HOW MEDICAL IS CANNABIS? Stephen Dahmer, MD Family Physician Chief Medical Officer | Vireo Health Assistant Clinical Professor | Family Medicine & Community Health | ICAHN School of Medicine
www.vireohealth.com/ny| 1 GENUS: Cannabis sativa FAMILY: Cannabinaceae
www.vireohealth.com/ny| 2 PLANTS AND MEDICINE Estimates that 80% of the world’s population rely predominantly on plants and plant extracts for healthcare. (Cox and Balick, 1994)
3 CANNABIS STIGMA (MARIJUANA) If Cannabis were unknown, and bioprospectors were suddenly to find it in some remote mountain crevice, its discovery would no doubt be hailed as a medical breakthrough. Scientists would praise its potential for treating everything from pain to cancer, and marvel at its rich pharmacopoeia—many of whose chemicals mimic vital molecules in the human body. (Economist, 2006)
A gullible Googler could easily believe we’re on the brink of a miracle cure. (National Geographic, 2015)
www.vireohealth.com/ny| 4 REINTRODUCTION TO CANNABIS o The cannabis plant (Cannabis sativa, C. indica and C. ruderalis) is an annual flowering herb o Somewhere between 6.38 and 34 million years old o It has more than 60 unique compounds (>500 total) o Δ-9-tetrahydrocannabinol (THC) is intoxicating (one of 100+). Cannabidiol (CBD) – the other major cannabinoid is not o Earliest recorded use of medicinal cannabis (“ma”) dates back to 2900BC – Emperor Fu His o 1964 – Anadamide discovered (Mechoulam, Devane and Hanus)
www.vireohealth.com/ny| 5 Cannabis in the United States
• Listed in U.S Pharmacopeia 1850-1941 • Marijuana extracts were among the top 3 most prescribed meds in the US from 1842-1890s
www.vireohealth.com/ny| 6 PRESCRIPTION CANNABINOIDS
www.vireohealth.com/ny| 7 Varieties of Cannabinoids
Synthetic Endocannabinoids Phytocannabinoids cannabinoids
Endogenous In plants From the lab
THC, CBD, CBG, CBDV, Nabilone, HU-210, AB- THCV, CBC, CBN, THCVA PINACA, JWH-018, K2 etc. etc
www.vireohealth.com/ny| 8 ENTOURAGE/SYNERGY/ENSEMBLE
When administered together potentiates therapeutic effect while mitigating side effects.
www.vireohealth.com/ny| 9 www.vireohealth.com/ny| 10 Major Cannabinoids THC* CBD* Minor Cannabinoids CBC, CBG*, CBN*, THC-V*, CBD-V*, THCA*, CBDA*, CBC-V, etc Terpenes trans-caryophyllene#, α-caryophyllene#, α-pinene, β-pinene, terpinolene, myrcene, limonene, linalool, phytol, squalene Carotenoids β-carotene# Fatty Acids Linoleic acid, Palmitoleic acid, Linolenic acid, Palmitic acid, Oleic acid, Stearic acid, Myristic acid, Arachidonic Sterols Β-sitosterol, campesterol, stigmasterol Vitamins Vitamin E Triglycerides
www.vireohealth.com/ny| 11 NATURAL ANTAGONISM
Loss of antagonism may lead to increased side effects and poor tolerability.
(Russo. Br J Pharmacol. 2011)
www.vireohealth.com/ny| 12 ECS (ENDOCANNABINOID SYSTEM)
www.vireohealth.com/ny| 13 ENDOCANNABINOID SYSTEM (ECS)
o RELAX o EAT o SLEEP o PROTECT o FORGET Homeostatic super-modulatory system
www.vireohealth.com/ny| 14 Dustin Sulak, DO
www.vireohealth.com/ny| 15 MEDICAL CANNABIS IN MINNESOTA
§ Licensed Pharmacists/Medical Model § CO2 Extraction § Formulation/”Real Dose” § Physician/Provider certification and follow-up § Precision of final product (within 10%) § 3rd Party testing (Heavy metals, bacteria, etc.) § No popularized names/strains
www.vireohealth.com/ny| 16 THIRD PARTY TESTING: QUALITY, SAFETY & Overall Process CLINICAL STRENGTH
• Cloning Extraction • Mixing with Excipient Packaging • Transport to Dispensary • Vegetative Growth • Quantitation of Cannabinoid • Dispensing to Patients • Flowering • Decarboxylation Content • Primary Packaging • Harvest • Extraction • Adjustment • Secondary Packaging • Drying • Winterization • Quality Assurance • Labeling • Grinding
Cultivation Formulation Dispensation
FUNGAL TOXINS, MICROBIOLOGY, HEAVY METALS, PLANT GROWTH REGULATORS AND PESTICIDES, CLINICAL STRENGTH/POTENCY
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Vireo Health/MinnMed Approved Delivery Forms
o BULK OIL
Cannabis Extract Syringes CAPSULES Cannabis Capsules o o ORAL SOLUTION o STARTER PACKS o TINCTURES o TOPICALS o VAPORIZERS Starter Packs Oral Solutions
Confidential Material // Products | 19 THERAPEUTIC WINDOW
www.vireohealth.com/ny| 20 LD50
www.vireohealth.com/ny| 21 “NATURAL” does not mean SAFE Plant Toxicology: arguably the oldest scientific discipline (recognition of which plants are safe to ingest)
www.vireohealth.com/ny| 22 MEDICAL CANNABIS CONTRAINDICATIONS
www.vireohealth.com/ny| 23 MEDICAL CANNABIS CAUTIONS
www.vireohealth.com/ny| 24 CANNABIS DEPENDENCE
www.vireohealth.com/ny| 25 CANNABINOID RESEARCH
www.vireohealth.com/ny| 26 VIREO HEALTH RESEARCH PROJECT PARTNERS
Exclusive agreement to study the use of Randomized trial of medical cannabis in University of Minnesota: Fasting, fed Captisol in the development and patients with newly diagnosed, stage IV and chronic therapy pharmacokinetic commercialization of pharmaceutical- cancer to assess impact on cancer-related research project combining grade cannabinoid-based products symptoms neuropsychological testing, DNA testing and seizure control monitoring
IRB-approved research study to examine National Institute of Health R01 $3.8MM Study to evaluate cannabis use among older adults’ use of medical cannabis for research grant for the first, long-term older adults – how they consume, why chronic pain study of medical cannabis’ impact on they consume and how often opioid use in adults with chronic pain
Confidential Material // Research Projects | 27 $3.8 million NIH Study on Medical Marijuana, Pain and Opioid Use
o National Institute of Health o Albert Einstein College of Medicine and Montefiore Health System o PI: Chinazo Cunningham, MD o First long-term study: medical marijuana and opioid use o Adults with chronic pain Confidential Material // Research Projects | 29 SUMMARY o Cannabis in Minnesota is standardized, third-party tested medicine and overseen by licensed pharmacists with safety stopgaps and measures o Effective in the treatment of chronic pain (Neuropathy has the highest quality evidence) o Medical cannabis exhibits a well-tolerated side effect profile without lethality o ECS has strong health potential, with research on benefits in its infancy o Additional tool to help patients manage disabling or troubling symptoms oClinician knowledge will help patients make informed choices about using medical cannabis oClinicians have a unique opportunity to guide selected patients in this emerging treatment strategy (ECS)
www.vireohealth.com/ny| 30 THANK YOU
www.minnmed.com [email protected]
www.vireohealth.com/ny| 31
HEMP vs. CANNABIS
www.vireohealth.com/ny| 33