Medical CannabisMATT WEBSTER DO, MS

Cannabis Sativa

One of the oldest used drugs and medicinal remedies

Most commonly abused illicit drug in the US

There has been increasing access for medicinal MJ use in the US over the past 20 years

What is Marijuana?

What we typically think of as MJ is primarily the dried flowers and leaves from plants of the genus Cannabis Sativa.

The active compounds in the plant are called cannabinoids.

There are hundreds of such compounds but the most important are THC (delta-9-tetrahydrocannabinol) and CBD (cannabidiol).

Cannabinoid Receptor System

We have naturally occurring cannabinoids and associated receptors in our bodies and this system was first described in the 1990s.

There are different receptors all throughout the body including the CNS and immune system.

The two most important receptors are CB-1 and CB-2

CB-1 (THC Receptor)

This receptor binds THC

Primarily located in the central and peripheral nervous system as well as some in the gut and adipose tissue

Causes release of downstream neurotransmitters in the CNS including dopamine which cause euphoria, alter spatial perception, decrease pain perception, stimulate appetite, and may cause a psychoactive effect

Causes the typical effects of the “high” associated with MJ

CB-2 (CBD) Receptor

This receptor binds CBD

Receptors primarily located in cells of the immune system including solid organs such as the spleen and lymphatics as well as blood based immune cells

Helps to decrease inflammation and likely has an anti-cancer effect

Chemical most likely to have a positive health effect

Adverse Health Effects of MJ

Central Nervous System Memory loss, learning disability Depression, paranoia, addiction Worsening bipolar disorder Anxiety Schizophrenia or other psychoses Increased incidence of suicidal

ideation and suicide attempt Cardiovascular system

Increased blood pressure and heart rate

Increased risk for acute heart attack

Digestive system Acute hunger (“munchies”)

Constipation

Respiratory (when smoked) Bronchitis

Lung cancer?

Pregnancy Low birth weight infant

Cannabis history in medicine

In the early 20th century was commonly included with many medicinal preparations including cough syrups and lotions

1937 Marijuana Tax Stamp act made it effectively illegal to possess or sell MJ without an expensive tax stamp

Controlled Substances Act of 1970 made it a Schedule I controlled drug with no accepted medical use and high potential for abuse

Recent Regulatory Changes

1996California –Proposition 215 – The Compassionate Use Act of 1996

Approved for use by “seriously ill” individuals with MD recommendation

Mid 90s-00sUS Attorney General – relaxed federal law enforcement

Rapid rise in medical marijuana licenses

2014US Department of Justice –advised US attorneys not to pursue action against physicians

201831 states and Puerta Rico have at least limited medical cannabis access

Synthetic Medical Preparations

THC preparations: Dronabinol (Marinol, Syndros)/ Nobilone(Cesamet)

Approved for chemo associated N/V and AIDS related weight loss Schedule II

CBD: Epidiolex Approved for treatment of childhood epilepsy syndromes Schedule V

Medicinal Cannabis

Medical cannabis may be smoked as the natural dried plant or consumed in other preparations to be ingested orally (oil, edibles, capsules, etc) or topically such as lotions

CBD:THC ratio is an important concept. Looking for higher CBD than THC content ideally. This is different than recreational MJ which may be 30% THC by weight

Iowa Regulations

Iowa Medical Cannabidiol Act was signed in May 2017 allowing for CBD with no more than 3% THC for select approved medical conditions

Five dispensaries throughout Iowa will open December 1

Patients will need certification from a PCP of a qualifying condition then apply with the Iowa Department of Public Health for a card allowing purchase of CBD/THC containing products

Iowa Regulations

Qualifying conditions include chronic pain, seizures, MS with muscle spasms, Parkinson’s Disease, ALS, HIV/AIDs.

No smoked or edible CBD/THC will be available but instead preparations will include capsules, oils, and creams

Over the counter CBD oil remains illegal in Iowa though is increasingly popular with online ordering and distribution

Conditions with Strong Evidence

There is solid evidence that cannabis is effective for the treatment of cancer related pain and the nausea and vomiting associated with chemo

Likely is effective for the treatment of spasticity related to MS

Limited Evidence for Effectiveness

There is limited evidence that cannabis is effective for treatment of anxiety, insomnia, dementia, ALS, epilepsy, glaucoma

Thus, there isn’t great clinical evidence that medical cannabis is effective for some of the conditions it is approved for

Summary

There is and will be increasing access to cannabis as a medical modality

New studies are commencing looking at effectiveness for many conditions

It is available in Iowa in a somewhat limited scope

Look at the CBD:THC ratio