THE GRASS IS ALWAYS GREENER: TBI AND THE CLINICAL UTILITY OF MEDICAL MARIJUANA

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1 THE GRASS IS ALWAYS GREENER: TBI AND THE CLINICAL UTILITY OF MEDICAL MARIJUANA JOE TRETTEL, MD, PHD THE CHASE FAMILY MOVEMENT DISORDERS CENTER, HHC GAYLE KLEIN, MD

2 OUTLINE AND OBJECTIVES 1. The Problem: TBI Severity, Disability, And Treatment Limitations 2. Spectrum of TBI Pathology 3. Endocannabinoid System (ecb): A Promising Target 4. Medical Marijuana: Overview, Case Examples, Prescribing, And Use 5. Q&A

3 THE DISABILITY CLASSIFICATION DISCREPANCY

4 THE DISABILITY CLASSIFICATION DISCREPANCY Patholog y: Mild Injury: Moderate Severe Primary -/ Secondary Sensory / Motor -/+ ++/ Cognitive / Behavioral / Emotional

5 TBI: A MULTIDIMENTIONAL DISORDER Mckenzie et al, 2017; Font Neurology

6 TBI PATHOPHYSIOLOGY - I ecb ecb

7 TBI PATHOPHYSIOLOGY - II Recent data suggests all severities of TBI involve biochemical changes Cascade effect excitotoxicity + neuro-inflammation

8 TBI PATHOPHYSIOLOGY: TREATMENT GOALS Early recognition Triage based on severity to manage primary effects Rapid treatment to reduce excitotoxicity and neuroinflammation in all severities Identify premorbid risk factors Safe medications, limited side-effect profile Multidisciplinary treatment

9 THE ENDOCANNBINOID STORY 1964 R. Mechoulam isolates THC 1988 Allyn Howlett & Bill Devane discover CB Lumis Hanus & Bill Devane identify anandamide 1990s Presynaptic CB1; CB2 on microglia; cells that make ecbs do not have CB1

10 ENDOCANNABINOID SYSTEM: RETROGRADE WE GO! 2002 Zeitgeist was right and the pieces were put together: Joe Trettel (cerebral cortex), Rachel Wilson (hippocampus) & Wade Regher (cerebellum) ecbs behave as retrograde neurotransmitters in multiple brain areas Met all criteria for neurotransmitters Novel: lipid-based, retrograde, homesostatic

11 HOW DO WE STUDY NEUROTRANSMISSION? Record V M 1 cm

12 MECHANISM OF ECB SIGNALLING Astrocyte Presynaptic Endocannabinoid CB1R Uptake/carrier? Ca 2+ channel Ca 2+ [Ca 2+ ] i Hydrolysis Cl - Cl - Cl - Depolarization Trettel & Levine (2002), J Neurophysiology; Trettel & Levine (2003), J Neurophysiology

13 ENDOCANNBINOIDS AND TBI: CELLULAR EFFECTS

14 PTSD & PCS: SYMPTOM OVERLAP PTSD Nightmares Flashbacks Guilt Depression Emotional Lability Irritability Memory Attention impairment Fatigue Hyperarousal Avoidance Apathy Anger PPCS Headache Sensory sensitivity Dizziness Tinnitus

15 HYPER-AROUSAL & MILD TBI mtbi Hypermetabolic Glycoltic State (1-2 wk) DLPFC Amygdala + Hypothal: ACTH NE / EPI / GC S H I F T VMPFC & Paralimbic Cognitive / emotional PTSD Like Syndrome

16 ...IT [MARIJUANA] DOESN T HAVE A HIGH POTENTIAL FOR ABUSE, AND THERE ARE AMAZING MEDICAL APPLICATIONS. IN FACT, SOMETIMES Dr. Sanjay MARIJUANA IS THE Gupta ONLY THING THAT

17 CONNECTICUT MMP QUALIFYING CONDITIONS Posttraumatic Stress syndromes Disorder Fibromyalgia Some Seizure Some Types of Spinal Disorders Injuries Some Types of Pain Disorders Intractable headache

18 POST TRAUMATIC STRESS DISORDER A: Stressor Exposure to:... actual or threatened death or serious injury Direct exposure Witnessing the trauma Learning of the details of a close friend or relative s trauma

19 POST TRAUMATIC STRESS DISORDER B: Intrusion The event is persistently re-experienced: Unwanted upsetting memories Nightmares Flashbacks Emotional and physical response to reminders

20 POST TRAUMATIC STRESS DISORDER C: Avoidance Trauma-related thoughts or feelings Trauma-related external reminders

21 POST TRAUMATIC STRESS DISORDER D: Negative thoughts and mood Trouble remembering details of event Overly negative thoughts about oneself or the world Blame Decreased interest in activities Feeling isolated

22 POST TRAUMATIC STRESS DISORDER E: Change in reactivity Irritability or aggression Risky or destructive behavior Easily startled Difficulty concentrating Difficulty sleeping

23 POST TRAUMATIC STRESS DISORDER F: Lasts more than 1 month. G: Symptoms create distress or functional impairment H: Symptoms are not due to medication, substance use, or other illness.

24 CANNABIS DEA Schedule I Cannabis contains around 500 known active compounds. Most well known cannabinoids to date: THC and CBD

25 THC: DELTA-9- TETRAHYDROCANNABINOL Euphoria/Intoxication Nausea relief Pain relief Anti-inflammatory Antioxidant

26 THE ENTOURAGE EFFECT The individual compounds in cannabis create various experiences with different strains of marijuana Follow your nose Terpenes Cannabinoids: THC, THCa, THCv, CBD, CBDa, CBC, CBG, CBN

27 CBD: CANNABIDIOL Not intoxicating Anti-anxiety, less potent than THC Re-experiencing symptoms Focus and concentration Anti-psychotic Pain relief Anti-inflammatory Anti-oxidant Anti-spasmodic

28 PROCESS OF GETTING YOUR MMP Find a Provider CARD that can diagnose you for one of the qualifying conditions. ($50+) Find a Provider that is qualified to certify your condition and recommend you for the program. At that time, they will register you in the system, and your Application for the CT MMP Card has begun! ($150-$250) Finalizing your registration. Contact the Dispensary of your choice from the list on the CT DCP website. Many of the dispensaries will assist you in finalizing the application. ($100)

29 MMP CARD WHAT YOU LL NEED Proof of Residence Federal or State Issued Photo ID Small Passport-sized Photo (do this at the dispensary!) $100 Fee paid to State of Connecticut via their website (debit/credit is usually needed) 3-5 Week wait time

30 $$$ OF YOUR MMP CARD $50* - Provider Diagnosis - For non-behavioral health qualifying conditions (cancer, glaucoma), this can sometimes be covered by insurance. In the case of PTSD, you can get a clinician s diagnosis, such as an LCSW. $150-$200 - MD, DO, or APRN - In addition, this Provider must be able to both recommend and register you into the State s system. $100 - State of Connecticut Processing Fee - This is the final cost, and it covers all admin and processing for your card. *Doesn t need to be done yearly, especially if you are following up with the same MD, DO, or APRN.

31 HOW TO FIND A DOCTOR Contact your desired dispensary for a list of providers. marijuanadoctors.com Google Search for CT medical marijuana Ask for a recommendation

32 CONTACT INFO CT MMP (860) Listed Dispensaries Will Help You Find a Medical Marijuana Doctor

33

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