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Medical Cannabis Maryland DEPARTMENT OF COMMUNITY RESOURCES INTEROFFICE MEMORANDUM TO: Board of County Commissioners VIA: Terry L. Shannon, County Administrator 115 FROM: Maureen T. Hoffman, Director DATE: July 22, 2016 SUBJECT: Dr. Mishka Terplan — Medical Cannabis Presentation Background: Dr. Mishka Terplan, Master of Public Health (MPH), Fellow of the American College of Obstetricians and Gynecologists (FACOG) Diplomat, American Board of Addiction Medicine (ABAM) certified, serves as the Medical Director for Behavioral Health System Baltimore (BHS). He joined BHS in 2014 and provides senior level medical and clinical management support, participates in quality assessment and improvement initiatives, and takes part in a variety of city-wide public health programs. Discussion: You have requested that Dr. Terplan be placed on the agenda to present information on medical cannabis during a weekly BOCC meeting. Conclusion/Recommendation: Please allot time during your September 13, 2016, BOCC meeting for Dr. Terplan to present (using the attached Power Point) information on medical cannabis. Fiscal Impact: None Copy: Dr. Laurence Polsky, Health Officer Medical Cannabis Maryland Mishka Terplan MD MPH FACOG FASAM Medical Director Behavioral Health System Baltimore Cannabis is … • Probably the most • A high potential for satisfactory remedy for abuse and no accepted the treatment of medical value migraine headaches • Controlled Substance Act 1970-2016 – Dr William Osler, Textbook of Medicine 1892-1915 2 Terminology • Cannabis Plant Names • Categories of – Hemp Cannabinoids • Refers to plant and its product – Phytocannabinoids • Oldest term • 104 cannabanoids – Marijuana • 545 total compounds • Refers to both plant and drug – Endocannabinoids • New “slang” term • 4+ cannabinoids – Cannabis – Synthetic cannabinoids • Refers to both plant and drug • Multiple – pharmaceutical and • DSM-5 “most appropriate scientific recreational term” 3 Cannabis: A Unique Plant • Source of 3 important types of products 1. Fiber (fabric, rope) 2. Food (seed, oil) 3. Psychoactive substances (religious ritual, medicine, recreation) • Compare with: – Opium plant: psychoactive substance, food (poppy seeds) – Coca plants: psychoactive substance only 4 Cannabis Ingredients: Tetrahydrocannabinol (THC) • Primary, but not only, psychoactive ingredient of plant • Not isolated until 1964 due to technological problems – Compare to morphine (1804) and cocaine (1860) • 1960’s to present: THC content increased from 3% to 20% 5 Cannabis Ingredients: Cannabidiol (CBD) • First isolated in 1940 • Medical benefits: – Anticonvulsant – Anti-anxiety – Counteracts psychoactive effect of THC • Treated as Schedule 1 substance despite not being euphorogenic and is therefore illegal in US – Legal in many countries including Canada and UK 6 Cannabis Ingredients: THC/CBD Ratio • Inversely proportional • Breeding drives developments of different strains based on goal of grower – “Charlotte’s Web”: 21% CBD, <0.1% THC (= hemp) 7 One of the Oldest Known Psychoactive Substances • Used for 12,000 years in China, India, and Central Asia • Compare with: –Alcohol 12,000 years –Opium 5,000 years –Coca 1,000 years • Introduced in Western Europe 2,500 years ago 8 Commercial Use in U.S. 1765 Post Civil War 1611 Grown by Declined due Grown by George to invention of Jamestown Washington cotton gin and settlers for at Mount competition from imported fiber Vernon hemp 1629 1800’s Major crop Grown throughout US, in New centered in England Kentucky • Cannabis slave plantations 9 History of Medicinal Use • 2700 BC. First documented – Used for centuries in India, China, Egypt, Middle East • Western medicine: mainstream use in 19th and early 20th Centuries – 1850 to 1942. Listed in U.S. Pharmacopoeia • Fluid extracts (not raw plant for inhalation) • Manufactured by major pharmaceutical companies – Prescribed for pain to Queen Victoria – Included in major medical publications • William Osler’s textbook and others 10 Context of Classification as Schedule I "Since there is still a considerable • High potential for abuse void in our knowledge of the plant and effects of the active drug contained in it, our • No currently accepted use for recommendation is that treatment in the United States marijuana be retained within Schedule I at least until the • Lack of accepted safety for use completion of certain studies under medical supervision now underway to resolve the issue.“ Dr. Roger O. Egeberg Assistant Secretary of Health August 14, 1970 11 Possible Medical Uses • FDA approved for – Chemotherapy-induced nausea and vomiting – Appetite stimulation • High quality evidence for – Chronic pain, neuropathic (especially HIV/AIDS) • Approved in Canada – Spasticity of multiple sclerosis, spinal cord injury – Anticonvulsant (CBD for Dravet Syndrome) – Glaucoma • Poor quality evidence for – PTSD, anxiety, sleep 12 Are there any confirmed studies that show the medical benefits of medical cannabis? • Yes – but depends upon indication • Indications from MMC: – A chronic or debilitating disease or medical condition that results in a patient being admitted into hospice or receiving palliative care; – Or a chronic or debilitating disease or medical condition or the treatment of a chronic or debilitating disease or medical condition that produces: cachexia, anorexia, wasting syndrome, severe or chronic pain, severe nausea, seizures or persistent muscle spasms. – PTSD 13 Cannabinoids and Pain • Analgesic properties extensively documented and widely accepted in Western medical practice in 19th and early 20th Centuries • Cannabinoids act centrally and peripherally • CB1 receptors : 10 x more in CNS than mu-opioid receptors, especially in pain areas – Modulate neuronal excitability and inflammation – None present in brainstem • No overdose from respiratory depression 14 15 Cannabis and Pain • Appears effective for different types of pain – Neuropathic, Fibromyalgia, rheumatoid arthritis – HIV neuropathy – no reduction in viral load or CD4 cell count • Minimal tolerance • No toxic overdoses or end organ failure • Enhances analgesic effect of opioids 16 Spasticity 17 Cachexia, anorexia, wasting syndrome • Results – overall benefit – (Rocha et al 2008) Systematic review – Dose-related adverse sedating and psychotropic effects • Limitations – most placebo controlled – fewer studies compare cannabis to newer anti-emetics 18 PTSD, anxiety, sleep • Studies mixed – at best • Poor study design • More likely that cannabis worsens rather than improves PTSD 19 Addiction & Side Effects 20 32 23 17 15 11 9 9 5 4 21 Cannabis Use Disorder Use of cannabis for at least a one year period, with the presence of at least two of the following symptoms, accompanied by significant impairment of functioning and distress: • Difficulty containing use of cannabis- the drug is used in larger amounts and over a longer period than intended. • Repeated failed efforts to discontinue or reduce the amount of cannabis that is used • An inordinate amount of time is occupied acquiring, using, or recovering from the effects of cannabis. • Cravings or desires to use cannabis. This can include intrusive thoughts and images, and dreams about cannabis, or olfactory perceptions of the smell of cannabis, due to preoccupation with cannabis. • Continued use of cannabis despite adverse consequences from its use, such as criminal charges, ultimatums of abandonment from spouse/partner/friends, and poor productivity. 22 Cannabis Use Disorder (Continued) • Other important activities in life, such as work, school, hygiene, and responsibility to family and friends are superseded by the desire to use cannabis. • Cannabis is used in contexts that are potentially dangerous, such as operating a motor vehicle. • Use of cannabis continues despite awareness of physical or psychological problems attributed to use- e.g., anergia, amotivation, chronic cough. • Tolerance to Cannabis, as defined by progressively larger amounts of cannabis are needed to obtain the psychoactive effect experienced when use first commenced, or, noticeably reduced effect of use of the same amount of cannabis • Withdrawal, defined as the typical withdrawal syndrome associate with cannabis, or cannabis or a similar substance is used to prevent withdrawal symptoms. Mild – Two or Three Symptoms Moderate- Four or five symptoms Severe- Six or more symptoms 23 Cannabis Withdrawal Syndrome • New diagnostic category in DSM-5 • Symptoms usually mild – Irritability, anxiety, insomnia, disturbing dreams, decreased appetite, restlessness, depressed mood • Cravings can be clinically significant • Time course – Onset 24 to 72 hours, peak within first week, duration 1 to 2 weeks • Sleep difficulties may last more than 30 days • Usually manageable with mild medication – Research: positive response to dronabinol 24 Negative Effects of Heavy Cannabis Use • Prospective study of 1,000 from birth to 38 found cognitive deficits if heavy use began before age 18 in: – IQ (8 points, no recovery) – Attention (poor recovery) – Memory – Processing speed – Reasoning skill • Insomnia: short term improvement but possible long term exacerbation 25 Interaction With Psychiatric Disorders Psychosis ADHD • Association is • Self-medication clear, but cause for anxiety, and effect not insomnia, and determined distractibility 26 Other consequences • Smoking cannabis – similar cancer and respiratory risks of tobacco – but less common 27 Drunk and Drugged Driving • Alcohol effects have greater impact on complex tasks that require conscious control • Cannabis effects have greater
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