8/2/19 Objectives 1. Explore who is eligible to obtain medical cannabis (marijuana). 2. Outline the process to receive an order for Medical Marijuana in Maryland medical cannabis. 3. Understand the various types of medical cannabis products available in Maryland. 4. List the three components of the medical cannabis market in Maryland. 5. Describe the number of dispensary locations in Maryland. Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services History of Cannabis • Documented in Chinese literature back to The 2700 BC GOOD • Netherlands back to 2459 BC • Used in Ayurvedic medicine back to 1700 BC Cannabis • 1550 BC Egyptian prescription found • 500 BC a Greek description of cannabis steam baths The The BAD UNKOWN Marijuana in Maryland Medical Cannabis in Maryland • 2013 bill signed for medical marijuana program • 2014 bill passed to decriminalize possession of 10 grams or less • September 2015 Maryland Medical Cannabis Law passed For Whom? • 2016 public smoking or possession of marijuana paraphernalia decriminalized (civil infraction with How? fine vs criminal charge) • 2017 bill to approve recreational marijuana did When? By Whom? not pass Photo Source: National Institutes of Health; U.S. Department of Health and Human Services 1 8/2/19 Maryland Medical Cannabis Medical Cannabis in Maryland Commission • MMCC develops policies, procedures, • Growers (14) regulations • Processors (12) • Named in honor of Natalie M Laprade • Dispensers (77 – will be up to 102) – Mrs. Laprade was mother of Baltimore City – 2 allowed per state senate voting district Delegate Cheryl Glenn. • Independent Laboratory – Mrs. Laprade died of kidney cancer; Delegate Glenn believes medical cannabis could have benefited her mother. http://mmcc.maryland.gov/Pages/home.aspx Cannabis sativa L. Endocannabinoid System • A very complex plant Memory – At least 489 compounds Sleep – 70 cannabinoids Mood Appetite Pain Immune response Life cycles M.A. ElSohly, D. Slade / Life Sciences 78 (2005) 539 – 548 Cannabis Phytocannabinoids • Tetrahydrocannabinol (THC) – psychoactive – has been selectively cultivated for many years – May have anti-inflammatory, analgesic, antispasticity, neuroprotective, reduction in intraocular pressure effects • Cannabidiol (CBD) – from cannabidiolic acid – May have anti-nausea effects, perhaps others indica • Cannabigerol (CBG) – May have appetite stimulant effects, perhaps others sativa • Canna bichromene (CBC) – May have anti-inflammatory, analgesic, and antidepressant effects • Cannabinol (CBN) – a byproduct of cannabis degredation Nabiximol = CBD + THC 2 8/2/19 Cannabis Cannabis Terpenoids Terpenoids • Pinenes – found in pine • Beta-carophyllene – found in black pepper, – May protect the brain from memory effects of THC; may copaiba, cloves, hops have antibiotic, anti-inflammatory, and antitumor effects – May have anti-inflammatory effects, internal and • Limonene – found in lemons and citrus peels; increases topical effects of THC and CBD • Terpinolene – found in allspice, tea tree, – May have antidepressant, anti-inflammatory, and blackcurrant buds, juniper; sativa antitumor effects – May have antibacterial and antitumor effects • Beta-myrcene – found in hops; indica • Ocimene – found in sweet basil and allspice – May have antioxidant, muscle relaxant, analgesic, sedative – May have antibacterial effects; said to have medication enhancing effects ‘Goldilocks’ effects – not too sedating or stimulating Entourage Effect (theory) Maryland Indications • Condition documented by a physician with whom the patient has a bona fide physician-patient relationship: – Chronic or debilitating disease or medication condition that results in patient admission to hospice or palliative care – Cachexia or wasting syndrome – Severe or chronic pain – Severe nausea – Seizures – Severe and persistent muscle spasms – Any other condition that is severe and resistant to conventional medicine • Annual review of petitions to add conditions https://www.scientificamerican.com/article/some-of-the-parts-is-marijuana- rsquo-s-ldquo-entourage-effect-rdquo-scientifically-valid/ All Reported Indications Therapeutic Options adolescence hyperemesis Huntington’s pediatrics sports med Alzheimer’s dx chronic fatigue insomnia PTSD stress ALS depression menopause pregnancy Tourette’s Pain Spasticity Nausea anxiety diabetes Migraine/HA lactation Women’s health arthritis drug addiction Multiple prevention Opioids Antispasmodics Anticholinergics sclerosis asthma fibromyalgia Nausea/ Restless legs acne vomiting ADHD gastrointestinal neuropathy schizophrenia cancer Muscle Autism gerontology osteoporosis seizures NSAIDs Ondansetron relaxants autoimmune glaucoma pain sexual dysfunction bipolar hepatitis C Palliative care skin cachexia HIV/AIDS Parkinson’s social anxiety 3 8/2/19 Pain Therapeutic Decisions Meta-analysis Chronic pain Known risks Unknown Multiple sclerosis spasticity (extract > smoked) risks fibromyalgia Cannabis Adverse Effects First use/short term Long-term • Tachycardia (rapid heart beat) • Altered brain function/ • Dry mouth lower educational • Dizziness/lightheadedness achievement (especially – Impaired motor coordination • Hypotension (low blood with use in early pressure) adolescence) • Red, irritated eyes • Hyper-emesis syndrome • Coughing (if smoked) • Chronic bronchitis (if • Short term memory decline • Altered judgement smoked) – Paranoia/psychosis, especially • Addiction (1 in 10?) with high doses of THC Pregnancy and Lactation • Limited data • Potential for brain development, weight, stillbirth, NICU admission https://www.fda.gov/NewsEvents/PublicHealthfocus/ucm421168.htm#notapproved 4 8/2/19 Changes with advanced age Drug Interactions Body changes Cannabis impact • Increase effects of other CNS depressants – Alcohol Less overall protein Highly protein bound (so more free drug) – Benzodiazepines – More body fat Very fat loving – effects last Opioids longer – Muscle relaxants Decreased kidney function Effects last longer/accumulate • Increase effects of amphetamines (ADHD) • Can interact with medications for seizures, Changes in liver enzymes Effects last longer/accumulate cancer, HIV, and others CBD Oil from Hemp Newest CBD oil products • Announced June 25 • Epidiolex (purified CBD) – For Lennox-Gastaut and Dravet syndromes; age 2+ https://www.fda.gov/newsevents/publichealthfocus/ucm484109.htm Medical Marijuana Parody Hope • https://www.youtube.com/watch? v=DVeas1dTCBc • Blinded by the Light by Manfred Mann’s Earth Band Scientific • Skepticism Parody by James McCormack 5 8/2/19 Patients Providers • Register to be qualifying patient online; • Seek registration with the Commission via an application; 2 year certification include government issued identification • Physician licensed in Maryland in good standing registered • Age 21 or caregiver to prescribe controlled substances • Issue a written certification – Caregivers can have up to 5 clients • 30 days at a time; can submit justification if professional • Patient/caregiver is issued an identification opinion patient requires more for 30 days card with their unique patient identification • Patient-provider relationship to include assessment – History number given by the Commission (optional?) – Physical examination • Use product only for intended person; – Review of symptoms intended use – Any other pertinent medical information – Approved indication • Must be evaluated in person at least every 365 days Dosage forms Medical Cannabis in Maryland • Growers – select strains, provide growing Edibles in Maryland – since May 2019 conditions, security standards on premises, Smoke control pests without pesticides • Processors – prepare the dosage forms, package Vaporize the product Oils – Topical or oral • Dispensers – display, aid in selection, sell, document, collect data, delivery option Suppository – 2 allowed per Senate voting district • Independent Laboratory – analyzes each lot for Pessary components of THC, CBD, terpenes Example Resource Sites • finding a dispensary & certified provider THC – http://mmcc.maryland.gov/Pages/ dispensaries.aspx – www.weedmaps.com • Reviewing available product – https://www.mpsbaltimore.com/ CBD 6 8/2/19 Cautions – Illegal marijuana Key Numbers in Maryland • 2 distributors per voting district • Synthetic = 36 grams per month è • 120 grams in possession at one time bleedingmajor Laced with • 5 patients per caregiver Fentanyl • 2 caregivers per patient Resources • http://www.dsd.state.md.us/COMAR/ subtitle_chapters/ 10_Chapters.aspx#Subtitle62 • http://cannabissafetyinstitute.org/wp- Michelle Fritsch, Pharm.D., BCGP, BCACP content/uploads/2015/01/Standards-for- PO Box 212 Cannabis-Testing-Laboratories.pdf Monkton, MD 21111 • http://mmcc.maryland.gov/Documents/ 410-472-5078 Subtitle%2033_Sept2015_Corrected.pdf [email protected] • http://mmcc.maryland.gov/Pages/home.aspx [email protected] www.medsmash.com www.retirewellness.com 7 .