1. MEDICAL USE OF CANNABIS– with a focus on Neuromuscular Disorders
Gregory T. Carter, MD, MS Medical Director
Muscular Dystrophy Association Regional Neuromuscular Center Olympia, WA

2. Overview of Lecture
the colorful history of cannabis in America: Politics, Paranoia, and Harry Anslinger
Pharmacology
Clinical Applications
Research – from bench to bedside

3. Cannabis cannabis is one of the oldest known psychoactive plants
First reported use as medicine > 5000 years ago
Introduced into Western medicine in 1840’s by
Dr. W.B. O’Shaughnessy
One of earliest non-food plants cultivated
fiber for rope, seeds for oil and birdseed
mixture of leaves, stems, tops
1960’s: 1-3% THC; 1990’s: up to 8-10%

4. The chemical makeup of cannabis
The active ingredients in cannabis are cannabinoids, a group of terpenophenolic compounds The cannabinoids are concentrated in a viscous resin that is produced in glandular structures known as trichomes, these are the tiny, sticky hair like formations you see at the end of buds.

5. Some of the more prominent cannabinoids include:
Delta-9-tetrahydrocannabinol (THC)
Cannabidiol (CBD)
Cannabinol (CBN)
Tetrahydrocannabivarin (THCV)
Cannabichromene (CBC)
Cannabicyclol (CBL)
Yet still another est other cannabinoids!

6. Cannabis – medical uses
Has been used medicinally, spiritually, and recreationally for thousands of years
Promoted for putative analgesic, sedative, antiinflammatory,
antispasmodic and anticonvulsant properties
Glaucoma (decreases intraocular pressure)
Antiemetic (reduce nausea and vomiting)
Enhance appetite (e.g., AIDS patients)

7. History of Cannabis
Chinese cultures were growing marijuana more than 3000 years ago.
there are 3,000-year-old Egyptian mummies that containing cannabis traces
The first written account of cannabis cultivation (ostensibly used as medical marijuana) is found in Chinese records dating from 28 B.C.

8. Examples of Flowers from Different Clones
“Bubble Gum”
“Big Bud”
“Dutch Northern Lights”

9. That came from
Cannabis seeds

10. Preparing the flowers to use
Wet flowers on a scale (L)
Dried flowers ready to use (R)

11. Hashish Hash Oil dried resin from top of female plant
THC usually 2-5%, but up to 15%
Hash Oil
organic extraction from hashish
THC usually ~ 10-20% up to 70%

12. FDA-Regulated Cannabinod-Based Medicines:
Chemicals, Extracts, Botanicals
Photo from pharmer.org
Photo from epocrates.com
Photo from Russo et al. 2002
Photo from nida.org
Dronabinol (Marinol™)
Nabilone (Cesamet™)
Cannabis Sativa L. Extracts (Sativex™)
Cannabis Sativa L. Cigarettes
Photo from Russo et al. 2002
Approximately 460 chemical constituents, >100 phytocannabinoids
1976
Photo from wikipedia.org
1985
1985
2006 12

13. SF General Hospital Inpatient Clinical Trials Ward—Smoked Cannabis in HIV Neuropathy, Pilot Study13

14. A different kind of pharmacy

15. CANNABIS AT A PHARMACY IN THE NETHERLANDS

16. Meanwhile, back at the warehouse

17. AN INDUSTRIAL GROW HOUSE – NOTE UNIFORMITY OF PLANTS

18. Here in the United States, circa 1900…
many cannabis based medications were produced by Eli-Lilly, Parke Davis, and Sharp Dohme (now Merck Sharp Dohme).
Tinctures
Pills
Liniments

19. Cannabis Tincture, circa 1910, Parke Davis

20. Cannabis for neuropathic pain…in 1906

21. Cannabis for Neuralgia 192521

22. And then along came Harry…

23. Harry Anslinger Had NO formal medical training Our first drug czar
Despite being “anti-drug”, he authorized a pharmacist near the White House to supply morphine for addicted Senator Joseph McCarthy during the communist crusades.
Openly prosecuted doctors for over-prescribing, sending some to prison Single-handedly created “Reefer Madness”
Anslinger was privately funded by William Randolph Hearst who wanted to eliminate hemp as an industrial competitor
This also allowed Anslinger, an avowed racists, to rid the southwest of Hispanics

24. Thanks to one man…
cannabis was criminalized in the United States by 1942
against the advice of the AMA
And just for entertainment value, we had…

25. REEFER MADNESS

26. The laws started to change…
Every government-appointed commission investigating marijuana's medical potential has issued favorable findings.
This include
1) The Nixon appointed Shafer Commission in 1972
2) the U.S. Institute of Medicine in 1982
3) the Australian National Task Force on Cannabis in 1994
4) the U.S. National Institutes of Health Workshop on Medical Marijuana in 1997
Institute of Medicine affirmed: "Scientific data indicate the potential therapeutic value of cannabinoid drugs ... for pain relief, control of nausea and vomiting, and appetite stimulation. ... Except for the harms associated with smoking, the adverse effects of marijuana use are within the range tolerated for other medications.“
Predictably, federal authorities ignored the IOM's recommendations

27. More history
the Drug Enforcement Agency (DEA) did finally held public hearings on the issue before an administrative law judge. Two years later, Judge Francis Young ruled that "Marijuana has been accepted as capable of relieving distress of great numbers of very ill people, and doing so with safety under medical supervision. It would be unreasonable, arbitrary and capricious for DEA to continue to stand between those sufferers and the benefits of this substance in light of the evidence in this record." Young recommended, "The Administrator transfer marijuana from Schedule I to Schedule II, to make it available as a legal medicine."
DEA Administrator John Lawn rejected Young's determination, effectively continuing the federal ban on the medical use of marijuana by patients.

28. Fifteen states and counting
Since 1996, voters in fifteen states -- Alaska, Arizona, California, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Jersey, New Mexico, Oregon, Rhode Island, Vermont and Washington -- and the District of Columbia have adopted initiatives exempting patients who use marijuana under a physician's supervision from state criminal penalties.
Yet states may not authorize medical marijuana clinical trials without federal approval. All medical marijuana research must meet NIDA approval and receive funding from the National Institutes of Health (NIH).

29. CLINICAL PHARMACOLOGY OF CANNABIS
95-99% plasma protein bound
hydroxylation, oxidation, and conjugation for rapidly clearance from plasma
First-pass metabolism with oral admin. (11-OH-THC)
Elimination over several days (adipose)
Breast milk distribution
Pregnancy Category C
Excretion: days to weeks 20-35% found in urine
65-80% found in feces
5% as unchanged drug (when given PO)
Works via RECEPTOR BASED MECHANISMS

30. Cannabinoid Receptors
Cannabinoid receptors are G-protein–coupled receptors consisting of seven transmembrane-spanning domains
CB1 receptors are located in several areas of the brain and in a variety of tissues such as adipose tissue, liver, muscle, the GI tract, pancreas, and sensory neurons
CB2 receptors are located in immune cells and do not appear to play a role in energy balance or food intake
Devane WA et al. Determination and characterization of a cannabinoid receptor in rat brain. Mol Pharmacol. 1988;34:
Munro S et al. Molecular characterization of a peripheral receptor for cannabinoids. Nature. 1993;365:61-65.
Ameri A. The effects of cannabinoids on the brain. Prog Neurobiol. 1999;58:
Osei-Hyiaman D, DePetrillo M, Pacher P, et al. Endocannabinoid activation at hepatic CB1 receptors stimulates fatty acid synthesis and contributes to diet-induced obesity. J Clin Invest. 2005;115:
Cota D, Woods SC. The role of the endocannabinoid system in the regulation of energy homeostasis. Curr Opin Endocrinol Diabetes. 2005;12: 30

31. AEA also an endovanalloid at TRPV1 (with 5-20-fold lower affinity cf with CB1); also PPARy
Key ECS Elements
Key ECS Elements
The ECS consists of two G-protein–coupled receptors, CB1 and CB2, and the endogenously produced ligands that activate these receptors
Cannabinoid receptors are found throughout the body and are normally bound by a family of endogenous lipids, the endocannabinoids
The first cannabinoid receptor (CB1) was cloned in Both CB receptor types belong to the G-protein coupled–receptor superfamily
CB1 receptors are widely distributed in the central nervous system (CNS) including hippocampus, cerebellum, and basal ganglia
Mainly localized presynaptically
Modulate the release of -aminobutyric acid, dopamine, noradrenaline, and glutamate
Also expressed in peripheral tissues including adipose tissue, lung, presynaptic sympathetic nerve terminals, vascular endothelial and smooth muscle cells, and hematopoetic cells
CB2 receptors, first cloned in 1993, are mainly expressed in the immune cells
AEA and 2-AG are the 2 best-studied endocannabinoids; they are lipid-derived agonists that bind to and activate CB1 and CB2 receptors
Felder CC, Glass M. Cannabinoid receptors and their endogenous agonists. Annu Rev Pharmacol Toxicol 1998;38:
De Petrocellis L, Cascio MG, Di Marzo V. The endocannabinoid system: a general view and latest additions. Br J Pharmacol. 2004;141:
Pertwee RG. Pharmacology of cannabinoid CB1 and CB2 receptors. Pharmacol Ther. 1997;74:
Roche R, Hoareau L, Bes-Houtmann S, et al. Presence of the cannabinoid receptors, CB1 and CB2, in human omental and subcutaneous adipocytes. Histochem Cell Biol. 2006;126: 31

32. The CB1 Receptor
Activation negatively coupled to adenylate cyclase, suppresses neuronal Ca2+ conductance, inhibits inward rectifying K+ conductance suppression of neuronal excitability
The CB1 Receptor
The CB1 receptor is a member of the rhodopsin subfamily of G-protein–coupled receptors. It consists of 7 transmembrane helices
G-protein–coupled receptors are the largest family of cell-surface receptors; they consist of a single polypeptide chain that threads back and forth across the lipid bilayer seven times
The issue of whether cannabinoid actions were mediated by receptors was resolved when functional inhibition of adenylyl cyclase was observed following the addition of Δ9-tetrahydrocannabinol to neuroblastoma cells. Treatment with pertussis toxin blocked this effect, indicating that cannabinoid action involved a Gi/o protein
Demuth DG, Molleman A. Cannabinoid signalling. Life Sci. 2006;78:
Shim JY, Welsh WJ, Howlett AC. Homology model of the CB1 cannabinoid receptor: sites critical for nonclassical cannabinoid agonist interaction. Biopolymers. 2003;71:
Howlett AC, Fleming RM. Cannabinoid inhibition of adenylate cyclase. Pharmacology of the response in neuroblastoma cell membranes. Mol Pharmacol. 1984;26: 32

33. Difference Between Classical and Retrograde Neurotransmission
Classical Neurotransmitter (ie, acetylcholine)
In a classical neurotransmitter system, for example, acetylcholine, an action potential invades presynaptically, thereby causing depolarization, which triggers the opening of calcium voltage-gated channels
Calcium ions flood in (they are at higher concentration in the extracellular solution) and interact with the synaptic vesicles, allowing for the release of stored neurotransmitter (exocytosis). Acetylcholine spills out into the synaptic cleft (exocytosis) and diffuses across the synaptic cleft
The neurotransmitter (acetylcholine) interacts with receptors at the postsynaptic membrane; these receptors tend to be ligand-gated channels, so they open when neurotransmitter binds
Ions flow through the ligand-gated channels, causing a change in the postsynaptic membrane potential. This is the critical step that initiates the cascade of downstream physiologic effects
The neurotransmitter is then degraded by the enzyme acetylcholinesterase  
Retrograde Neurotransmitter (ie, endocannabinoid)
ECS paradigm: in contrast to the classical paradigm, endocannabinoids are not stored in vesicles. An action potential that triggers the opening of calcium channels activates the synthesis of endocannabinoids from membrane-bound lipid precursors. This takes place postsynaptically
Endocannabinoids are released and diffuse freely into the synaptic cleft. The transport mechanism is currently unknown
Endocannabinoids then bind to and activate CB1 receptors located presynaptically. This reverse path is referred to as retrograde signaling. After binding to the CB1 receptors the G proteins are stimulated to relay the signals to regulate a number of cellular processes
The importance of this signaling paradigm is that the ECS is normally quiet until endocannabinoids are synthesized on demand, they are taken up back into cells rapidly, and degraded immediately. Thus, they act locally at the site of synthesis
Di Marzo V, Matias I. Endocannabinoid control of food intake and energy balance. Nat Neurosci. 2005;8:
Di Marzo V, Bifulco M, De Petrocellis L. The endocannabinoid system and its therapeutic exploitation. Nat Rev Drug Discov. 2004;3:
Wilson RI, Nicoll RA. Endogenous cannabinoids mediate retrograde signalling at hippocampal synapses. Nature. 2001;410:
Vaughan CW, Christie MJ. Retrograde signalling by endocannabinoids. Handb Exp Pharmacol. 2005: 33

34. Physiological Effects of Endocannabinoids
The ubiquitous expression of various components of the ECS, as well as its presence in lower-level organisms, indicates a vital role for this system in normal physiology. In general, the ECS—and the CB1 receptor in particular—is believed to regulate energy balance and behaviors such as food intake, fear, and anxiety, and to modulate lipid and glucose metabolism
Since at least 300 AD, cannabis has been known to stimulate hunger and increase appetite, especially for sweet and palatable food. The ECS is postulated to connect the physical and emotional responses to stress with appetite and energy regulation. As such, it is hypothesized to function as a general stress-recovery system, which remains silent under normal physiologic conditions. Preclinical data using direct and indirect CB1 receptor agonists as well as CB1 receptor antagonists support an anxiolytic role for the ECS
It is postulated that the ECS becomes transiently activated in response to stressful stimuli to protect steady-state homeostatic activity of neuropeptides, hormones, and neurotransmitters. This hypothesis is supported by data showing that the ECS affects a wide variety of physiologic processes, including nociception (pain sense), motor control, memory and learning, appetite, food intake, and energy balance. After stressful stimuli, ECS activation promotes food ingestion, relaxation, pain reduction, and extinction of aversive memories. In this scenario, the ECS-induced drive to eat may be viewed as the need to replenish energy stores to recover from one of the physiologic consequences of stress
Other functions of the ECS in normal physiology may be related to immune function, neuroprotection, fertility, and bone mass
Cota D, Woods S. The role of the endocannabinoid system in the regulation of energy homeostasis. Curr Opin Endocrinol Diabetes. 2005;12: ; De Petrocellis L, Cascio MG, Di Marzo V. The endocannabinoid system: a general view and latest additions. Br J Pharmacol. 2004;141: ; Pagotto U, Marsicano G, Cota D, Lutz B, Pasquali R. The emerging role of the endocannabinoid system in endocrine regulation and energy balance. Endocr Rev. 2006;27:73-100; Ameri A. The effects of cannabinoids on the brain. Prog Neurobiol. 1999;58: ; Cota D, Marsicano G, Tschop M, et al. The endogenous cannabinoid system affects energy balance via central orexigenic drive and peripheral lipogenesis. J Clin Invest. 2003;112: ; Di Marzo V, Matias I. Endocannabinoid control of food intake and energy balance. Nat Neurosci. 2005;8: ; Kershaw EE, Flier JS. Adipose tissue as an endocrine organ. J Clin Endocrinol Metab. 2004;89: ; Correa F, Mestre L, Molina-Holgado E, et al. The role of cannabinoid system on immune modulation: therapeutic implications on CNS inflammation. Mini Rev Med Chem. 2005;5: ; van der Stelt M, Trevisani M, Vellani V, et al. Anandamide acts as an intracellular messenger amplifying Ca2+ influx via TRPV1 channels. Embo J. 2005;24: ; Wang H, Dey SK, Maccarrone M. Jekyll and hyde: two faces of cannabinoid signaling in male and female fertility. Endocr Rev. 2006;27: ; Idris AI, van 't Hof RJ, Greig IR, et al. Regulation of bone mass, bone loss and osteoclast activity by cannabinoid receptors. Nat Med. 2005;11: ; de Oliveira Alvares L, Genro BP, Vaz Breda R, Pedroso MF, Da Costa JC, Quillfeldt JA. AM251, a selective antagonist of the CB1 receptor, inhibits the induction of long-term potentiation and induces retrograde amnesia in rats. Brain Res. 2006;1075:60-67; Arenos JD, Musty RE, Bucci DJ. Blockade of cannabinoid CB1 receptors alters contextual learning and memory. Eur J Pharmacol. 2006;539: ; Mikics E, Dombi T, Barsvari B, et al. The effects of cannabinoids on contextual conditioned fear in CB1 knockout and CD1 mice. Behav Pharmacol. 2006;17: ; Guindon J, De Lean A, Beaulieu P. Local interactions between anandamide, an endocannabinoid, and ibuprofen, a nonsteroidal anti-inflammatory drug, in acute and inflammatory pain. Pain. 2006;121:85-93. 34

35. Common Misconceptions
No evidence-based studies demonstrating that chronic cannabis use can cause or exacerbate schizophrenia
Smoking cannabis is not associated with an increased risk of developing COPD or lung Ca
In fact, protective effects of cannabis smoking seen in two large retrospective, population-based case-control studies

36. Clinically Useful Drug Interactions
When THC co-administered with CBD, as can occur with the usage of some strains of herbal cannabinoid medicines and certain cannabinoid-based extractions
anxiogenic, dysphoric, and possibly short-term memory interrupting effects of THC are mitigated
Evidence suggests cannabinoid drugs can enhance the analgesic activity of co-administered opioids
Opioid dose reductions

37. Neuropathic Pain 3-8% prevalence in industrialized countries
Due to direct damage to or abnormal functioning of the nervous system
2/2 infections, diabetes, trauma, stroke, etc.
Often refractory to existing treatments
Currently available treatments: gabapentin and other anticonvulsants, NMDA receptor antagonists – limited by their SE
NP medicine market forecast: expected to double to $5.2 bil by 2018 37

38. Cannabinoid Suppression of Neuropathic Pain – Basic Science
Cannabinoids have been shown to suppress neuropathic nociception in at least 9 different animal models of surgically-induced traumatic nerve or nervous system injury1
Chronic constriction injury: infraorbital nerve, saphenous nerve
Partial nerve ligation: sciatic, saphenous
Spinal nerve ligation: L5
Spared nerve injury
Spinal cord injury
Tibial nerve injury
Streptozotocin-induced diabetic neuropathy
1Rahn EJ and Hohmann AG. Cananbinoids as Pharmacotherapies for Neuropathic Pain: From the Bench to the Bedside. Neurotherapeutics :4, 38

39. Cannabinoid Suppression of Neuropathic Pain – Basic Science
In CCI of infraorbital nerve model, CB1 receptor upregulation was observed in both the ipsalateral and contralateral superficial layer of the trigeminal caudal nucleus (I>C)
CB2 receptor immunoreactivity is increased in the ipsilateral dorsal horn after L5 spinal nerve transection
Saphenous partial nerve ligation increased u-opioid, CB1, and CB2 receptor protein levels in ipsalateral/contralateral hind paw skin, DRG, and ipsalatera/contralateral L-cord (1-7 days post-surgery)
Tibial nerve injury upregulation of CB1 receptor mRNA in the contralateral thalamus, 1 day post-surgery
SCI model—mechanical allodynia was reduced with chronic administration of WIN (mixed CB agonist) with no decrease in effectiveness, unlike morphine
1Rahn EJ and Hohmann AG. Cananbinoids as Pharmacotherapies for Neuropathic Pain: From the Bench to the Bedside. Neurotherapeutics :4, 39

40. Cannabinoid Suppression of Pain
Analgesia: different mechanism than opiates, some synergy though.
Spasticity: likely GABA mediated
Appetite enhancement: hippocampal?
Anti-emetic: cerebellar?
Elevated levels of the CB1 receptor - like the
opioids are found in areas of the brain that
modulate nocioceptive processing
CB1 and CB2 agonists have peripheral analgesic actions
CBs may also exert anti-inflammatory effects
Analgesic effects not blocked by opioid antagonists

41. Results: Neurology RCT
Abrams et al Neurology 2007 41

42. EBM One Clinical trials
Abrams DI, Jay CA, Shade SB, Vizoso H, Reda H, Press S, Kelly ME, Rowbotham MC, Petersen KL. Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial. Neurology 2007; 68(7):
Ellis RJ, Toperoff W, Vaida F, van den Brande G, Gonzales J, Gouaux B, Bentley H, Atkinson JH. Smoked medicinal cannabis for neuropathic pain in HIV: a randomized, crossover clinical trial. Neuropsychopharmacology 2009;34(3):
Rog DJ, Nurmikko TJ, Friede T, Young CA. Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis. Neurology 2005; 65(6):812-9.

43. Cochrane reviews
Phillips TJ, Cherry CL, Cox S, Marshall SJ, Rice AS. Pharmacological treatment of painful HIV-associated sensory neuropathy: a systematic review and meta-analysis of randomised controlled trials. PLoS One 2010; 28;5(12):e14433.
Martín-Sánchez E, Furukawa TA, Taylor J, Martin JL. Systematic review and meta-analysis of cannabis treatment for chronic pain. Pain Med 2009; 10(8):
Campbell FA, Tramèr MR, Carroll D, Reynolds DJ, Moore RA, McQuay HJ. Are cannabinoids an effective and safe treatment option in the management of pain? A qualitative systematic review. BMJ 2001; 323(7303):13-6.

44. Cochrane reviews
Smith PF. The safety of cannabinoids for the treatment of multiple sclerosis. Expert Opin Drug Saf May;4(3):
Mills RJ, Yap L, Young CA. Treatment for ataxia in multiple sclerosis. Cochrane Database Syst Rev 2007; Jan 24;(1):CD
Machado Rocha FC, Stéfano SC, De Cássia Haiek R, Rosa Oliveira LM, Da Silveira DX. Therapeutic use of Cannabis sativa on chemotherapy-induced nausea and vomiting among cancer patients: systematic review and meta-analysis. Eur J Cancer Care 2008;17(5):

45. Other Neuropathic Indications
spasticity and pain associated with multiple sclerosis, amyotrophic lateral sclerosis, or spinal cord injury;
physical or verbal tics caused by Tourette's syndrome.
Refractory seizure disorder
Nerve pain, nausea and loss of appetite resulting from chemotherapy, radiotherapy or HIV combination therapy

46. So how does this all work in clinic?
Methods of Use
Pros and Cons of inhalation versus ingestion
How to educate patients in usage and dosage

47. Vaporization of cannabis – safe alternative to smoking
examples

48. How do vaporizers work?
When cannabinoids are heated to between 285 °F (140 °C) and 392 °F (200 °C) they literally boil and vaporize.
Studies show that vaporization is most effective at around 338 °F (170 °C)
a vaporization temperature over 392 °F (200 °C) will burn the cannabis, creating unwanted smoke.

49. Serum levels after inhalation
THC Administration
Blood levels
17.2

50. Absorption slow absorption with oral THC Administration 17.4
Blood levels
Rated “high”
17.2

51. rapid initial drop due to redistribution to fats
slower metabolism in liver
metabolites may persist for a week
Primary metabolic product of 9-THC (11-OH-9-THC) is more potent than 9-THC
Delay between peak plasma levels and peak effect

52. With so many choices…how do I pick the RIGHT medicine??
Sativa?
Indica?
Genetic clones?
Hashish?
Oils?

53. And how do I use it?
Vaporize?
Ingestion?
Transdermal?

54. Start by understanding the differential effects of major cannabinoids
Cannabis strains with high levels of both THC and CBD will create a strong energetic high. This is typical of Cannabis Sativa (or Sativex!!)
low levels of THC and high levels of CBD will be more of a body, sleepy feeling. This is typical of Cannabis Indica
Tetrahydrocannabivarin (THCV) is found primarily in strains from African and Asian cannabis.
THCV intensifies THC effects
Cannabis with a potent smell (aka “skunk”) indicates a high level of THCV.
Some cannabinoids, including Cannabichromene (CBC) and Cannabicyclol (CBL) are not psychoactive but may enhance the effects of THC.

55. KNOW THE SIDE EFFECTS disinhibition, relaxation, drowsiness
feeling of well being, exhileration, euphoria
sensory - perceptual changes
recent memory impairment
balance/stability impaired
decreased muscle strength, small tremor
poor on complex motor tasks (e.g., driving)

56. Blurred vision? Psychomotor performance-dose dependent decline
Performance decrement (s)
17.5

57. Effects on behavior Not lethal even at very high doses
pseudohallucinations
synesthesias
impaired judgement, reaction time
pronounced motor impairment
increasingly disorganized thoughts, confusion, paranoia, agitation
Not lethal even at very high doses

58. DOSING: Start LOW and go SLOW
Adverse effects: mainly seen in new users
Euphoria versus paranoia
Short term memory impairment
Balance, incoordination
These are reversible, short lived effects (3-4 hours max)
Serious adverse effects NOT seen in chronic users

59. Components of pain that may respond to cannabis
Cramping (anti-spasticity)
Neuropathic: allodynia, hyperpathia
Mechanical: Dull, aching (anti-inflammatory)

60. Pros/Cons/Risks/Benefits
Good analgesia
High dosing ceiling vs minimal toxicity
Risk for psychological addiction not an issue
Minimal physical dependence
Not many drug-drug interactions

61. Pros/Cons/Risks/Benefits
Some tolerance may develop in heavy, long term users may need higher doses
Patient/family will have to purchase or grow it
Dronabinol is NOT as effective –

62. Dronabinol (Marinol)
Dronabinol is 100% THC, the most psychoactive ingredient in cannabis. Natural cannabis is 20% THC or less
The physiological effect of THC is modulated when the other cannabinoid forms are present. Dronabinol is associated with too many psychoactive effects.
DEA classifies dronabinol as schedule III
FDA approved dronabinol for treatment of nausea and vomiting associated with chemotherapy and anorexia associated with weight loss in patients with HIV/AIDS
Dronabinol is not an appropriate substitute for natural cannabis.
Dronabinol is very expensive
Sativex is much better but not available in US (50% THC, 50% cannabadiol in a sublingual spray)

63. Metz, L., and S. Page Oral cannabinoids for spasticity in multiple sclerosis: will attitude continue to limit use? Lancet 362 (9395):1513.
“ We now have as much evidence to support the use of the oral cannabinoids for spasticity in ambulatory people with multiple sclerosis as we do for many standard therapies for spasticity, including baclofen.”

64. Sativex Oromucosal Extract
1:1 combination from two clonal cannabis cultivars yielding a high THC extract (Tetranabinex®) and a high CBD extract (Nabidiolex®).
a botanical drug substance (BDS) of defined composition with controlled reproducibility batch to batch.
THC and CBD comprise some 70% (w/w) of the total BDS, with minor cannabinoids (5 – 6%), terpenoids (6 – 7%, most GRAS), sterols (6%), triglycerides, alkanes, squalene, tocopherol, carotenoids and other minor components (also GRAS).
each 100 μL pump-action spray provides 2.7mg of THC and 2.5mg of CBD, the minor components, plus ethanol: propylene glycol excipients, and 0.05% peppermint as flavouring.
Intermediate onset: minutes
Allows dose titration
Reduces first pass metabolism
Acceptable to patients

65. Primary Endpoint Mean change in Spasticity Score from Baseline (ITT)
Collin C, Davies P, Mutiboko IK, Ratcliffe S. Randomized controlled trial of cannabis-based medicine in spasticity caused by multiple sclerosis. Eur J Neurol (3):290-6.
*Anova

66. Sativex – better than marinol BUT…
Sativex produced a statistically significant improvement in spasticity
Improvement gained over and above concomitant anti-spasticity medication
Improvements gained without decrease in muscle strength
Sativex was well tolerated
Few withdrawals due to adverse events
Extension data
sustained and continuing improvement in spasticity
Patients did not develop tolerance to Sativex over 28 weeks

67. Conclusions of National Clinical Advisory Board of the National Multiple Sclerosis Society
Key recommendations for research priorities include:
Better study outcome measures need to be developed.
A consensus is needed on standards for trial design to test the efficacy of cannabinoids for symptomatic management.
Because inhaled smoked cannabis has more favorable pharmacokinetics than administrationvia oral or other routes, research should focus on the development of an inhaled mode of administration that gives results as close to smoked cannabis as possible.
Longer-term side effect data need to be obtained.
There are sufficient data available to suggest that cannabinoids may have neuroprotective effects that studies in this area should be aggressively pursued.

68. Cannabis and amyotrophic lateral sclerosis
Significant advances have increased our understanding of the molecular mechanisms of amyotrophic lateral sclerosis (ALS), yet this has not translated into any greatly effective therapies. It appears that a number of abnormal physiological processes occur simultaneously in this devastating disease. Ideally, a multidrug regimen, including glutamate antagonists, antioxidants, a centrally acting anti-inflammatory agent, microglial cell modulators (including tumor necrosis factor alpha [TNF-alpha] inhibitors), an antiapoptotic agent, 1 or more neurotrophic growth factors, and a mitochondrial function-enhancing agent would be required to comprehensively address the known pathophysiology of ALS. Remarkably, cannabis appears to have activity in all of those areas. Preclinical data indicate that cannabis has powerful antioxidative, anti-inflammatory, and neuroprotective effects. In the G93A-SOD1 ALS mouse, this has translated to prolonged neuronal cell survival, delayed onset, and slower progression of the disease. Cannabis also has properties applicable to symptom management of ALS, including analgesia, muscle relaxation, bronchodilation, saliva reduction, appetite stimulation, and sleep induction. With respect to the treatment of ALS, from both a disease modifying and symptom management viewpoint, clinical trials with cannabis are the next logical step. Based on the currently available scientific data, it is reasonable to think that cannabis might significantly slow the progression of ALS, potentially extending life expectancy and substantially reducing the overall burden of the disease.
Carter GT, Abood ME, Aggarwal SK, Weiss MD. Cannabis and amyotrophic lateral sclerosis: hypothetical and practical applications, and a call for clinical trials. Am J Hosp Palliat Care 2010;27(5):

69. Conclusions/Comments
Preclinical data indicate that cannabis has powerful antioxidative, anti-inflammatory, and neuroprotective effects.
Cannabis is also useful in management of pain, particularly neuropathic pain, spasticity, seizures, tics, siallorhea, bronchospasm,cachexia and wasting, and insomnia.
Based on available scientific data,cannabis may slow progression of ALS and other neurodenerative disorders
Vaporization is a safe, effective alternative to smoking
Cannabis is remarkably safe, few drug interactions

70. Comments
Sativex is better than Marinol but not as good as natural cannabis
Cannabis plant is indiginous to North America, is relatively easy to grow, dry out, and use as medicine, following a tradition that has existed for thousands of years.
This could be done for pennies
Risk to society? Not much

71. What about the war on drugs?
Five years after the Portugese government decriminalized the use and possession of heroin, cocaine, marijuana, LSD and other illicit street drugs, the number of deaths from street drug overdoses dropped almost 50% and the number of new HIV cases caused by using dirty needles to inject heroin, cocaine and other illegal substances plummeted from nearly 1,400 in 2000 to about 400 in 2006
Instead of going to prison, addicts go to treatment centers
Under the Portuguese plan, penalties for people caught dealing and trafficking drugs are unchanged; dealers are still jailed and subjected to fines depending on the crime.
“No problem can be solved from the same level of consciousness that created it” Albert Einstein

72. If you choose to recommend cannabis…
FOLLOW THE LAW
Counsel the patient and family
Patient should use high quality cannabis to improve efficacy: high CBD, CBN, lower THC – do not need to be high to get pain relief
Use a delivery route that maximizes benefits and minimizes side effects

73. How to prescribe medical cannabis

74. Primum Non Nocere:

75. Thanks…
Q&A
Contact info: