutic benefit.
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Start Low, Go SlowIf this is your patient’s first time ordering Spectrum Therapeutics softgels or oil, use the starting dose listed in the appropriate chart (see p. 18) and wait a day. Patients should not exceed the recommended starting dose. If the starting dose is ineffective, have them consume the Day 2 dose and wait a day to assess the effects before consuming more. Continue in this manner until they reach a dose that provides optimal benefit with minimal side effects. Only increase by the recommended amount per day to avoid any uncomfortable effects.
Once-daily dosing is recommended during the dose escalation phase. Once the patient has identified their optimal dose, they can adjust dose frequency based on the severity of symptoms throughout the day (e.g., take a morning and an evening dose).
Though most people will find their ideal dose in the first few days, it may take longer for others. Taking Spectrum Therapeutics oil or softgels with a fatty meal may increase the effects that your patient experiences.
Dosing GuidancePrecautions for your patients1. It can take 30 minutes–1.5 hours to
feel the effects of oil or softgels.
2. Effects can last up to 12 hours or longer. Consume when the patient has enough time to allow for the effects to pass to understand how they are affected.
3. These products should not be consumed by women who are pregnant or breastfeeding.
4. Always store cannabis products in their original packaging and out of reach of children and pets. Ensure any food made with cannabis oil is carefully labeled.
5. Never operate a motor vehicle or heavy machinery while impaired.
6. Avoid consuming alcohol in combination with cannabis in any form.
If you need more assistance, please contact our Customer Care Team.
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Increase only if needed
Spectrum Therapeutics Oil Product
Colour
Starting Dose Day 1 Day 2 Day 3 Day 4
Red 0.1 mL 0.2 mL 0.3 mL 0.4 mL
Blue 0.25 mL 0.5 mL 0.75 mL 1.0 mL
Yellow 0.25 mL 0.5 mL 0.75 mL 1.0 mL
Spectrum Therapeutics Oil Dosing Charts
*This guidance applies if the patient has already determined that the most effective dose is 10 mg THC or greater. If the patient intends to increase the dose, it is recommended that it be done by only 2.5 mg of THC. The patient should NOT increase their dose by 10 mg of THC.
Spectrum Therapeutics Softgel Dosing Charts
2.5 mg THCThis can be applied to:
DAY # SOFTGELS TAKEN TOGETHER
TOTAL THC
Increase dose only if needed, and only increase by 2.5 mg in a day.
1 1 2.5 mg
2 2 5 mg
3 3 7.5 mg
4 4 10 mg
10 mg THC*This can be applied to:
DAY # SOFTGELS TAKEN TOGETHER
TOTAL THC
Increase dose only if needed, and only increase by 2.5 mg in a day.
1 1 (10 mg) 10 mg
2 1 (10 mg) + 1 (2.5 mg)
12.5 mg
3 1 (10 mg) + 2 (2.5 mg) 15 mg
4 1 (10 mg) + 3 (2.5 mg) 17.5 mg
20 mg CBD
20 mg yellow softgels are meant for patients who have determined their optimal dose is 20 mg CBD or greater.
If you are new to CBD, you should start with cannabis oil to find your optimal dose.
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Dosing Guidance for VapourizingThe approach to vapourizing is similar to that for use of oil: first find the optimal dose and, once this is determined, then it can be dosed regularly. Because inhaled cannabis has a faster onset (seconds to minutes) and shorter duration of action (up to 6 hours or longer) than oil, it can be titrated up more quickly.
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Vapourizing Unlike cannabis oil, vapourizing is not dosed in mg of THC and CBD, but in inhalations of cannabis using a vapourizer. This is impacted by the concentration of the dried product selected. For most patients—particularly the cannabis naïve—it is suggested to start with products containing low THC and equal, or higher, CBD concentration, as CBD can balance the side effects of THC (MacCallum and Russo 2018). For example, the patient may want to start vapourizing with a cannabis product that has 10% THC or less and an equal or greater percentage of CBD. An example is Spectrum Green No. 3, which has 6.5% THC and 10.2% CBD.
The following is one method commonly used by physicians and patients to determine the therapeutic dose:
w Start with 1 inhalation and wait 15 minutes before consuming more.
w Increase by 1 inhalation every 15–30 minutes until optimal dose (i.e., number of inhalations) is achieved.
w If unwanted side effects occur, then the patient may try a lower dose or a product with a different CBD to THC ratio.
w Once optimal dose has been determined, including the duration of effect, it can then be dosed regularly or as needed.
Slower titration and care should be taken with the elderly and those with complex health conditions.
SmokingFor patients who are self-medicating with cannabis joints, use the rough estimate that an average cannabis joint contains 0.5 grams of dried cannabis (not to be confused with the amount of active THC). There is no definite rule to cannabis dosing, but as a guide, a large safety study reported a median daily dose of 2.5 g/day (Ware et al. 2015). This is equivalent to 75 g/ month of dried cannabis. These weights should not be confused with the amount of THC consumed.
These recommendations are strictly for guidance. Clinicians can increase or decrease the starting dose and titration rate based on the patient, cannabis variety, previous use and overall response.
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How to Authorize Medical Cannabis
Register with usIt’s simple to create an account with Spectrum Therapeutics. Once you’ve done this you’ll have access to our Patient Management Portal. Register at SpectrumTherapeutics.com
Complete a Medical Document for your patientThis includes the period of use (up to 12 months) and the authorized amount, expressed in grams per day. The Medical Document can be found at SpectrumTherapeutics.com
Make sure your patient is also registeredYour patients need to be registered with us before they can order medical cannabis. Registration processing time is usually less than 48 hours once the Medical Document and Registration Form are received. Patient registration is available at SpectrumTherapeutics.com
Prescribe medical cannabisYou can now advise your patients about the medical cannabis product that is right for them.
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Submitting DocumentsThere are three ways to send us this information:
SpectrumTherapeutics.com Patient Management Portal
w SpectrumTherapeutics.com
The easiest way to authorize is via electronic transmission of the two necessary documents. This coordinates speedy and accurate patient registration that is fully compliant with the Cannabis Act.
Patient files can be searched and reviewed, and documents can be created, quickly renewed, and submitted, all with the click of a mouse. Your patient’s registration with SpectrumTherapeutics.com is normally confirmed the same business day that the Medical Document and Registration Form are received via the Patient Management Portal. It’s the fastest way to provide patient access to medical cannabis.
You can register for an account at SpectrumTherapeutics.com
Secure fax
w Fax to 1-888-977-2595
We can accept a Medical Document by fax only if it is sent directly from the office of the prescribing healthcare professional, and only with an acknowledgement that the faxed Medical Document will become the original Medical Document.
By mail
w Spectrum Therapeutics 1 Hershey Drive Smiths Falls, ON K7A 0A8
If sent by mail, we require the original version of the Medical Document, completed and signed by the healthcare professional.
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Equivalency FactorsHealth Canada requires healthcare professionals to specify the number of grams of dried cannabis a patient is authorized to receive on a daily basis. An equivalency factor converts the volume of oil or the number of softgels being purchased to a dried cannabis equivalent for the purpose of tracking the purchased amount against the authorized amount in grams per day. Patients can purchase and possess up to their 30-day supply of dried cannabis, or its equivalent, to a maximum of 150 grams. Should the 30-day limit exceed 150 grams, the patient will have to place more than one order in the month.
For OilAll of our standard bottle sizes for oil are equal to 5 grams of dried cannabis
The equivalency calculation should never be used to establish the oral dose. The oral dose should always be established independently. Conservative dosing and titration guidance is provided in this document and accompanies all Spectrum Therapeutics products.
ProductGrams equivalent of dried cannabis
All bottles of oil 5 g
2.5 mg THC | 2.5 mg THC 5 g
10 mg THC | 10 mg THC 10 g
20 mg CBD 10 g
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Why Choose Spectrum Therapeutics?
Spectrum Therapeutics provides medical cannabis products to improve the lives of patients around the world. In addition to a consistent supply of lab-tested products, you can rely on us to keep you up to date with clear and accurate information. As we invest in ongoing research, our goal is to deliver innovative products that raise the bar on therapy and outcomes for patients everywhere.
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Your medicine is importantWe ensure a consistent supply of lab-tested cannabis products, always available in Canada, to give you peace of mind.
We make medical cannabis simple and accessibleWe make it easy for patients and healthcare providers to understand how to optimize the therapeutic benefits of medical cannabis. Count on our educators to help you make an informed choice.
We’re only just beginningOur original scientific research and product innovation will lead to novel approaches that will advance care and therapeutic options
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ReferencesAggarwal SK. Cannabinergic pain medicine: a concise clinical primer and survey of randomized-controlled trial results. Clin J Pain 2013;29(2):162-171.
Blessing EM, Steenkamp MM, Manzanares J, et al. Cannabidiol as a potential treatment for anxiety disorders. Neurotherapeutics 2015;12(4):825-836.
ElSohly M. Chemical Constituents of Cannabis. In: Cannabis and Cannabinoids – Pharmacology, Toxicology, and Therapeutic Potential. The Haworth Press 2002; p. 27-36.
Grotenhermen F, Müller-Vahl K. The therapeutic potential of cannabis and cannabinoids. Dtsch Arztebl Int 2012;109(29-30):495-501.
Health Canada. Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids. Government of Canada. https://www.canada.ca/en/health-canada/services/ drugs-medication/cannabis/information-medical-practitioners/ information-health-care-professionals-cannabis-cannabinoids.html. Published 2018. Accessed October 26, 2018.
Howlett AC, Bonner BF, Cabral G, et al. International Union of Pharmacology. XXXVII. Classification of cannabinoid receptors. Pharmacol Rev 2002;54(2):161-202.
Izzo AA, Borrelli F, Capasso R, et al.. Non-psychotropic plant cannabinoids: new therapeutic opportunities from the ancient herb. Trends Pharmacol Sci 2009;30(10):515-527.
MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med DOI: 10.1016/j.ejim.2018.01.004
Parker L, Rock EM, Limebeer CL. Regulation of nausea and vomiting by cannabinoids. Br J Pharmacol 2011;163(7):1411-1422.
Ware MA, Wang T, Shapiro S, et al. 2015. Cannabis for the management of pain: Assessment of safety study (COMPASS). J Pain 2015;16(12):1233-1242.
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Our dedicated support team for healthcare professionals is available to answer any questions that you may have.
1-833-HCP LINE / 1-833-427-5463
SpectrumTherapeutics.com
Feel free to contact us.
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