the “budding” of medical cannabis use in floridaweb.brrh.com/msl/im2018/day-2_saturday/saturday...

The “Budding” of Medical Cannabis Use in Florida

Dr. Matthew Soff, MD

Gastroenterology

Plantation FL

It’s taking off like a weed!!!

Faculty Disclosure

I have no financial disclosures

I am certainly not disclosing my personal, intense study of the affects of Marijuana in college students

Agenda

Review of the historical use of Marijuana in medicine

Explore and understand the Endocannabinoid system

Discuss the chemistry and physiologic affects of the compounds from the Cannabis plant (Phytocannabinoids)

Describe the current legal status of Cannabis in FLA

How Medical Marijuana is used today

The “Original Medical Cannabis”

1850-1936 used for 100’s of indications

A Brief Medical History of Marijuana

1830: British physician in India (Wm O’Shaugnessy) experiments with Cannabis……. And was knighted by Queen Victoria

1854: Cannabis entered The Dispensatory of the United States of America

1880: Sir William Osler, “a most satisfactory remedy for migraine”

1936: “Reefer madness” (FBN)

1937: Marijuana Tax Act

A Brief Medical History of Marijuana

1942 : Cannabis removed from US Pharmacopoeia

1945: La Guardia Committee

1964: THC and CBD isolated by Israeli scientists

1971: Shafer commission & Controlled Substance Act

John Mitchell and Richard Nixon

1996: California passes Compassionate Use Act (Prop 215)

1998: Institute of Medicine report

Barry McCaffrey, Janet Reno and Bill Clinton

2012: Colorado and Washington legalize recreational marijuana

8/8/13: Dr. Sanjay Gupta goes on air to say, “I mistakenly believed the DEA listed Marijuana as Class1 because of scientific proof. The DEA has no proof…… (Marijuana) has very legitimate medical applications.”

2014: Rohrabacher-Farr amendment

Endocannabinoid System

1. Endocannabinoids (endogenous)

1. AEA: Anandamide

2. 2-AG: 2-arachidonylglycerol

2. Cannabinoid Receptors

1. CB1

2. CB2

3. Regulatory Enzymes

1. Synthesize

2. Catabolize


An internal homeostatic regulatory system

Modulates

Pain perception

Seizure threshold

Appetite

Digestion

Mood


Modulates Immune System

Tumor surveillance

Fertility

Bone physiology

Intraocular pressure

Hypothalamic-pituitary-adrenal axis

Retrograde system Paracrine hormone – acts locally

Inhibits release of other neurotransmitters

Excitatory or inhibitory

Receptors?

Retrograde system Paracrine hormone – acts locally Inhibits release of other neurotransmitters

It’s all about the receptors

CB1 and CB2: GPCRs (G protein-coupled receptors)

CB1 located in the CNS (Central Nervous

System)

CB2 located on immune cells

Found in all vertebrates

CB1 Receptor

Highly expressed throughout the brain

Ten times more prevalent than narcotic receptors

Primary Psychoactive CB Receptor

Basal Ganglia Hippocampus Cerebral Cortex

Cerebellum Amygdala Hypothalamus Brain Stem

CB2 Receptor

Highly expressed Immune Cells B cells

T cells

Macrophages

Inhibits Immune Cell activation

Inhibits Proinflammatory cytokine production

Neurotransmitter Deficiency Syndromes

Deficiency

Acetylcholine

Dopamine

Serotonin

Norepinephrine

Endocannabinoids

Alzheimer's

Parkinson's

Depression

Depression

Endocannabinoid Deficiency Syndrome

Syndrome

e


Lower pain threshold

Failure to inhibit pain

Sleep disturbances

Mood disorders

Digestive disorders


Possible associations (hyperalgesia)

IBS (Irritable Bowel Syndrome)

Migraine

Fibromyalgia

Chronic Fatigue

Dysmenorrhea


Cannabinoid receptors respond to:

Endocannabinoids (endogenous)

AEA (Anandamide)

2AG (2-arachidonylglycerol)

Phytocannabinoids (exogenous)

From Cannabis sativa

80-100 Cannabinoids in Marijuana

“Phytocannabinoids”

THC: Δ9-tetrahydrocannabinol

CBD: Cannabidiol

CBC: Cannabichromene

CBG: Cannabigerol

CBN: Cannabinol

THCA: Tetrahydrocannabolic Acid

THCV: Tetrahydrocannabivarin

THC: Δ9-tetrahydrocannabinol

CB1 Affects in the CNS

especially in the brain

Most psychoactive

GI

Reproductive tissues

Adrenal

Heart

Lung

Bladder

CB2 Affects immune cells

Agonist of CB1 and CB2 receptors

CBD: Cannabidiol

Attenuates the “High” feeling caused by THC

CBD inhibits:

convulsions

anxiety

Insomnia

neuropathic pain.

Cannabinoid Effects

Euphoria and relaxation – THC

CBD modulates the psychoactive effects

Stimulates appetite

Decreases nausea

Decreases pain perception

Somnolence – helps with sleep

Intensifies sensory experiences

Cannabinoid Side Effects

Anxiety*

Paranoia*

Panic attacks*

Impairs cognitive function

Time distortion

Somnolence

Impairs short term memory

*Treat with benzodiazepines or antipsychotics No lethal dose: does not suppress respiration

Over the last few years, 8 states and Washington, D.C., have legalized Marijuana for recreational use;

Medical Marijuana is legal in 29 states plus D.C

The Beginning of Medical Cannabis in Florida

2014: SB1030

Compassionate Medical Cannabis Act

Legalized under STATE law – Low THC

Plant of the Genus Cannabis

Contains less than 0.8% THC

More than 10% CBD

Cancer related symptoms

Persistent seizures

Persistent muscle spasms

The Beginning of Medical Cannabis in Florida

2016: “Right to Try Act” - HB307

“Permitted” use of Medical Cannabis

All parts of any of the genus Cannabis

Any part of the Plant

Flowers, Leaves, Seeds or Resin

Terminal, progressive disease

Significant functional impairment

Less than one year prognosis even with all available medical treatment

Status of Medical Marijuana Florida 2018

November 8, 2016

Amendment 2 passes with 71% of Florida voters approving

Mandates the state legislature to broaden indications

June, 2017 – Senate Bill 8-A passes in special legislative session.

Broadens the indications for Medical Cannabis

Current Indications - 2018

Crohns Disease

Cancer

Multiple Sclerosis

Parkinson's Disease

Seizures/Epilepsy

Spasticity/Muscle Spasm

Terminal Condition/Illness

PTSD

HIV/AIDS

Glaucoma

ALS

Chronic pain *

Physician determination * *

*Pain due to one of the other conditions * * Another condition similar in nature to one of the above specified conditions

What can Medical Cannabis Do for Patients?

Helps with pain

Improves appetite

Improves disease related nausea and vomiting.

Help with sleep

Decreases anxiety

Improves sense of well being

Cancer-related symptoms

Euphoria

Combines the Benefit of THC and CBD

Entourage Effect

What can Medical Cannabis Do for Patients?

Helps with pain

Improves appetite

Improves disease related nausea and vomiting.

Help with sleep

Decreases anxiety

Improves sense of well being

Cancer-related symptoms

Euphoria – a feeling of well being or elation

Combines the Benefit of THC and CBD

Entourage Effect

Affects of Phytocannabinoids Depends on:

Dose

Ratio of cannabinoids

Route of administration

Timing of onset

Health status

Age of patient

Hx of cannabis use

Co-administration of meds

Dose related affects

CBD

Low dose: Sedating

High dose: Stimulating

THC:

Low dose: Less anxiety

High dose: Increased anxiety

The Strain Matters

Mode of Administration

Which Patients are Eligible

Florida resident

Age 18 (or needs a guardian)

Patient must have a clinical relationship with the prescribing physician for 3 months

Which Patients are Eligible

Florida resident

Age 18 (or needs a guardian)

Have an approved medical condition

Current Indications

Crohns Disease

Cancer

Multiple Sclerosis

Parkinson's Disease

Seizures/Epilepsy

Spasticity/Muscle Spasm

Terminal Condition/Illness

PTSD

HIV/AIDS

Glaucoma

ALS

Chronic pain *

Physician determination * *

*Pain due to one of the other conditions * * Another condition similar in nature to one of the above specified conditions

How Does the Doctor Do It

1) Initial in office evaluation

1) Document the Diagnosis and Symptoms

2) Confirms Pregnancy, Mental Illness and Abuse history

3) Patient signs informed consent

4) Patient signs ABN

2) Registers the patient with FL DOH Department of Medical Marijuana

1) Patient needs to respond to the E-mail

1) $75 check – now can be done electronically on web site

2) Passport photo – connected to Motor Vehicle Bureau

3) Copy of Fla License or ID Card

2) Approval takes 1-3 months

How Does the Doctor Do It

After the patient is approved:

1. On the Department of Medical Marijuana Website

1. Certifies the patient for up to 70 days

2. Places an order for CBD and/or THC

1. Can order up to 2 forms of each

1. Capsule

2. Sublingual

3. Vape

4. Topical

2. Needs to specify mgs/dose and doses/day

3. Needs to specify Sativa or Indica

2. Patient gets the Cannabis from an approved dispensary

3. Regular follow up visits to monitor benefits, adverse affects and dosing needs

What Does the Patient Get

No smoking…. No Joints…. No Bongs

What Does the Patient Get

Oil for under the tongue or swallowed

Oil in a capsule

Oil to be “Vaped”

No smoking…. No Joints…. No Bongs

Important Items to Remember

Medical Marijuana is not legal with regards Federal Law

No insurance will cover Medical Marijuana or the required office visits

Do not fly with Marijuana….. Ever!!

Do not drive with Marijuana across state borders.

How NOT to think of Medical Cannabis

We need to consider Medical Cannabis as a Medical Treatment

The END

Thank you for your attention

the “budding” of medical cannabis use in floridaweb.brrh.com/msl/im2018/day-2_saturday/saturday...

Documents