Introduction+To+The+MMP.Pdf

Table of Contents

Introduction to Medical Cannabis ...... 01

Explaining Cannabis’ Effect ...... 06 From Head to Toe

Effects of ...... 08 Cannabis Consumption

Different Routes of Administration ...... 11

Cannabis Dictionary & Terminology ...... 15

References ...... 16 Introduction to Medical Cannabis

Cannabis is a genus of flowering plants in the family Cannabaceae . This family that also Anatomy of a Cannabis Plant includes the hemp plant produces fibrous stalks and offers diverse utility for multiple purposes . A documented historical use of medical cannabis for symptomatic relief has been reported for over 5 centuries . The leaves, flowers, and roots have noted medicinal use throughout the world in: China, India, Israel, the United Kingdom, and Canada . Cannabis leaves and flowers are traditionally consumed in several forms . Cured flower (bud) is more commonly available compared to various types of concentrated, loose or pressed resin extracted directly from the cannabis plant . As the cannabis plant matures from its vegetative state to the flowering phase, the development of trichomes (tiny, crystal-like glands containing cannabinoids and terpenes) will be visible and abundant on the cannabis fan leaves, stems and flowers . Together, the chemical compounds of cannabinoids and terpenes, an array of natural resinous essential oils, provide physical, psychoactive, and therapeutic effects in a combined, complimentary action . The potency of cured cannabis depends on the wide range of cannabinoids, which are chemical Entire Cannabis Plant compounds that act in the body to stimulate a (Photo Courtesy of Kris Brandyberry) “lock-and-key” effect . The popularity of cannabis’ best-known psychoactive properties (the mind-altering, euphoria-inducing “high”) is due to delta-9-tetrahydrocannabinol (THC), and its pain-relief, anti-inflammatory, and anxiety- reducing benefits (among others) to the non-psychoactive cannabidiol (CBD) . These cannabinoids are naturally found in cannabis Bud Fan Leaves Trichomes so they are also known as phytocannabinoids, or naturally occurring plant cannabinoids; as different chemicals, THC and CBD have different alleviating effects for certain symptoms .

Sugar Leaves Stem

THC and CBD act at specialized and natural receptors CB1 Receptors in the brain found in the body known as the CB1 and CB2 receptors . The term “cannabinoids” broadly applies to the natural CB Receptors phytocannabinoids (chemical compounds organically CB Receptors 1 1 in the lungs found in the cannabis plant) and endocannabinoids in the liver (chemical compounds which are automatically produced by the body) to make up the Endocannabinoid CB2 Receptors in the System (ECS) . immune The ECS acts as a biological balancing mechanism system in the body through various processes (or homeostasis) . CB Receptors Through different methods of administration, varying 1 levels of THC and CBD will be available in the body . in the kidneys The onset of effect varies depending on the form of administration, which alters THC and CBD entry into the bloodstream for symptom relief . The two most common methods for consuming cannabis are inhalation (smoking or vaporizing) and ingestion (prescription synthetic capsules or edibles) .

CBD binds THC binds indirectly with directly with cannabinoid receptors cannabinoid receptors

THC is psychoactive

CBD is non-psychoactive

2 - A Guide to Using Medical Cannabis © COMPASSIONATE CARE RESEARCH INSTITUTE, INC. By the 1960s, scientific research Cannabis’s Mechanism of Action established enough evidence to prove that the Endocannabinoid System (ECS) exists THC binds to THC interferes Biological naturally in humans and animals . Because the cannabinoid receptors with endogenous Effects 1 2 3 cannabis plant produces phytocannabinoids in the brain neurotransmitters occur that act similarly to the endocannabinoids naturally produced by the human body, this

Cannabinoid Receptor communication system within the body THC binds to target neuron involves receptors that bind to all types of receptors and triggers a new cannabinoids in a lock-and-key effect for electrical message symptom relief through multiple pathways . Neurotransmitter releases THC and CBD will mimic natural cannabinoids chemical signal to help regulate the body’s numerous biological Electrical Impulse responses, including pain .

Altered Consciousness, Perceptual Distortion, Brain Cells Release Memory Impairment, Occasional Delusions and Dopamine to Frontal Cortex Hallucinations Ventral tegmental area Nausea Relief, Rapid Heart Rate, Reduced Blood Cerebellum Pressure, Drowsiness Limbic System Increased Appetite Nuceleus Accumbens (Nerve Fibers) Impairment in Memory Reward Pathway Reduced Spasticity, Impaired Coordination Nausea Relief, Rapid Heart Rate, Reduced Blood Pressure, Drowsiness

Minor Cannabinoids

THC and CBD are the most commonly discussed and prevalent phytocannabinoids in the cannabis plant, but they are not the only ones . There are over 100 other Cannabinol minor cannabinoids working simultaneously when helps with insomnia consuming cannabis as a whole plant . Currently, there is limited knowledge and understanding of individual effects of these minor cannabinoids due to cannabis Cannabigerol being scheduled as a Class 1 Controlled Dangerous used as a neuro-protective agent Substance by the DEA . This federal designation hinders clinical research being done at larger, substantial Cannabichromene scales . The limited studies surrounding these minor cannabinoids have shown promising results so far . A few reduces inflammation & tumor growth examples include using cannabinol (CBN) to help with insomnia, cannabigerol (CBG) used a neuro-protective Tetrahydrocannabivarin agent, cannabichromene (CBC) to reduce inflammation and tumor growth, and tetrahydrocannabivarin (THCV) regulate blood sugar and insulin levels to help regulate blood sugar and insulin levels .

Along with your major and minor cannabinoids, every single cannabis plant has a unique odor and fragrance linked to their plant genetics . Terpenes are responsible for the distinct smells of citrus, pine, berry, and even fuel depending on specific strains . Some cannabis plants have been described to have either sweet or skunky undertones and all contribute to the complexity of the plant . Terpenes are produced by the same mechanisms as cannabinoids and can vary in concentrations depending on environmental factors such as temperature, humidity, and soil types .

Having a unique smell is beneficial in being able to identify strains, but research has also shown that terpenes provide medical benefits as well . There have been over 100 terpenes identified and each has been studied to some degree showing positive traits for inflammation, bronchodilation, and antioxidation . Terpenes combined with cannabinoids of the plant work side by side producing what’s known as the entourage effect . This synergistic relationship means that consuming the whole plant will have a larger benefit than using individual cannabinoids . Above are a handful of the most common terpenes found and their medical uses .

4 - A Guide to Using Medical Cannabis © COMPASSIONATE CARE RESEARCH INSTITUTE, INC. Decarboxylation

Cannabinoids in its raw form on the cannabis plant need to be activated in order to produce medicinal benefits . Sometimes, you will see the term “THCa” (Tetrahydrocannabinolic acid) and “CBDa” (Cannabidolic acid) listed when describing cannabis strain potencies . The “a” or acid molecule is removed by adding a heat source to the plant to activate the cannabinoids . Traditionally, using a heat source like a lighter will heat up cannabis beyond 451oF, burning the entire plant up . This process is called combustion and produces smoke that you inhale through the lungs . The cannabinoids are being activated, but the entire plant is burned in the process leading to the added inhalation of toxins and carcinogens .

CH3 CH3

O OH OH

H C H C 3 O 3 O H3C H3C

Newer methods of activating cannabinoids in the cannabis plant is through a process of vaporization . This process involves maintaining the cannabis plant cannabinoids at a steady temperature under the point of combustion of 451oF . This process activates the cannabinoids and releases vapor that is inhaled instead of smoke . Every cannabinoid and terpene has a different temperature at which it is activated, so being able to adjust the temperature of vaporization will produce different flavors, and more importantly, different medicinal effects .

Indica Generally sedating, Generally energetic, vs. relaxing & soothing uplifting & happy Sativa Better suited for Better suited for night time usage day time usage

The origin of the commonly mentioned terms Indica Described as more of a Described as more of a and Sativa come from the official scientific plant name . “body high” “head high” Cannabis Sativa are cannabis plants cultivated in hotter May help with sleep, May help with focus, climates usually surrounding the equator . They usually relaxation & muscle spasm creativity, and mood grow taller and are characterized by longer, thinner leaves . Cannabis Indica are cannabis plants cultivated under more harsh environments and typically have broader, wider leaves . However, over time, these two terms have and Sativa strain and combine them to highlight their been adapted to describe the physical and cerebral effects best qualities . Hybrids are usually not a perfect 50/50 typically felt when consuming these plants . This chart blend of sativa or indica, but you may hear them referred highlights some of trait differences between Indica and to as being indica-dominant, or sativa-dominant . They Sativa cultivars . maintain characteristic traits of both their parents to Over the years, cannabis horticulturists have bred create an entirely new combination of cannabinoids and both Cannabis Indica and Cannabis Sativa plants together effects . Usage of these plants will vary and a dispensary to create a separate class of plants called Hybrids . Hybrids technician should be consulted for specific characteristics were created to take the desired features of each Indica of these cultivars . Explaining Cannabis’ Effect from Head to Toe

The active components of cannabis BODY PART interact with the brain’s pleasure centers; constant ingestion has been linked to psychological dependence and addiction. However, it is BRAIN believed to be significantly less addictive than harder drugs (e.g. heroin or cocaine).

Improves global symptoms of PTSD including enhancing sleep quality, reducing frequency of nightmares, and reducing A 1994 study measured the addictive hyperarousal severity potential of several common drugs May prevent or slow the development of Alzheimer’s Disease by quantitating the percentage of Shown to have an analgesic effect and reduce pain associated participants showing dependency. with migraines According to their data: Reduces pain perception and improves spasticity in patients Tobacco: 32% became dependent showing symptoms of Multiple Sclerosis Heroin: 23% | Cocaine: 17% | Alcohol: 15% Has been suggested to aid in preventing spontaneous Cannabis: 9% became dependent epileptic seizures

6 - A Guide to Using Medical Cannabis © COMPASSIONATE CARE RESEARCH INSTITUTE, INC. Explaining Cannabis’ Effect from Head to Toe

BODY PART EYES

Cannabis has been shown to transiently lower intraocular pressure (IOP) associated with glaucoma, although not as effectively as prescription medication.

BODY PART CHEST

Cannabidiol (CBD), an active component in cannabis, has been shown to hinder the expression of the transcription factor ID-1, a key regulator of the metastatic potential of breast and other cancers.

BODY PART PANCREAS

In one study, cannabis use was associated with lower fasting insulin levels, reduced insulin resistance, and similar waist circumference.

BODY PART INTESTINES

Two compounds in cannabis, THC and CBD, have been shown to improve symptoms of Crohn’s Disease.

BODY PART HANDS

A cannabis-based medicine (CBM), Sativex®, may reduce pain associated with Rheumatoid Arthritis (RA) and significantly suppress disease activity.

BODY PART MUSCLES

Studies have shown that cannabis significantly reduces muscle spasticity, a condition characterized by prolonged and involuntary muscle contraction, resulting in stiffness and rigidity.

Please consult with a healthcare professional Beneficial if considering medical cannabis as a potential alternative for eligible patients. Neutral

Unfavorable

Anxiety Relief Insomnia Relief Short Term Memory Problems Impaired Judgment Dry Mouth Red Eyes In the Bloodstream Slowed Reaction Time Phlegmy Cough Psychoactivity Lung Irritation Paranoia Increased Hunger Accelerated Heartbeat Settled Stomach Pain Relief Reduced Muscle Spasms Suppressed Nausea Physiological Dependence Dizziness / Lightheadedness

8 - A Guide to Using Medical Cannabis © COMPASSIONATE CARE RESEARCH INSTITUTE, INC. Potential Side Effects of Cannabis Consumption

Unintentionally consuming too much cannabis, or Over-medicating with cannabis can trigger acute accidentally over-medicating, is rare and most likely anxiety or panic, increased heart rate, low blood pressure, to happen to patients who have little to no previous dry mouth and red eyes . Overestimating the potency, experience . To avoid this risk, use the “Start Low & or strength, of the cannabis may result in unintended Go Slow” method: initially, start with a small dose and over-medicating and the patient may need to reduce the titrate up (or gradually increase the dose) as needed amount of cannabis administered in the future . until symptom-relief is achieved . More can be found on page 13 under the Dosing section . Possible Effects of Cannabis

Physiological Psychomotor Cognitive

• Hunger • Impaired Motor • Short-Term Skills Memory Damage • Lowered Body Temperature • Slowed Reaction • Impaired Time Perception • Lowered Immune Response • Altered • Impaired Peripheral Vision Cognition

• Impaired Learning Ability

Dependency Potential of Cannabis

LOW RISK With chronic excessively frequent HIGH cannabis use, approximately 10% of heavy cannabis users may develop a dependency on cannabis . MEDIUM

LOW

Side Effect Remedy

Coughing • Reduce amount of smoke/vapor being inhaled • Drink some cold water after coughing subsides

Rapid Heart Beat • Usually resolves around 15-20 minutes after consumption • Breathe deeply and slowly for a few minutes • If accompanied by chest pain, contact an emergency healthcare professional immediately

Dry Mouth • Drink beverages like water or lemonade • Use citrus flavored gum or lozenges to increase saliva production

Red, Irritated Eyes • Use over the counter eye lubricant eye drops or ointments

Dizziness/Lightheadedness • Keep your eyes open and focused on something until symptoms resolve

Short Term Memory Loss • Completely reversible when usage is decreased or stopped completely

Psychoactive Effects • Use the 4-7-8 Technique • Sitting comfortably, empty your lungs through the mouth with a whoosh. • Close your mouth and fill your lungs by inhaling through your nose on a mental count of four. • Hold your breath for a count of seven, then slowly exhale through the mouth, with a whoosh, over a count of eight • Repeat four times or until your symptoms are better

If you experience any mental changes or physical discomfort of any kind that has not been discussed, notify your certifying prescriber immediately . Some patients initiate cannabis while actively taking prescription medications . You should check with your certifying prescriber or dispensing pharmacist for any drug-drug interactions that may occur while using medicinal cannabis . Stopping, starting, and/or changing any of your medication therapy- including over the counter items is not recommended while using cannabis without the direct supervision of your prescriber .

10 - A Guide to Using Medical Cannabis © COMPASSIONATE CARE RESEARCH INSTITUTE, INC. Different Routes of Administration

There are a broad range of options for routes of administration which patients can choose from based on individual lifestyle choices . Cannabis can be smoked or vaporized . Also, ingested in food or beverages (these edibles can be home-cooked and prepared as “infused” cannabis combined with fat-soluble cooking mediums such as salt-free butter or coconut oil ). Another route is where it can be absorbed sublingually (under the tongue i e. . lozenge) . A different route can be used topically (applied locally to the skin on affected areas of the body i e. . creams, lotions or ointments) .

Safety profiles have not been established for other potential forms of cannabis delivery including: transdermal, rectal, and sublingual forms; these options may minimize potential risks experienced with common methods of cannabis administration . Clinical research focusing on cannabinoids has led to several FDA-approved medications that contain synthetic cannabinoid(s) in pill or liquid form .

Vaporizing vs . Smoking

Vaporization is a form of inhalation that involves as “smoke ”. Smoking devices that use water filters (i e. . heating cannabis to produce steam or vapor instead of bongs or water pipes) have been shown to involve equal directly burning the cannabis to combustion . The devices amounts of tar in comparison to smoking cannabis using (specifically known as vaporizers) are equipped to heat the a glass pipe, blunt, or joint and these water filters do not marijuana to a temperature ranging from 356°F to 374°F reduce potential risks of cannabis smoke and inhalation . in order to vaporize THC without burning plant materials Vaporizing Smoking

Desktop Portable Handheld Joint Bong Glass Pipe Vaporizer Vaporizer “Vape Pen”

Edibles Other Forms

Candy Cookies & Breads & Other Lozenges Capsules or Tinctures Brownies Baked Goods Tablets or Oils Dosing forms available

Flower: Also known as nuggets, nugs, or bud . Female flowering part of the cannabis plant that produces cannabinoids . It is usually ground down and smoked/vaporized, or can be infused into oils or butters to prepare edibles with .

Shake: Finely ground cannabis flower that can be consumed or prepared in all the ways regular flower is used right out of the container .

Pre-rolls: Flower or shake that is rolled into a cigarette form using a filter and unbleached rolling paper, also ready to use out of the bag .

Concentrated oils: Cannabinoids are extracted and refined from the cannabis plant into a more purified and potent form . They can be smoked, vaporized, used to cook edibles, or applied directly in the mouth as a tincture .

Concentrated dabs/wax/shatter/rosin: Cannabinoids that are extracted and refined from the cannabis plant into extremely high concentrated and potent solid/semi-solid states . They are usually consumed by smoking or vaporization only .

Topical formulations: Lotions, ointments, balms, and creams can be great for local application of specific areas of the body for arthritis or pain .

Sublingual tinctures/lozenges: Absorption of cannabinoids through the buccal or sublingual route leads to a quick and clean option .

Capsules: Activated cannabinoids that can be swallowed by mouth similarly to other medications . Dosing options are more precise and can be increased or decreased accordingly .

Suppositories: Applied rectally for patients that do not have the ability to intake anything orally, have severely impaired lung function, or have an inoperable digestive tract .

Transdermal patches: Patches that are applied to the skin that allows for a slow release of cannabinoid(s) throughout the day . Application can be discreet and hidden under clothing .

It may take up to Duration of Effects 15-90 minutes Inhalation Edibles for most edibles to take effect Intensity of Effects of Intensity 0 1 2 3 4 5 Remember... Hours after Consumption start low, go slow!

Dosing

One of the primary concerns that every new patient Repeat this step as many times as needed until you do will experience is “how much do I use for my particular achieve the desired effect . Going forward, this will be condition?” Unfortunately, there are currently no your established baseline dose . The next time you need officially recognized therapy protocols or guidelines to medicate, start with your baseline dose and medicate found like with traditional prescription medications . We as frequently as you feel necessary . Keep in mind, that encourage patients to follow a concept called microdosing the higher the dose and more frequently you medicate, which is simply to “start low, and go slow.” You will the more you are also at risk for adverse effects . From start with the smallest dose possible, and gradually time to time, doses may need to be increased or decreased increase the dosage in controlled increments until you based on therapeutic relief or unwanted side effects . We achieve the desired response for your condition . This encourage and recommend that you keep a cannabis log fine tuning process will allow you to maximize outcomes to document cultivars used, number of doses, frequency while limiting the amount of adverse effects you may of doses, and comments on effects . This will help you take experience . Also by using the most minimal amount of more of a scientific approach to your cannabis therapy medication, you will reduce your out of pocket costs from and will help the dispensary technicians give additional wasting excess . recommendations if needed . These are a few tips that can help you get started with Dosing methods and strain selection will be microdosing . Start with one small dose . Whether it be 1 dependent on your lifestyle habits, tolerance levels, and puff, 1 lozenge, 1 capsule, or 1 application, keep it simple . physical capabilities . The most important takeaway is Repeat the same dose in 10-15 minutes if symptom relief that you, the patient, be 100% comfortable with using is not achieved . You should wait between 1-2 hours for and administering your medical cannabis on your own . orally ingested medicine due to a longer onset of action .

Consumption Onset of Advantages Disadvantages Method action Smoking 5-10 • Less expensive upfront costs • Adverse respiratory effects minutes • Convenience • Strong odor • Technical skills required for rolling a blunt or joint, or packing a bowl

Vaporizing 5-10 • Minimal odor • More expensive upfront costs minutes • Less respiratory effects • Requires electrical power source or • Healthier than smoking charging

Oral 1-2 • No odor after preparation • Unpredictable onset and duration (edibles/capsules) hours • Discreet consumption • Digestive enzymes may increase • Longer lasting effects variability • No effects on lung health • Added time needed to prepare/bake • More precise dosing available

Tinctures 10-15 • Discreet packaging • Alcohol based minutes • Precise measured dosing options • Taste may be unpleasant

Topicals 10-15 • No psychoactive effects • Odors from product minutes • Therapeutic physical benefits • Greasiness on skin

Rectal 10-15 • Great absorption • Can be messy minutes • Available for patients with • Uncomfortable administration no oral function Storage Considerations

After purchasing your cannabis, you want to make powdery mass . It should immediately be discarded and sure you keep your product in its original packaging not consumed due to severe health issues that may occur removing all the excess air if possible . Your cannabis if it gets into your lungs . When you use your fingers to should be stored in a cool, dark place . Avoid putting pick up the plant, it should not crumble or have an overly your cannabis in the refrigerator or freezer because dry consistency . Smell is also a great indicator of how it can remove too much of the moisture that is needed fresh your flower product is . When you first purchase to have a fresh product . Avoid leaving your cannabis your cannabis flower, it will have a potent, fresh odor due in hot temperatures and/or in direct sunlight because to the abundance of terpenes . Older cannabis flower will this will cause oxidation and degradation of the active have a musty, chemical-like odor to it and will not have phytocannabinoids leading to a less effective product . as strong of an odor compared to when you first open it . There is no exact shelf life or expiration for cannabis Lastly, the taste of the product will become less noticeable products, but keep in mind that the potency of your and have a sour or earthy undertone if it’s too old . product will decline over time . Manufactured products like concentrated oils, topical There are a few ways to tell if your cannabis flower formulations, and tinctures should be stored in a cool, product has exceeded its shelf life . Some visual cues will dry place away from a direct heat source or sunlight . include mold formation on the plant appearing as a white

14 - A Guide to Using Medical Cannabis © COMPASSIONATE CARE RESEARCH INSTITUTE, INC. Check with your States Department of Health for specific program details, qualifying conditions, registration process, and FAQs.

Cannabis Dictionary/Terminology

Blunt: Cannabis rolled into a cigarette form using tobacco Pipe: Device used to smoke cannabis . Usually made of paper glass or ceramic material Bowl: Device used to smoke cannabis . Usually made of Pre-rolls: Cannabis rolled into a cigarette form using a glass or ceramic material . filter and unbleached rolling paper Bud: See “flower” Rosin: Concentrated cannabis created using heat and Bong: See “water pipe” compression to form a sticky sap like substance Cannabinoid: An active ingredient of cannabis Screen: Object used to prevent cannabis from being inhaled through device of choice . Usually metal or glass CBD: Cannabadiol- a non-psychoactive cannabinoid Shake: Finely ground cannabis flower Cone: A type of joint that is more conical in shape than a typical joint or cigarette Shatter: Concentrated cannabis that resembles honey- colored solid pieces . Combustion: The process of burning a material at high temperatures Spliff: A joint rolled with tobacco and cannabis Dabs: General term used to describe concentrates like Terpene: Ingredient of cannabis plant that provides flavor hash, oil, wax, shatter and taste but also has medicinal value Decarboxylation: Heating process to transform Tincture: Concentrated cannabis usually placed under the cannabinoids into their active forms tongue for sublingual absorption Distillate: Refined and purified version of a cannabis Topicals: Anything applied directly to the skin such as extract creams, lotions, ointments, salves, patches, or rubs Flower: Female reproductive part of the cannabis plant THC: Tetrahydrocannabinol- a psychoactive cannabinoid that produces and contains cannabinoids Trichome: Tiny crystals located on cannabis flowers that Grinder: Device used to break up cannabis flower pieces contain cannabinoids and terpenes Hash: Concentrated cannabis collected using a dry sieve Vaporization: The process of heating the cannabis plant or water extraction at specific temperatures under the point of combustion . Hemp: Cannabis that contains less than 0 .3% THCa Vaporizer: A device used to convert cannabis into vapor for inhalation Joint: Cannabis rolled into a cigarette form using lighter translucent paper Water pipe: A pipe for smoking cannabis that draws the smoke through water to cool it Kief: Potent powder-like substance that falls off the cannabis plant . Usually collected at the bottom of grinders Wax: Concentrated cannabis that resembles the texture of candle wax . Also known as budder, badder, crumble, or Nug: Abbreviation for nuggets, also a term used to honeycomb describe flower pieces One hitter: Device used to smoke cannabis that provides one dose at a time

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