DEPARTMENT OF COMMUNITY RESOURCES INTEROFFICE MEMORANDUM

Transcription

1 DEPARTMENT OF COMMUNITY RESOURCES INTEROFFICE MEMORANDUM TO: Board of County Commissioners VIA: Terry L. Shannon, County Administrator 1.45 FROM: Maureen T. Hoffman, Director -7"ffr DATE: May 19, 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 June 7, 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

2 Medical Cannabis Maryland Mishka Terplan MD MPH FACOG FASAM Medical Director Behavioral Health System Baltimore

3 Cannabis is Probably the most satisfactory remedy for the treatment of migraine headaches Dr William Osler, Textbook of Medicine A high potential for abuse and no accepted medical value Controlled Substance Act

4 Terminology Cannabis Plant Names Hemp Refers to plant and its product Oldest term Marijuana Refers to both plant and drug New slang term Cannabis Refers to both plant and drug DSM-5 most appropriate scientific term Categories of Cannabinoids Phytocannabinoids 104 cannabanoids 545 total compounds Endocannabinoids 4+ cannabinoids Synthetic cannabinoids Multiple pharmaceutical and recreational 3

5 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

6 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

7 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

8 Cannabis Ingredients: Inversely proportional THC/CBD Ratio Breeding drives developments of different strains based on goal of grower Charlotte s Web : 21% CBD, <0.1% THC (= hemp) 7

9 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

10 Commercial Use in U.S Grown by Jamestown settlers for fiber 1765 Grown by George Washington at Mount Vernon Post Civil War Declined due to invention of cotton gin and competition from imported hemp 1629 Major crop in New England 1800 s Grown throughout US, centered in Kentucky Cannabis slave plantations 9

11 History of Medicinal Use 2700 BC. First documented Used for centuries in India, China, Egypt, Middle East Western medicine: mainstream use in 19 th and early 20 th Centuries 1850 to 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

12 Context of Classification as Schedule I "Since there is still a considerable void in our knowledge of the plant and effects of the active drug contained in it, our recommendation is that marijuana be retained within Schedule I at least until the completion of certain studies now underway to resolve the issue. Dr. Roger O. Egeberg Assistant Secretary of Health August 14, 1970 High potential for abuse No currently accepted use for treatment in the United States Lack of accepted safety for use under medical supervision 11

13 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

14 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

15 Cannabinoids and Pain Analgesic properties extensively documented and widely accepted in Western medical practice in 19 th and early 20 th 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

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17 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

18 Spasticity 17

19 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

20 PTSD, anxiety, sleep Studies mixed at best Poor study design More likely that cannabis worsens rather than improves PTSD 19

21 Addiction & Side Effects 20

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23 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

24 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

25 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

26 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

27 Interaction With Psychiatric Disorders Psychosis Association is clear, but cause and effect not determined ADHD Self-medication for anxiety, insomnia, and distractibility 26

28 Other consequences Smoking cannabis similar cancer and respiratory risks of tobacco but less common 27

29 Drunk and Drugged Driving Alcohol effects have greater impact on complex tasks that require conscious control Cannabis effects have greater impact on automatic driving functions Cannabis users are more aware of being impaired and tend to use various behavioral strategies to compensate for impairments Adding alcohol eliminates the ability to use these strategies effectively Result: impairments at doses that would be insignificant if either substances were used alone 28

30 Maryland MMC 29

31 Current Local Legal Status DC Legal for medical use Recreational use legalized by ballot initiative (65%) Approved in all but one precinct Home use only. Commercial sales not legal Unsuccessful attempt by U.S. Congress to block Maryland Legal for medical use (not yet implemented) Recreational use decriminalized 30

32 Medical Cannabis in Maryland Law enacted 2013 and 2014, amended 2015 Regulated by Maryland Medical Cannabis Commission January, 2015: first full-time paid director October, 2015: final regulations issued Process Physicians must register Producers and dispensaries must be licensed Physician writes recommendation for patient Patient obtains medication from dispensary 31

33 Current Status of Program September, 2015: Applications for licenses for producers and dispensaries were released November, 2015: Deadline for submission of applications End of January, 2016: Commission to award preapprovals Commission is not yet registering physicians or patients Updates and answers to FAQs at mmcc.maryland.gov 32

34 Prescriptions? Indicating type of cannabis? No prescriptions recommendations Patients legal card holders if 1) legal resident MD and 2) possess a document-driven condition as outlined by DHMH and MMC Physicians in order to recommend must register via MMC and renew every 2 yrs. As certifying physicians they can issue written certificates for their patients to obtain and use medical cannabis. CME-like resources available for physicians, but not required 33

35 Will there be a pharmacist onsite at the dispensary responsible for dispensing? No Max 2 dispensaries per senatorial district (47) Licenses to grow will be awarded in summer no sales until 2017 Cannabis will be dispensed in dried flower or processed form including extracts, oils, tinctures, but not as food Edible cannabis not permitted 34

36 Will there be warning labels included on the package or container of the medical marijuana? Yes sort of Each batch of usable cannabis will state the THC quantity (as expressed as a percentage) 30 day supply = 120 grams of usable cannabis, 36 grams THC max Patients will sign a statement (at the dispensary) attesting to risks and uncertainty of medical science Pregnant Women - Before a patient can receive medical cannabis at a dispensary, the patient has to sign a statement ( attest ) that the patient understands, among other things, that scientific research has not established the safety of the use of medical cannabis by pregnant women, and that the use of medical cannabis is not approved by the U.S. Food and Drug Administration. 35

37 Questions 36

38 Synthetic Cannabinoids: History 1970s-80s. Synthesized for scientific research Trying to identify the molecular structure that activates the endocannabinoid receptors Results became publicly available as research papers and patents Information appropriated by drug dealers Appeared in Europe as Spice, K2 Subsequent chemical alterations to evade illegality and detection Broad array of non-cannabinoid molecules 37

39 Synthetic Cannabinoids: Clinical Motivation to use: initially promoted as a safer and legal alternative to cannabis Routes of administration Smoked after being sprayed on herbal material or as vaporized liquid Drunk as a tea Full agonists: 100 times more potent than THC (a partial agonist) Acute effects Tachycardia, increased BP, nausea and vomiting Anxiety, agitation, paranoia, hallucinations, violence 38

40 Synthetic Cannabinoids: Treatment No specific treatment for toxicity or withdrawal Management problem in acute care settings 39

41 Synthetic Cannabinoids: Good News Synthetic Drug Abuse Prevention Act Increased enforcement of laws Significant decrease in use by 8 th, 10 th, 12 th graders. See Monitoring the Future ( Appears to be due to both increased perception of risk and decreased availability 40

42 Synthetic Cannabinoids Trends in Annual Use: Grades 8, 10, 12 41