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Medical Cannabis - Review of Risks and Benefits

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Medical Cannabis - Review of Risks and Benefits MEDICAL CANNABIS - REVIEW OF RISKS AND BENEFITS INTRODUCTION Medical cannabis, or medical marijuana, refers to the use of the cannabis plant and its constituents (cannabinoids, terpenes, flavonoids) to treat disease or improve symptoms. Cannabis was used for its medicinal qualities by most of ancient civilizations, with first documented use in Ancient China dating back to 2737 BC. As a mainstay of the American Pharmacopeia, cannabis extract was used to relieve symptoms of over 100 medical conditions from 1851 until 1941. In the next 55 years, it was banned due to political reasons, against the advice of the American Medical Association. Cannabis returned to its due place of being a medicine in the United States in 1996, when the Californian law allowed the use of cannabis by patients. At present, 41 states have reenacted their medical cannabis laws, along with many other countries in the world. The first active constituents of cannabis, cannabinoids THC and CBD, were discovered in the early 1960s. Further research led to an even more important discovery of the Endocannabinoid System in the early 1990s. This system includes internally produced cannabinoids and their receptors, which are present in almost every organ and tissue of the human body. Over 22,000 studies performed to date helped to reveal numerous important physiological roles of the endocannabinoids, which control not only how the human body operates under normal conditions but also in the disease. This also helped us understand why cannabis has so many medicinal qualities. It works through interaction of the phytocannabinoids (plant cannabinoids) with our own endocannabinoid system, by acting through its receptors, by helping to restore the normal function of the cells and systems, and most importantly by helping to maintain homeostasis - the inner balance of the human body and mind. THC (Tetrahydrocannabinol) THC is the most studied cannabinoid. It works by interacting with the endocannabinoid system’s CB1 (cannabinoid-1) and CB2 receptors. It provides many of the medicinal properties of cannabis (see table below). THC Effect analgesic reduces pain neuropathic pain (resistant to regular analgesics) reduces pain originating from damaged nerves antiemetic reduces nausea and vomiting orexigenic stimulates appetite muscle relaxant and anti-spasmotic helps to relieve muscle spasms and spasticity bronchodilation helps to open narrowed airways and breathe better anti-pruritic helps to relieve itching anti-cholestatic helps to relieve bile retention anti-proliferative inhibits cancer cell growth anti-inflammatory has considerable anti-inflammatory effect antioxidant protects cells from oxidative damage antiepileptic relieves or reduces seizures neuroprotective slows nerve cell degeneration, promotes new cell growth glaucoma lowers intraocular pressure and protects retinal neurons peptic ulcers helps to heal peptic ulcers multiple sclerosis protects neurons and improves symptoms Alzheimer’s disease protects neurons and improves symptoms THC is also responsible for most of psychoactive effects of cannabis, including euphoria, transient changes in short-term memory, sense of space and time, heightened sensory perception (five senses). Finding an individual dose of THC which produces therapeutic benefits without affecting activities of daily living is the goal for most of patients. It is recommended not to use high-THC strains, especially in the beginning of the treatment. Copyright ©2016 REN Health, LLC. All Rights Reserved. Page 1 of 6 CBD (Cannabidiol) CBD produces the majority of therapeutic effects of cannabis. It has numerous mechanisms of action in the body that do not involve CB1 and CB2 receptors, though it has been shown to modify the effects of other substances at these receptors, including its close relative THC. CBD Effect analgesic reduces pain levels antiepileptic relieves or reduces seizures antiemetic reduces nausea and vomiting anti-inflammatory has considerable anti-inflammatory effect antibiotic treats bacterial infection, effective against MRSA antifungal treats fungal infection anti-proliferative inhibits cancer cell growth anxiolytic relieves anxiety antidepressant relieves symptoms of depression antipsychotic treats psychosis/hallucinations anti-addiction treats addiction antispasmotic reduces spasms, including bowel contractions vasorelaxant reduces vascular tension/blood pressure anti-psoriatic treats psoriasis anti-diabetic reduces blood sugar levels anti-ischemic reduces risk of artery blockage bone stimulant promotes bone growth immunosuppressant helps to treat autoimmune conditions neuroprotective slows nervous system degeneration (e.g., Multiple Sclerosis, ALS, Parkinson’s disease, Spinal Cord Injury) glaucoma protects retinal neurons antioxidant protects cells from oxidative damage increases levels of Anandamide main endocannabinoid with THC-like properties balances effects of THC lowers psychoactive effects of THC* *CBD is considered a “non-psychoactive” cannabinoid, although it can alter one’s consciousness to some extent. Combining CBD and THC decreases the psychoactivity and other side effects of THC, while enhancing some of THC’s benefits. At the ratio of CBD and THC as 1:1, the psychoactive effects of THC start to diminish. At the ratio of 2:1 or more with CBD predominance, psychoactive effects of THC are minimal to none. ROUTES OF ADMINISTRATION INHALATION (vaporizer) Pros Cons 1.The most rapid onset of action (0.5-2min), may 1. The shortest duration of effects (1-3 hours) provide quick relief for breakthrough symptoms 2.Easy to titrate the dose needed for relief of symptoms 2. Less economically friendly - 85% of each dose is (another puff may be taken in 10 min if needed) lost with exhalation 3. Requires equipment (e.g., vaporizer or vape-pen) 4. May irritate the airways, induce cough or mucus Vaporization - is a lower temperature process (180-195 C), compared to smoking (600 C), and produces a smaller amount of toxic by-products, while the subjective effects and blood concentrations of cannabinoids are similar to those obtained by smoking cannabis. Heating the plant to 180 C makes cannabinoids activated and volatile. Unlike burned material with smoking, vaporized cannabis may be effective with repeated use. Copyright ©2016 REN Health, LLC. All Rights Reserved. Page 2 of 6 Note: Smoking cannabis is not a recommended route of administration, and especially should be avoided in patients with cardiovascular and pulmonary disease. Although it was not shown to increase the risk of lung cancer, cannabis smoke is known to contain up to 3 times the amount of carcinogens of the tobacco smoke (tobacco smoke is known to increase the risk of lung cancer by up to 55 times). TINCTURE (also known as extract or drops) Pros Cons 1. Faster onset of action (10-45 min) than oral route 1. Longer onset of action than inhalation 2. Longer duration of effects (2-6 hrs) than inhalation 3. Does not require additional equipment 4. 4x times more economically friendly than inhalation 5. Easy to titrate the dose (amount of drops needed) 6. Does not have smell, easy to carry and use discreetly Note: For a quicker onset of action, it is best to put the drops under the tongue and keep them in the mouth for 1-2 minutes before swallowing. This helps to facilitate absorption through capillaries directly into the bloodstream. Alcohol-based tincture may cause irritation of the oral mucosa. Diluting it in 1-2 oz of water can prevent irritation. Oil-based extract does not cause irritation and can be applied directly into the mouth. Note: Please remember, Extracts are not the same as Concentrates (hash, keef, dabs, shatter, RSO), which contain high concentration of cannabinoids and are not recommended for inexperienced users. ORAL (capsules, edibles) Pros Cons 1. Longest duration of effects (4-8 hrs), may be 1. Longest onset of action (30min-2hrs). To avoid especially helpful for chronic, constant symptoms overdosing, wait for 2 hours before taking more 2. Absorption is more erratic, some patients do not reach peak concentration for as long as 6 hours, some may have more than one peak of concentration 3. Oral cannabis may be more psychoactive than inhaled (due to x3 higher levels of 11-hydroxy-THC which is one of the initial metabolites of THC in the liver known to be more psychoactive than THC) Note: Because absorption rate is less with oral intake than with inhalation, equivalent dose is 2.5 times higher for oral intake. For example, 1 mg of inhaled THC is equal to 2.5 mg of oral THC. TOPICAL (salves, lotions, creams, oils) Pros Cons 1. May be helpful for localized areas of pain, 1. Limited amount of research data on this route of inflammation, itching, or skin cancer administration 2. Unless used in significant quantities, systemic absorption and effects are minimal to none RAW CANNABIS (juicing, unheated edibles) Raw cannabis mostly contains cannabinoids in their acid form - THCA, CBDA, etc. With heating, the acid form of each cannabinoid is converted to alcohol form - THC, CBD (more active form). THCA does not produce psychoactive effects of THC. Both THCA and CBDA were shown to have anti-inflammatory, anti-nausea, and anti- seizure properties (they can be effective against resistant seizures even when THC and CBD are not effective). Copyright ©2016 REN Health, LLC. All Rights Reserved. Page 3 of 6 DOSING Start Low - Go Slow approach is recommended in all patients, and the correct dose is the lowest dose that produces a therapeutic benefit. It is important to understand that cannabis is not a standardized medicine with a single isolated molecule but rather a medicinal plant with various constituents (over 800 are known to date). It is best to start with very small doses of cannabis, i.e. not more than 1-2 mg of total cannabinoids per dose. Then gradually increase the dose, if needed, by 1 puff of vapor or 1-2 drops of tincture at a time. Write down both wanted and unwanted effects for each dose (and each strain) and try to grade these effects on a scale from 1 to 10. Observe your response after each new dose and try to find the minimal dose that has the most beneficial effects on you.
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