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Final Medical Cannabis

Final Medical Cannabis

Medical … Clinical and Legal Considerations

Christine Roussel, PharmD, BCOP Director of Pharmacy, Doylestown Hospital Disclosures

• No financial Disclosures Relevant to the Cannabis Industry

• Program Director, Education Course, Philadelphia College of Pharmacy, University of the Sciences Outline

•

• Cannabis Pharmacology and Formulations

• Clinical Considerations and Adverse Effects

• Legal Considerations

Photo by C.Roussel Pharmacist Objectives

1. Describe key features of the endocannabinoid system, pharmacology, and non- components of cannabis.

2. Outline dosage forms, pharmacokinetics, potential adverse effects and adverse effects including use disorder.

3. Discuss medical cannabis risk versus benefits and patient counseling opportunities.

4. Review federal cannabis law and possible conflicts between state and federal law. Pharmacy Technician Objectives

1. Describe main components of cannabis and their pharmacology.

2. List dosage forms available and how they work differently.

3. Describe adverse effects associated with medical cannabis and identify resources for more information.

4. Review federal regulations and their conflict with state medical and recreational laws. Disclaimer

• Cannabis is currently not FDA approved for any condition.

• Cannabis is currently DEA Schedule 1 (Federal) under the Controlled Substance Act of 1970. • No currently acceptable medical use • High Potential for abuse

• Investigational use only – IND applications must receive triple agency approvals: National Institute of Abuse (NIDA) / DEA / FDA – Product for Federal Research is Sole Source through NIDA (Unless Import permission is granted) as antioxidants and neuroprotectants

US Government Owns Patent “Cannabinoids are found to have particular application as neuroprotectants, for example limiting neurological damage following ischemic insults, such as stroke and trauma, or in the treatment of neurodegenerative diseases, such as Alzheimer's disease, Parkinson’s disease and HIV dimension”

https://patents.google.com/patent/US6630507B1/en - Worth Reading!!!! 7 U.S. Government Grows Cannabis and Supplies it to Patients

1977 – 1993 Federal Compassionate IND (n=13) Grown by University of Mississippi & NIDA

Pictures by Irvin Rosenfield, author My Medicine. Used with Permission. 8 Nerve Communication

https://www.shmoop.com/animal-systems/nervous-system.html Presynaptic 1. Neurotransmitters Neuro Signal Neuron Synthesized and Transmission stored in vesicles Across the until ready to release Synaptic Cleft 2. Neurotransmitter Binding to • Glutamate Corresponding • GABA Receptor • Acetylcholine • Norepinephrine • Dopamine 3. Initiates • 5-HT3 Postsynaptic Downstream • Cholecystokinin Neuron Effects Image by C. Roussel Presynaptic 3. Binding at the CB1 Neurotransmitter Neuron Receptor stabilizes Signaling vesicles to decrease neurotransmitter release Endocannabinoid Signaling is Retrograde Inhibition 2. Endocannabinoids (, 2-AG) Synthesized on 1. Too demand for much Postsynaptic immediate release activity Neuron Image by C. Roussel CB1 Receptors CB1 – Primarily in Brain • NOT significant in brainstem (RR,HR) Other Locations • Adipocytes • Endocrine and Exocrine Glands • Liver • Heart, Vascular Smooth Muscle Cells Cannabinoid Pharmacology in CNS ● Parasympathetic ● Anti-Nociceptive Human brain after injection of radio tracer ● Neuroprotection to show the regional distribution of CB1R ● Neuroplasticity Originally publication: Burns, et al. [18F]MK-9470, a positron emission tomography (PET) tracer for in vivo human PET brain imaging of the cannabinoid-1 receptor. PNAS June 5, 2007 vol. 104 no. 23. Pg. 9800–9805 © [2007] All rights reserved. Reprinted with permission." Shohami E and Horowitz M (ed). Cannabinoids in Health and Disease. Themed special issue, Journal of Basic and Clinical Physiology and Pharmacology 2016; 27(3). 12 CB2 Receptors • Signally ↓ release of activators and sensitizers Immunomodulation: • Monocytes and Macrophages • B-cells and T-cells Liver, Spleen, Tonsils Central & Enteric Nervous System Endocrine and Exocrine Glands

"Originally publication: Ahmad R,, et al. 2016 Whole-body bio-distribution and radiation dosimetry of the cannabinoid type 2 receptor ligand [11C]-NE40 in healthy subjects. Mol Imaging Biol. 2013 Aug;15(4):384-90© [2013]All rights reserved. Reprinted with permission." 13 Medical Cannabis vs Marijuana • Plant reliably grown and handled • Good Manufacturing Practices • Assayed, Labeled and Dated for cannabinoids and terpene content • Proven absence of typical contaminants: • Mold / Yeast • Pesticides • Heavy Metals Pictures from www.Steephill.com/science. All rights reserved. Reproduced with permission • Residual Solvents 14 Same Plant – With Different Cannabis Sativa Chemovars

Hemp – Fiber Type Drug Type (aka Cannabis , Tall, thick stalk Marijuana )

THC + Terpenes Fiber Oil Food / Feed Cannabinoids

Industrial : stalk and seeds are used for Cannabis / Marijuana: medicinal / textiles, paper, food, detergents, building recreational use of cannabinoids materials (excludes flower) THC content – 5 – 15+% THC Content < 0.3 – 1.5% DEA Controlled Substance Not Scheduled Seed to Sale Tracking

Pictures by C. Roussel 16 CO2 Extraction

Pictures by C. Roussel “Genetic tools weed out misconceptions of strain reliability in Cannabis sativa”

No consistent genetic differentiation between the widely held perceptions of Sativa and Indica Cannabis types. Instances were found where samples within strains are not genetically similar.

Schwabe A and McGlaughlin M. Genetic tools weed out misconceptions of strain reliability in 1 Cannabis sativa: Implications for a budding industry. bioRxiv preprint first posted online May. 28, 2018. NOT PEER REVIEWED 18 Cannabis:

THC CBD tetrahydro- Limonene Pinene

THC-A

+ CBC Myrcene Linalool THCV Tetrahydro- Tetrahydro- cannabinolic Cannabi- acid chromene Linalool Cannabinoids ß-Caryo- CBN Flavonoids phyllene CBG Lipids Cannabinol Terpenes Sterols 19 CB1

Endocannabinoids (Anandamide, 2-AG)

Image by C. Roussel (THC)

• Partial Agonist of CB1 and CB2 • Euphoria • Analgesia (primary Pain relief molecule) • Muscle Relaxant • Anxiolytic (low dose) -> Anxiogenic (higher doses)

Image by C. Roussel TETRAHYDROCANNABINOL (THC)

ADVERSE EFFECTS Dizziness, Weakness Increase risk of falls Psychoactivity vs Psychotoxicity Tachycardia • Impaired cognition Vasodilation, Hypotension • Difficulty concentrating Addiction (1 in 10 chronic • Memory Impairment recreational users) Hypothermia

Caution in patients with unstable mental health conditions (especially bipolar disorder and ).

Image by C. Roussel Cannabidiol (CBD)

• Enhances natural endocannabinoid activity • inhibits anandamide hydrolysis • Agonist at 5-HT (anti-nausea) and TRPV1 (Pain relief) • Potent Immune Modulator = Strong Anti-Inflammatory Activity • Anti-seizure Negative Allosteric Modification • Neuroprotective • Decrease negative effects of THC (anxiety, memory impairment, psychoactivity) Image by C. Roussel Cannabidiol (CBD) ADVERSE EFFECTS Diarrhea Headache Suppress Appetite Stimulating (trouble sleeping) …. …..Somnolence Drug Interactions

World Health Organization: Cannabidiol Critical Review TERPENES

MYRCENE LINALOOL ß CARYOPHYLLENE PINENE Analgesic Sedative Select CB2 Agonist Anti-Inflammatory Anti-Inflammatory via Anxiolytic Analgesic Bronchodilator PGE-2 Analgesic Gastric Protective Acetylcholinesterase Anti-Convulsant Modulate GABA Anti-Inflammatory via Inhibitor (Aids memory) and Glutamate Skeletal Muscle Relaxant PGE-1

Russo, E. B. (2011). Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid 25 entourage effects. Br.J.Pharmacol. 163: 1344-1364. THC Inhalation

Bioavailability is Variable due to smoking dynamics (10 – 60%) • Depth of inhalation • Duration of Breath Holding • Temp of Vaporizer

Good For Titration and break through because of rapid effects

Typical Onset 0 – 10 min Import to Teach: Duration 2- 4 hours • Patient Proper Technique • To wait 5 -10 minutes between inhalations during titration Huestis M. Human Cannabinoid Pharmacokinetics. Chem Biodivers. 2007 August ; 4(8): 1770–1804. MacCullum C and Russo E. Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine. 49 (2018) 12-19. Cannabis (THC) Oral Administration

• Onset 30 – 120 min • ↑ Inter/Intra Patient Variable Absorption • Absorption ↑ w/ high fat meal

• Duration 4 – 8 hours • *Up to 24 hours dose dependent • Lower Peak [THC] • ↑ [11-Hydroxy-THC] – Longer T1/2 – More potent analgesic activity After Administration of 2.5 mg – More lipophilic

Huestis M. Human Cannabinoid Pharmacokinetics. Chem Biodivers. 2007 August ; 4(8): 1770–1804. MacCullum C and Russo E. Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine. 49 (2018) 12-19. Oral Mucosal Products

Bypasses Liver Metabolism Onset 15 – 60 mins Inhalation

• higher doses that exceed therapeutic threshold in most patients • poor ability to dose • delivers smaller doses • able to measure dose Don’t confuse Recreational and Medical. MacCullum C and Russo E. Practical considerations in medical cannabis More Appropriate for Medicinal Use administration and dosing. European Journal of Internal Medicine. 49 (2018) 12-19. Dustin Sulak, Heaer.com CBD Routes of Administration Oral CBD • bioavailability is between 13% and 19% • significant first-pass metabolism • absorption ↑ w/ high fat meal • sublingual Aerosolized CBD • rapid peak plasma concentrations in 5–10 minutes • higher bioavailability than oral administration Rectal or Vaginal Suppositories • Increased bioavailability: higher absorption + less first pass metabolism

Topical Huestis M. Human Cannabinoid Pharmacokinetics. Chem Biodivers. 2007 August ; 4(8): 1770–1804. WHO 2018 Cannabidiol Critical Review Considerations in Dosing Patient … Patient Self-Titration Education

Higher Doses -> Increased ADRs Dose Possible Decrease in efficacy Finding Optimal Dose “The Sweet Spot” Rooted in the Concept: Minimal Side Effects Less is Really More! Start Low, Go Slow Want up regulation of Sub-psychoactive dosing Cannabis Sensitization Endocannabiniod receptors…. (not down regulation) 31 Medical Goals of Therapy: Symptom Management vs. Disease Modification

- Pain - Nausea / Vomiting - Spasticity - Appetite - Inflammation - Anxiety / Depression - Sleep Disorders THC: CBD Chemotypes or Ratios

THC-predominant Ex. 50:1, 19:1, 16:1

Balanced = Intermediate Psychoactivity Ex. 1:1, 4:1 Psychoactivity is Dose Dependent and can be affected by tolerance CBD-dominant and setting. Ex. CBD Only, 1:>20 33 Average [THC] in DEA specimens 1995 - 2014

“All things are poisons, for there is nothing without poisonous qualities. It is only the dose which makes a thing poison.” – Paracelsus

Elsohly MA, et al. Changes in Cannabis Potency over the Last Two Decades (1995-2014) - Analysis of Current Data in the . Biol Psychiatry. 2016 April 1; 79(7): 613–619. doi:10.1016/j.biopsych.2016.01.004. ECS and the Gastrointestinal Tract

ECS regulates energy balance & food intake, acting both in brain & GI tract •Anandamide (AEA) is mediator of hunger in intestines •Starvation increases AEA levels & CB1 expression •THC increases food uptake via CB1 activation

Anandamide on CB receptors in adipose tissue stimulates lipogenesis. Increased adiposity, insulin resistance

Inhibit nausea and vomiting

National Academy of Science, 2017 Handbook of Cannabis and Related Pathologies. Chapter 45 Cannabis, Cannabinoids, and Visceral Pain by R. Abalo, M. Isabel Martin-Fontelles 35 ECS in the Gastrointestinal Tract and affects of Cananbinioids THC = Direct activation of CB 1 receptors • Analgesia • ↓ gastric acid secretion • ↓ contractility • ↓ motility • ↓ formation of gastric mucosal lesions through enhanced intestinal epithelial barrier functions • Stimulates hunger sensation CBD = targets upregulated CB2 receptors • Anti-inflammatory • Control fluid accumulation • ** controls hunger ** Handbook of Cannabis and Related Pathologies. Chapter 45 Cannabis, Cannabinoids, and Visceral Pain by R. Abalo, M. Isabel Martin-Fontelles and National Academy of Science, 2017 36 Cannabis Hyperemesis Syndrome • THC and CBD both have antiemetic properties low doses … but high doses associated with…..

• Cyclic periods of vomiting and, often, epigastric pain. • Improvement by hot showering or bathing

• Typically remitted within 2–3 days after cessation of cannabis.

• Possible resistant to usual antiemetics • consider haloperidol or lorazepam

• Fluid and electrolyte replacement

Handbook of Cannabis and Related Pathologies Cannabis. Chapter 48 Hyperemesis Syndrome. Bonnet, U. CANNABIS IN PATIENT CARE ENDOCANNABINOIDS IN THE RESPIRATORY SYSTEM

Short-term (Acute) Bronchodilation and consistent Cardio-pulmonary Smoke may • Improve specific airway conductance exchange transfers irritate large air • ↑ peak flow measurements cannabinoids to blood passages of • ↑ forced expiratory volume (FEV1) then brain lungs, throat, • Reverse bronchospasm in windpipe methacholine challenges Heavy habitual smokers of cannabis alone • Symptoms of chronic bronchitis (cough and sputum) Dries mucous • membranes of Histopathological bronchial mucosa mouth and nasal abnormalities (destruction of ciliated passages epithelial cells, increase mucus secreting surface epithelial cells) • Not associated with increased lung cancer

• National Academy of Science. (2017). The Health and Cannabinoids: The Current State of Evidence and Recommendations for Research. • Preedy, V. (2017). Handbook of Cannabis and Related Pathologies (1st ed.). Oxford, UK: Academic Press, Elsevier. Cardiovascular Effects of “Marijuana” ↑ SYMPATHETIC STIMULATION

SUPINE ↑ SYSTOLIC AND DIASTOLIC BLOOD PRESSURE

Hypotension ↓ Time to ANGINA

ORTHOSTATIC HYPOTENSION

39 Pacher, et al. Nature Reviews Cardiology, 2017; Kattoor, Marijuana and Coronary Heart Disease, ACC Expert Analysis Online, 2016. Increased Risk of Myocardial Infarction with Inhaled Cannabis Population Analysis 4.8-fold higher risk of MI within first hour after Inhaling Product • 124 / 3882 patient cohort

• Patients with history of MI, marijuana use > once a week associated with 3 x ↑ Risk of Death

Increased CVD in cannabis users • 316,397 of > 20 million Bradycardia (chronic)

Pacher P, et al. Cardiovascular effects of and : The good, the bad and the ugly, Nature Reviews Cardiology, Online 2017 Sept Marijuana not associate with increased CVD Kattoor A, et al Marijuana and Coronary Heart Disease. ACC Expert Analysis Online, 2016 Sept 22 • 4286 with h/o marijuana use SELECT PHYTOCANNABINOIDS Cannabinoid Areas of Investigation

CBD-A Cannabidiolic acid Anti-emetic, anti-anxiety

Anti-inflammatory effects via antagonism of tissue necrosis THC-A Tetrahydrocannabinolic acid factor alpha (TNF-α); anti-emetic, anti-convulsant, clinical trial on-going for diabetes 1/10th the psychoactive potency, sedative, antibacterial, CBN Cannabinol inhibition of keratinocytes in psoriasis CBC anti-inflammatory, anti-fungal, anandamide reuptake inhibitor

DGABA uptake inhibitor, antibacterial, inhibition of CBG Cannabigerol keratinocytes in psoriasis

Russo, E. B. (2011). Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid 41 entourage effects. Br.J.Pharmacol. 163: 1344-1364. Synthetic Cannabinioids (ie. K2, Spice, Crazy Monkey, Chill Out) • Developed to study the endocannabinoid system

• Up to 200 times more potent that plant based cannabis products • Extreme Potency = Extreme Toxicities

• Vaporizers, E-cigarettes, plant products sprayed with chemicals to burn

• 2015 – 7,797 toxic exposures reported • 25% of events in children 13 to 18 years old

Neurologic symptoms: • Agitation, coma, seizures, toxic psychosis, hallucinations Synthetic Cannabinoids Extreme Potency = Extreme Toxicities

Organ Function • Severe nausea / vomiting, acute kidney injury, respiratory depression, death, Cardiac Symptoms

Bleeding … contamination with Brodifacoum • 2018 – 320 cases of severe bleeding and abnormal coagulation (CUDIT-SF) How often in the past 6 months: 1. Did you find you were unable to stop using cannabis once you had started? 2. Have you devoted a great deal of your time to getting, using or recovering from cannabis? 3. Have you had a problem with memory or conversation after using cannabis?

Never(0) Less than monthly (1) Monthly (2) Weekly (3) Daily (4) CUD present with > 2

Bonn-Miller M. et al., Cannabis Cannabinoid Res. 2016 Dec 1;1(1):252-261. 44 Ratio of Average [THC]:[CBD] in DEA specimens

Elsohly MA, et al. Changes in Cannabis Potency over the Last Two Decades (1995-2014) - Analysis of Current Data in the United States. Biol Psychiatry. 2016 April 1; 79(7): 613–619. doi:10.1016/j.biopsych.2016.01.004. Defining Products

USP Expert Panel on Cannabis • Botanical Identification • Chemical Analysis & Contaminants Analysis. Steep Hill Labs. All rights Reserved. • Monograph Development Reprinted with permission. 46 Nabiximols

THC CBD • Dronabinol • Nabilone •Cannabidiol

US Approval DEA Schedule Dronabinol (Marinol) 1985 Solid = III; Liquid = II Nabilone (Cesamet) 2006 II Cannabidiol (Epidiolex) 2018 V Nabiximols (Sativex) NOT APPROVED I (listed as such in NDA)

(1:1 THC: CBD) 47 Slow Titration Decreases Adverse Effects The focus is on maintaining / establishing favorable endocannabinoid tone Most Adverse Effects are early and transient Goal is avoid patients ever feeling uncomfortable Safety profile is improved by going slow and Low

MacCullum C and Russo E. Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine. 49 48 (2018) 12-19. Drug Interactions: Cannabis Effects on Other

Potentiate the Effects of Other CNS Depressants •Alcohol, Opioids, Benzos, Muscle Relaxers Cardiac Effects •Amphetamines CYP Interactions 2C19, 2C9, 3A4 •Cancer •HIV •Anti-Seizure

Oral Chemotherapy Food and Drug Interactions: A Comprehensive Review of the Literature Segal EM 2013 49 Cannabidiol Drug Interaction Examples

Case Report Multiple Pediatric Patient Study • Patient INR Stable between 2-3 • Initiation of cannabidiol led to: on warfarin dose of 7.5 mg/day • average increase of 60% clobaz • Initiated CBD 15 mg/kg/day and • average increase of 500% INR went to 7 clobazam’s active metabolites Dronabinol US Package Inert serum concentration Contains Cautions when use • Additional studies show with Warfarin interactions with Depakote Geffrey, et al. Drug-Drug Interaction between Grayson, L, et al. An interaction between warfarin clobazam and Cannabidiol in Children with and cannabidiol, a case report. Epilepsy & Behavior Refractory Epilepsy. Epilepsia 2015; 56: 1246-1251 50 Case Reports 9 (2018) 10-11. Drug Interactions Effects of other drugs on Cannabis

Increase Effects of Cannabis (2 -3 times higher levels) Amiodarone Clarithromycin Antifungal Drugs Diltiazem Fluvastatin Certain HIV Drugs

Decrease Effects of Cannabis (50% less Cannabis Effects)

Carbamazepine St. Johns Wort Phenobarbital Phenytoin

Nabiximols Summary of Medicinal Product Characteristics, European Medicines Agency 3/15 51 World Health Organization: CANNABIDIOL (CBD) Critical Review Report

• No current evidence of that oral CBD administration in humans results in clinically relevant THC-like subjective or physiological effects, or appreciable plasma concentrations of THC or its metabolites.

• At present no public health problems related to misuse, abuse or dependence, including no concern related to “ driving under the influence” Dependence & CBD

• In a human physical dependence study, administration of cannabidiol 1500 mg/day (750 mg 2x daily) to adults for 28 days did not produce signs or symptoms of withdrawal over 6-week period after drug discontinuation • Suggests that cannabidiol (CBD) does not produce physical dependence Epidiolex package insert. Carlsbad, CA: Greenwich Biosciences, Inc. 2018 June)

• However, cannabis dependence & withdrawal symptoms are reported in the literature. • Thus THC (and/or minor cannabinoids) are driving the neuroadaptation that results in a withdrawal syndrome

Marijuana dependence occurs when the brain adapts to large amounts of the drug by reducing production of and sensitivity to its own endocannabinoid neurotransmitters.” (Rotter et al,2013; Morgan et al,2013) - NIDA. (2018, June 25). Marijuana. Retrieved from https://www.drugabuse.gov/publications/research-reports/marijuana on 2018, September 18 https://www.drugabuse.gov/publications/research-reports/marijuana/references 53 Patient Case #1 • 65 year old male with history of DM, neuropathy, dyslipidemia, uncontrolled HTN, A fib • Current medications include: Metformin, Gabapentin Rosuvastatin, Amlodpine/Benzapril, Diltiazem

He asks you: “I plan to start Medical Marijuana, What do you think?

You Reply: • What are your goals in taking it? • Are you aware of possible adverse effects? • Are there any concerning drug interactions? Patient Case # 2 • 15 year old male with ADHD and Autism spectrum disorder • Current medications include: Ritalin

The patients mother asks you: “I hear that Medical Marijuana can help my son, Do you know how I can get it?

You Reply: • What are your goals in giving it to him? • Are you aware of possible adverse effects? • Are there any concerning drug interactions? LegalTHE CANNABIS LEGAL PUZZLE Puzzle

Bradycardia (chronic)

• Procon.org. (2018). 33 Legal Medical Marijuana States and DC: Laws, Fees, and Possession Limits [Image]. Retrieved from https://medicalmarijuana.procon.org/view.resource.php?resourceID=000881 • Wikipedia. Updated as of March 15th, 2019 Heterogeneity of State MMJ Programs

Licensed HCP + State Regulated Products atient Safety + State Regulated Production Regulation = P CBD falls within the MMJ State Allowed Home Grown program if purchased at dispensaries OR if state Illegally Obtained specifically allows high CBD, low THC products to be sold 57 Physicians Cannot Prescribe Medical Marijuana

Physicians may NOT: • Order a patient to consume/obtain or order the dispense of a CS I Physicians Can: • Discuss treatment options, Pros/Cons (including cannabis products) • Recommend that a patient consider the use of cannabis for symptoms

The court held that what it regarded as physicians' "legitimate need to discuss with and to recommend to their patients all medically acceptable forms of treatment" outweighs the government's "legitimate interest in suppressing and controlling the flow of dangerous drugs and controlled substances within the United States." https://www.justice.gov/osg/brief/walters-v-conant-petition 58 Where Does Cannabidiol Fit ?

Permission not requested from this company that fills my email full of Sign in a window of a vape shop 0.1 miles from a Police Station cannabis spam and false information that has not been requested!! 59 DEA – Marijuanan Extract Rule (MER) Cannabidiol considered CS I (Dec 2016) • New drug code established for marijuana extracts = Schedule 1 • An extract containing 1 or more cannabinoids that has been derived from any plant of the genus Cannabis, other then the separated resin (whether crude or purified) obtained from the plant.

• For practical purposes, all extracts that contain CBD will also contain at least small amounts of other cannabinoids.

• Hemp Industry Association contested this, but was denied by court

Drug Enforcement Agency, Establishment of a New Drug Code for Marihuana Extract. Final rule. Federal Register 2016 Dec.14;81(240):90194-6. 60 https://www.deadiversion.usdoj.gov/schedules/marijuana/m_extract_7350.html Agricultural Improvement Act of 2018 (aka Farm Bill) and HEMP • Allows for legal cultivation of Hemp for growers registered with the state and the Department of Agriculture. • Hemp removed from the Controlled Substance Act • Allows interstate commerce of legally grown hemp or hemp products • Does not supersede the Food Drug and Cosmetic Act • Does not prohibit the ability to promulgate Federal regulations and guidelines that relate to the production of hemp

The term ‘hemp’ means the plant Cannabis sativa L. and any part of that plant, including the seeds thereof and all derivatives, extracts, cannabinoids, isomers, acids, salts, and salts of isomers, whether growing or not, with a delta- tetrahydrocannabinol concentration of not more than 0.3 percent on a dry weight basis. www.congress.gov/115/bills/hr2/BILLS-115hr2enr.pdf THE CANNABIS LEGAL PUZZLECANNABIDIOL: FOOD DRUG AND COSMETIC ACT HAS AUTHORITY

Unlawful under the FD&C Act to introduce food containing added CBD or THC into interstate commerce, or to market CBD or THC products as, or in, dietary supplements, regardless of whether the substances are hemp-derived. This is because both CBD and THC are active ingredients in FDA-approved drugs and were the subject of substantial clinical investigations before they were marketed as foods or dietary supplements.

• Drug Enforcement Administration. (2017). Establishment of a New Drug Code for Marihuana Extract. Retrieved from https://www.federalregister.gov/documents/2016/12/14/2016-29941/establishment-of-a-new-drug- code-for-marihuana-extract • https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm628988.htm Labelling Accuracy of Cannabidiol containing Products obtained on Internet

• Using +/- 10% for label accuracy of CBD content (n=84) • 43% over label • 26% under label • 31% on label

• 18 / 84 samples (22%) contained detectable THC • THC contamination detected as high as 6.43 mg/mL

Bonn-Miller MO, Loflin MJE, Thomas BF, Marcu JP, Hyke T, Vandrey R. Labeling Accuracy of Cannabidiol Extracts Sold Online. JAMA 2017;318:1708-1709. 63 THE LEGAL PUZZLE THE FDA ACTIVITY ”introduction of a misbranded drug into interstate commerce is a violation “

“intended for treatment of one or more diseases that are not amenable to self- diagnosis or treatment without the supervision of a licensed practitioner. Therefore, it is impossible to write adequate directions for a layperson to use your products safely for their intended purposes. ” Warning Letters 2015 • 6 companies ->18 products 2016 • 8 companies -> 24 products 2017 • 4 companies 2018 • 1 company • https://www.fda.gov/ICECI/EnforcementActions/WarningLetters/2015/ucm436069.htm • https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm628988.htm Store in a local Mall …. Selective Reinforcement ?

Photos taken by C. Roussel while school shopping with her children Question #1

Which of the following statements about the endocannabinoid system is true?

A. Endocannabinoids are synthesized from amino acids. B. Endocannabinoid receptors are the most concentrated g-protein coupled receptor in the brain. C. Endogenous endocannabinoids have relatively long half lives.

Answer: B Question #2

Which of the following statements about the pharmacokinetics of cannabis is false?

A. Sublingual cannabis has an onset of action of about 15 min-60 mins. B. Orally ingested cannabis has a predictable onset of action in 5 - 60 minutes. C. Cannabis has a duration of action of 4 - 6 hours.

Answer: B Question #3 Which statement is TRUE about Cannabidiol products?

A. Cannabidiol is associated with dependency. B. Cannabidiol is reliably extracted from hemp seeds, stalks and leaves. C. Over-The-Counter Cannabidiol Products are regulated by the FDA. D. The study by Bon-Miller et al from JAMA showed that Cannabidiol products purchased on the internet showed consistent compliance with labelling and did not have any contamination with THC. E. The DEA considers Cannabidiol a “Marijuana Extract” and today it is considered Federally Illegal, while the Cannabidiol product by Greenwich Pharma (brand name Epidiolex) awaits scheduling.

Answer: E Question #4

The following statements about THC are TRUE?

A. THC can cause impairment and increase a patients risks of falls. B. THC is a molecule that can provide symptom relief for pain, nausea and sleep disturbances, but at higher doses it can cause anxiety and is not recommended in patients with uncontrolled psychiatric issues. C. THC is associated with dependency. D. All of the above are true Statements about THC.

Answer: D References

• Information for Health Care Professionals Cannabis (marihuana, marijuana) and the cannabinoids Prepared by Health Canada. February 2013 • Corroon J, Knight R. Regulatory Status of Cannabidiol in the United States: A Perspective. Cannabis Cannabinoid Res. 2018 Sep 27;3(1):190-194 • Mead A. The legal status of cannabis (marijuana) and cannabidiol (CBD) under U.S. law. Epilepsy Behav. 2017 May;70(Pt B):288-291. • Russo, E. B. (2011). Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. Br.J.Pharmacol. 163: 1344-1364. • Pertwee RG. Handbook of Cannabis. New York, NY: Oxford University Press; 10016. CE Evaluation Code: 19024

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