1. Cannabis and Digestive Disorders
Hi, Im am Dr. Nick Salamie one of the registered pharmacists at PDI Medical and I am here to have a discussion about Cannabis and Digestive Disorders.
Cannabis and Digestive Disorders
Dr. Nick Salamie PharmD, RPh
PDI Medical

2. Crohn’s Disease Inflammatory Bowel Disease
Affects the ileum and/or the colon
Symptoms range in severity
Cause is unknown
1 of the 41 qualifying conditions in IL
-Crohns disease is one of the main Inflammatory Bowel Diseases.
-Crohns can affect the ileum or the colon or both. The ileum is the last segment of the small intestines. The colon refers to the large intestines.
-Symptoms can range in severity and can come on suddenly. Active symptoms may include: diarrhea, fever, fatigue, abdominal pain and cramping, blood in your stool, mouth sores, reduced appetite, malnutrition and weight loss. Inflammation in the Joints and other parts of the body may be experienced as well.
-The exact cause of Crohns Disease is unknown. Some possible causes are an abnormal immune response and heredity.
-Crohn’s is one of the qualifying conditions for a medical cannabis card in the state of Illinois.

3. Ulcerative Colitis Inflammatory Bowel Disease
Affects large intestine and rectum
Inflammation and ulcers
Symptoms vary depending on where the inflammation occurs
NOT one of the qualifying conditions in IL
-Ulcerative Colitis is another inflammatory bowel disease.
-Ulcerative Colitis affects any part of the Colon and rectum.
-The main issue with ulcerative colitis is inflammation and ulcers that can cause debilitating symptoms.
-These symptoms may include diarrhea, abdominal pain and cramping, rectal pain, rectal bleeding, urgency to defecate, inability to defecate despite urgency, weight loss, fatigue, and fever.
-Ulcerative Colitis is not currently one of the qualifying conditions in Illinois, but hopefully will be added when they make the medical program permanent.

4. Pharmaceutical Treatments
azathioprine
mercaptoprine
infliximab (Remicade)
adalimumab (Humira)
certolizumab pegol (Cimzia)
methotrexate (Trexall)
natalizumab
vedolizumab
Here’s a list of some of the more common pharmaceutical treatments for inflammatory bowel diseases. Which I won’t discuss.
You all have probably seen the drug commericals where everybody is living their best lives and having a great time. Then right at the end they quickly cover the risks like these on the next slide…

5. These are the major risks with taking humira
These are the major risks with taking humira. People have died from serious infections that occurred while taking the drug. If a serious infection wasn’t enough to worry about, Cancer including a rare type of cancer called hepatosplenic T-Cell lymphoma that often results in death is a risk.
Medical Cannabis does not have these serious risks associated with it.

6. Endocannabinoid System
Found in all animals
CB1 and CB2 receptors
Located all over body
Anandamide and 2-AG
Balance In the body
Regulatory Function in the GI tract
Phytocannabinoids as treatment
THC
CBD
-Which leads us into the Endocannabinoid System.
-The endocannabinoid system is a complex regulatory system found in all mammals. The endocannabinoid system regulates functions such as memory, digestion, motor function, immune response and inflammation, appetite, pain, blood pressure, and bone growth, just to name a few.
-The CB1 and CB2 receptors are the primary endocannabinoid receptors involved. These receptors are located all over the body as you can see in the graphic. However, there are other receptors involved and mechanisms that still need to researched.
-Our body produces our own cannabinoids. These 2 endocannabinoids are called anandamide and 2-AG.
-Endocannabinoids seemed to connected to the concept of homeostasis, meaning they play a major role in maintaining a balance throughout the body.
-Regulatory functions of the GI tract are linked to the endocannabinoid system and the body’s endocannabinoids regulate almost all gut function.
-Phytocannabinoids like THC and CBD used are used to treat Irritable Bowel Diseases. Many patients using cannabis with severe inflammatory bowel disease have reported that cannabis reduces the frequency and severity of nausea episodes. It has been found that cannabinoids modulate gut pain and visceral sensation in a variety of experimental models, which supports patient reports of cannabis medicines providing distraction and relief from Crohns related pain.

7. THC Major Therapeutic Cannabinoid
Potent anti-inflammatory and analgesic activity
Excellent Appetite Stimulant
Reduces Nausea
Slows down movement through intestinal tract
-Delta-9-tetrahydrocannabinol also know as THC is one of the major therapeutic cannabinoids. Out of all the cannabinoids this is the one cannabinoid most people are familiar with.
-THC has potent anti-inflammatory and analgesic activity. It reduces the perception of pain.
-THC is an excellent appetite stimulant. Appetite stimulation typically requires only small doses of THC around 2mg.
-THC reduces nausea, but typically requires higher doses of THC.
-THC can reduce gut motility, meaning that it can slow down movement through the intestinal tract.

8. CBD Non Psychoactive Potent Anti-inflammatory action
May increase gut motility
CBD more effective with THC
“Power Couple”
Hemp CBD vs. Whole Plant CBD
-CBD also known as Cannabidiol is the other major therapeutic cannabinoid and has no psychoactivity by itself.
-CBD has potent anti-inflammatory action and it calms gut inflammation specifically blocking the GPR55 receptor which is proinflammatory when activated.
-CBD may increase gut motility and in certain patients CBD may cause diarrhea, but that affect seems rare based off of anecdotal evidence I have seen.
-CBD and THC work syngestically together. They are seen as the power couple in the cannabis world.
-A lot of patients who come into PDI say they have tried hemp CBD. Theres a big difference between between Hemp based CBD and Whole plant CBD. The Hemp based CBD with little to no THC that’s found legally in all 50 states is not as effective therapeutically as whole plant based CBD you find in dispensaries. The whole plant CBD rich medicines offer higher concentrations of THC for better therapeutic effects.

9. Beta-Caryophyllene Terpene/Cannabinoid
Found in Black Pepper and Cloves
Drug Dogs
Potent anti-inflammatory compound
Effective in mouse model of colitis
-Beta-Caryophyllene is a very interesting molecular compound found in cannabis. It’s a terpene and a cannabinoid at the same time. Terpenes give off aroma and can physiological effects in the body. They are found in essential oils, foods and other products. Beta-Caryophyllene is also a cannabinoid because it has action on the CB2 receptor.
- Beta Caryophyllene is also found in black peppers and cloves. That’s interesting because Black Pepper and Cloves may technically be illegal under laws that prohibit the distribution of cannabinoid analogs.
Beta-Caryophyllene oxidizes into the compound caryophyllene oxide which drug detection dogs are trained to smell. THC has no scent by it self.
- Its a potent anti-inflammatory compound as well, so its important to consider products high in beta-caryophyllene when making a cannabis selection.
- Beta-Caryophyllene may be useful in Ulcerative Colitis as it has been shown to be effective in limiting intestinal damage in a mouse model of colitits.

10. First PDI Visit Goals Increase Quality of Life Drug Interactions
Assess Patients Cannabis Experience
No or little cannabis experience
Intermediate cannabis experience
Advanced Cannabis Experience
Tapering Strategy if Necessary
Product selection and initial strategy
Minimum Effective Dose
Follow Up
When a patient first comes into PDI ideally they will have a brief conversation with me or another healthcare professional to devise a game plan. PDI is the only dispensary in Illinois to have a health care professional available at most times.
The goals differ from patient to patient, but the universal goal always is to increase the quality of life. And to be clear getting the patient “stoned” is never a goal with just about every patient.
We do drug cannabis interactions to make sure there are no significant interactions between the patients pharmaceuticals and cannabis. For example, we have to be careful when a patient is on warfarin due to a cannabis-drug interaction that could potentially increase the risk of bleeding.
Initial Dosing Strategies with patients are typically based off the patients experience and comfort with cannabis.
Patients with no or little cannabis experience I will take a way different approach than someone with Advanced Cannabis Experience. Patients with no or little cannabis experience I typically recommend starting out with CBD Rich cannabis products and/or microdosing of a THC rich product. This conservative approach reduces the chances of any unwanted side effects and allows patients to find their sweet spot in a comfortable fashion.
A patient with intermediate cannabis experience can be defined as someone who is familiar with the effects of THC on their body and have somewhat of an idea how well they tolerate cannabis. I typically will recommend either a 1:1 cbd to thc product and/or thc rich products at low to moderate doses for these types of patients.
A patient with advanced cannabis experience can be defined as someone who has been self medicating for quite some time and knows exactly how well and the amount of cannabis they can tolerate. These patients are the easiest to dose since you don’t have to worry as much about adverse effects.
If the patient is currently coming off of opioids a sound tapering strategy should be discussed. Each tapering approach will be unique from patient to patient. A patient who has been on extended release and intermediate release oxycontin for years may have a completely different approach than a patient who has been taking norco twice a day for 1 month.
-Initial product selection and strategy is going to be based on the patients current cannabis use and any limitations, like if the patient cant inhale and so forth.
The idea is to get the patient to the minimum effective dose, also known as the sweet spot, which is the dose where they are getting sufficient relief without any adverse effects.
Following up is important because it may take multiple visits to find the best possible regimen.

11. Products/Dosage Forms
Inhalation
Combustion
Vaporization
Oral
Sublingual
Oromucosal
Gastrointestinal
Transdermal
Rectal
- When it comes to selecting products, I like to recommend a high THC inhalation product to most people with any digestive disorders, like crohns. It’s the fastest way to deliver cannabinoids into the body. Inhalation of cannabinoids hits the blood stream within seconds or so and takes max effect at 10 minutes give or take. If we want quick nausea reduction or appetite stimulation an inhaled formulation with mostly THC can be quick and effective. I tend to stay away from combustion, like out of a pipe or joint since it can be irritating and possibly give off unwanted biproducts. Vaporization of cannabis flowers or oils tends to be less irritating on the throat and there’s less of a chance of inhaling any harmful biproducts.
-The other essential dosage form I like to recommend is an oral formulation with some CBD and THC to get the benefit of both major cannabinoids. Sublingual or under the tongue dosing can be achieved using a tincture or cannabis oil. Oromucosal, the lining of the cheeks and gums, can be achieved using a cannabis oil. Gastrointestinal absorption can be achieved by using edibles, oils, tablets, capsules and liquid solutions. The downside to oral formulations is that their onset is much longer than inhaling. Oral formulations can take any where from 20 min- 2 hours to take effect with sublingual and oromucusal being on the quicker side , but they can last anywhere from 4-8 hours. Another advantage of oral dosage forms is that they can be very soothing to the gut.
-Cannabinoids can be also be delivered transdermally via a patch. This dosage form tends to take effect within 30 minutes and can last up to 12 hours. The downside is that it can be expensive.
-Rectal Suppositories are great for patients who mainly have inflammatory issues located in the large intestines or rectum. An advantage with rectal suppositories is that they have little to no psychoactivity.

12. PDI Patient X 22 y/o male Crohns Disease Medications Cimzia Humira
Caused Psoriasis
Remicade
methotrexate
prednisone
Moody and weight gain
Lialda
Proctofoam
Canasa
Currently uses cannabis and bi-monthly infusions of Entyvio
-This is a current patient at PDI. A 22 year old male who was diagnosed with Crohns when he was 15 years old.
-He tried all of these medications at one point or another. He experienced some side effects from his past medications. Humira caused some psoriasis issues, shown in the photos which has been present for 3 years now. Predinisone made him moody and fat.
-He currently keeps his Crohns in check with cannabis products and bi-monthly infusions of Entyvio without any undesirable side effects.

13. Irritable Bowel Syndrome
Affects the large intestine
Signs and Symptoms vary
Cause unknown
More prevalent in females
Cannabis Treatment
Depends on Symptoms
Not a qualifying condition
-I am going to briefly cover a few other digestive issues starting with Irritable Bowel Syndrome.
-This condition affects the large intestines.
-The signs and symptoms vary. The most common are abdominal pain, excess gas, diarrhea or constipation with it sometimes alternating between diarrhea and constipation, and possibly mucus in the stool.
-The exact cause is not known but a few factors that may play a role are Muscle contractions in the intestines, abnormalities in the nervous system, inflammation in the intestines, severe infection and changes in the gut microflora.
-Females seem to be at higher risk of developing Irritable Bowel syndrome.
Treating IBS with cannabis really depends on the symptoms. If diarrhea is an issue you may want avoid ingesting excessive CBD since it can possibly exacerbate the issues and for constipation you may want to avoid ingesting excessive THC since it slows down gut motility.
IBS is not currently a qualifying condition for a medical cannabis card.

14. Cachexia and Appetite Loss
Complex metabolic syndrome
One of the 41 qualifying conditions
Treatment
“Munchies”
-Cacheixia is a complex metabolic syndrome typically caused by an underlying illness and is characterized by the loss of skeletal muscle with or without loss of fat mass. It is one of the 41 qualifying conditions in Illinois. Cachexia is associated with the later stages of some diseases like cancer, HIV/AIDS, heart, liver, and kidney failure, tuberculosis, dementia, COPD and RA and neurodegenerative disorders.
-Because the endocannabinoid system has a role in regulating appetite, cannabis medicines have been used to help stimulate appetite in hopes of curbing the loss of body mass.
-Treatment with cannabis to stimulate appetite can be achieved with small amounts of THC. Inhalation before meals is desirable since its fast acting.
-The munchies effect of THC is thought to be the action on the nucleus accumbens, an area in the midbrain that causes over eating and increases food palatability.

15. Cancer Controversial/Experimental
Promising evidence in intestinal cancer
Chemotherapy-Induced Nausea
Appetite
Quality of Life
One of the qualifying conditions
-This next topic is somewhat controversial. Treating cancerous tumors and lesions with cannabis is a hot topic. There is not much evidence in the medical community as far as peer reviewed studies go, but there are plenty reports of patients going into remission using only cannabis after conventional treatment failed. It usually takes high daily doses of cannabinoids that can achieved with cannabis oils. Upwards of 300mg CBD and/or 300mg THC a day and possibly even higher doses.
-There are limited preclinical studies of cannabinoids and intestinal cancer. Recent reviews are promising though, Showing that activation of CB1, CB2, and TRPV1 receptors reduce tumor growth and protect mice from induction of colon cancer experimentally. This is unrelated to digestive disorders, but you have to cautious because in certain types of cancer like HER-2 receptor positive breast cancer as THC can actually proliferate tumor growth.
-Cannabis is very helpful with treating other aspects of cancer. It does wonders for Chemotherapy-Induced Nausea and Vomiting by helping to reduce nausea via THCs action on the CB1 receptor.
-Poor appetite can also be addressed with cannabis.
-It can also increase a patients quality of life struggling with depression and anxiety due to a cancer diagnosis.
-Also, its one of the qualifying conditions in Illinois.

16. Cannabis Oils/RSOs Best medical dosage form
Whole Plant/Full Spectrum Extract/Herbal Shotgun
Varying Cannabinoid Profiles
Different CBD:THC ratios
Acidic Cannabinoids: THCa, CBDa, CBGa
“Varin” Cannabinoids: THCV, CBDV
Less abundant Cannabinoids: CBN, CBG, CBC
Terpenes Captured
Beta-Caryophyllene
Lets discuss Cannabis Oils also known as Rick Simpson Oils, RSO for short, even though Rick Simpson doesn’t like his name being used in commericialized cannabis products. And that’s Rick Simpson in the picture.
In my opinion Rick Simpson Oils are the best medical cannabis dosage form currently available.
The way the extract process works is that it literally extracts everything from the plant including the cholorphyll when ethanol is used as the main solvent.
Luckily medical cannabis patients in Illinois have access to a wide variety of RSOs ranging from all THC to nearly all CBD and everything in between. There are some with very unique cannabinoid profiles you can find offered from Shelby county. For instance when the traditional THC and CBD rich medicines don’t provide much relief we may look at using a RSO that’s rich in acidic cannabinoids since THCa shows promise in neurological problems. Or we can find one with a decent amount of the varin cannabinoids like CBDV. Typically the varin cannabinoids are found more in Oils that use Carbon dioxide as a solvent like Shelby uses. Also, you will find the less abundant cannabinoids listed here in some of these RSOs. RSOs are the best way to get as many cannabinoids and terpenes into the body as possible per dose size and we may be getting a better synergistic effect than just a typical thc dominant edible.
RSOs are typically rich in terpenes as well. The specific terpene profile or entourage will really be dependent on the strain. It best to look for Oils rich in Beta-Caryophyllene since this particular terpene also acts as an anti-inflammatory agent.

17. Getting Your Cannabis Card
Formal Diagnosis of 1 of the 41 qualifying conditions
Completion of Physician Written Certification Form by Licensed Physician
Fingerprint/Background Check
Completion of Online Forms and Payment
Provisional Registration
Dispensary Transfer
-The actual process of getting a medical marijuana card in Illinois seems like an involved process, but its relatively simple especially with the help of PDI medicals staff or the with people at compassionate clinics
The first step is to determine whether you have a formal diagnosis of 1 of the 41 qualifying conditions like PTSD.
The next step and probably the most important step is to have a physician complete and sign a Physician written certification form. If your personal doctor wont sign compassionate clinics has cannabis educated physicians on staff.
The next step is to call PDI Medical and schedule an application appointment, which we do free of charge. Fingerprints and background checks are no longer required, but we will take your passport photo and we will also help you to make sure you have all the documents and paperwork the state requires. Finally, we will help you submit your application online. Sending a paper application is discouraged since the state implemented provisional registration earlier this month.
Provisional registration allows patients a temporary access card to a dispensary within 24 hours of application submission online that’s good for 90 days while they wait for the plastic hard card.
Some Illinois medical cannabis patients don’t realize this but you are allowed to change dispensaries once you get the plastic hard card. If youre interested in transferring to PDI you can give PDI a call and we can take care of the rest. Once you’re a PDI patient you can schedule appointments with myself or with anybody on our knowledgeable staff.

18. Down The Pipeline Adult Use Medical Patient Side
New Qualifying Conditions
Autism
Chronic Pain
Irritable Bowel Syndrome
Migraines
Osteoarthritis
Anorexia Nervosa
Ehler-Danlos Syndrome
Neuro-Behcet’s Autoimmune Disease
Neuropathy
Polycystic kidney disease
Superior Canal Dehiscense Syndrome
New Vet Pathway
OAPP
Adult Use
Higher Taxes
Flower 10%
Edibles 20%
Concentrates 25%
Medical Patient Side
Separate From Adult Use
Inventory Control Measures
Heres an update on the evolving changes in regards to cannabis in Illinois. Heres the List of the new qualifying conditions that will be added once the governor signs bill SB Illinois military veterans will be able to try cannabis without committing to the 1 year minimum card through the OAPP pathway which only costs 10 dollars for a 90 day card.

19. References
Backes, Michael, et al. Cannabis Pharmacy: the Practical Guide to Medical Marijuana. Black Dog & Leventhal Publishers, 2017.
Bersten, Melani PharmD, RPh. “Advanced Medical Cannabis: Dispensing and Dosing Considerations.” Powerpoint File.
“Crohn's Disease.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 8 Mar. 2018, disease/diagnosis-treatment/drc
“Crohn's Disease.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 8 Mar. 2018, disease/symptoms-causes/syc
d29jlv5g6rsjhb.cloudfront.net/images/thumbs/md/d7b6eb53f8d5083a c6f222e82e87d93.jpg.
Goldstrich, Joe D MD, FACC. “Unleashing the Full Potential of Cannabis’ Antineoplastic Benefits: Reimagining the Concept of Full Extract.” Powerpoing File.
“ Meta.jpg.
“Important Safety Information | HUMIRA.” English |US, information?cid=ppc_ppd_ggl_franchise_brand_2015_exact_Important_Safety_Info_stlk_64X
“Irritiable Bowel Syndrome.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 17 Mar. 2018, conditions/irritable-bowel-syndrome-causes/syc
nurseslabs.com/wp-content/uploads/2017/04/Small-and-Large-Intestine-Digestive-System-Anatomy-and-Physiology.png.
Russo, Ethan B., and Jahan Marcu. “Cannabis Pharmacology: The Usual Suspects and a Few Promising Leads.” Cannabinoid Pharmacology Advances in Pharmacology, 2017, pp. 67–134., doi: /bs.apha
“Ulcerative Colitis.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 8 Mar. 2018, colitis/symptoms-causes/syc

20. Questions?