CORE CANNABIS TRAINING

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1 CORE CANNABIS TRAINING Advanced Endocannabinoid System Education

2 The Endocannabinoid System This section will cover the following topics: Patient Focused Certification The Expanded ECS Pharmacological Tools and Definitions Interactions between THC, CBD, and other components Review of Dosing from Clinical Trials (i.e., CINV and Appetite studies) Recent Breakthroughs and Promising Research (Diet)

3 Jahan Marcu, Ph.D Chief Scientist, Americans for Safe Access Chief Auditor for Patient Focused Certification Serves on multiple expert government, trade association committees, and scientific organizations including AHPA, ACS, AOCS, AOAC, ASA, IACM, IMCPC, ICCI, and others Author of the American Herbal Pharmacopeia Cannabis Quality Control and Therapeutic Monographs and other international guidance documents Research has focused on the structure and function of cannabinoid receptors, the anticancer properties of cannabis compounds, as well as method development & validation for analyzing complex formulations

4 American Herbal Products Association (AHPA) Largest trade association representing the botanical and nutraceutical industry. Played an integral role in the most successful grassroots movement in US History. AHPA s ongoing role: Galvanizing the botanical and nutraceutical industry Developing sensible national regulatory policy Fighting onerous FDA regulations Cannabis Committee Standards Adopted in 16 States

5 American Herbal Pharmacopoeia (AHP) Cannabis Monograph: Standards of Identity, Analysis, and Quality Control Therapeutic Compendium Standards That Ensure: Identity Purity Accuracy o Quality o Potency o Dosage

6 AHPA & AHP Guidelines Standards for Patient Focused Certification Enhance and Promote Product Safety Ensures consistency of quality and effectiveness Ensures proper labeling Standardized cannabis botanical medicine First standardized testing protocols developed for medical cannabis and medical cannabis products Builds foundation for human clinical trials and case studies Increases patient and practitioner confidence Medical cannabis will no longer be a last resort

7 PFC Seal of Approval Document and Facility Assessment Compliance with state and local regulatory guidelines Compliance with AHPA and AHP standards Commitment to purity and identity of products Implemented standardized methods: Cultivation Manufacturing, Packing, and Labeling Laboratory Distribution Ancillary Operations

8 What is PFC? Nonprofit Third Party Certification Peer Reviewed Seed to Consumption Quality Standards Staff Training Educational Materials Documentation & Facility Audits Complaint Hotline Government Relations Phone: americansforsafeaccess.org

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10 The Endocannabinoid System (ECS) Discovered with the help of phytocannabinoids (Cannabis Sativa, Voacanga Africana, Rhodenderon Anthpogonoides, Radula Marginata, and Helichrysum Umbraculigerum) Consists of endocannabinoids, cannabinoid receptors (i.e.,gpcrs), and enzymes for synthesis and catabolism Eat, sleep, relax, forget, and protect Clinical Endocannabinoid Deficiency (CECD; Russo 2004) Helichrysum Umbraculigerum Rhodenderon Anthpogonoides Cannabis Sativa Radula Marginata Voacanga Africana

11 The basics of GPCRs (CB 1 /CB 2 ) Inactive Receptor Agonist Active Receptor GDP GTPase G I GTP G I GTP G I GDP (-) Adenylyl cyclase camp Downstream Cellular responses

12 The Endocannabinoid System CB1 inhibit forskolin-stimulated AC inhibit N,Q, L-type calcium channels stimulate inwardly rectifying potassium channels activation of MAP kinase CB2 inhibit forskolin-stimulated AC activation of MAP kinase

13 The Endocannabinoid System Neurotransmitters - Endocannabinoids Proteins/Receptors Synapse - Cannabinoid Receptors (CB1 and CB2) -Endocannabinoids and CB1

14 The Endocannabinoid system - Receptors Two main receptors have been identified to date, CB 1 and CB 2, members of the G-protein coupled receptors (GPCRs) family In general, activation of CB 1 results in inhibition of neurotransmitter release, due to hyperpolarization of membrane potential in the pre- or post-synaptic neuron CB 2 receptors are primarily associated with cells derived from the bone marrow lineage GPR55, GPR18, and other orphan receptors may be a cannabinoid receptors Ion channels play an important role

15 Localization of cannabinoid receptors - CB1 Widespread, high level expression, pre- and post-synaptic in central nervous system Distribution parallels known pharmacology Nucleus of solitary tract Hypothalamus Motor systems - Motor cortex, basal ganglia, cerebellum. spinal cord - Motor neurons in spinal cord Eye Sympathetic ganglia, also enteric nervous system Immune system - bone marrow, thymus, spleen, tonsils Breast cancer cell lines Other peripheral sites - heart, lung, adrenal, kidney, liver, colon, prostrate pancreas, testes, ovaries, placenta one

16 Subcellular localization of Cannabinoid Receptors Plasma membrane Endoplasmic reticulum Perinuclear association Other organelles?

17 Localization of cannabinoid receptors -CB 2 Immune system - bone marrow, thymus, spleen, tonsils - T and B lymphocytes, monocytes, NK cells, PMN, mast cells - level of expression increased during activation/ differentiation Uterus Lung Bone (osteoclasts, osteoblasts, osteocytes) - CB2 polymorphisms associated with osteoporosis - CB2 KO mice have accelerated age-related trabecular loss (controversial) Microglia Brainstem neurons

18 Cannabinoid Receptor Structure NH 2 Extracellular Intracellular M 1 M 2 M 3 M 4 M 5 M 6 M 7 COOH

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21 CB Receptor Analysis Tools and Mutational Analysis Amino Acids Binding Activation Conformation Structure Ligand Classifications Bicyclic (CP55,940) Tricyclic (THC, HU-210) Indoles or AAI (WIN55,212) Fatty Acids (Anandamide, 2-AG) Antagonist/Inverse Agonist (SR141716A) Assays GTPγS Stimulation 3 H Binding

22 Receptors, Ligand, and their Interactions Orthosteric (agonist binding site) Allosteric (Other site for AMs) Agonist Antagonist Allosteric Modulator (AM) Negative AMs (NAM) Positive AMs (PAM) Heterodimers/heteromers Console-Bram and Marcu 2012

23 ECS Genetics and Disease Associations Mutation Description Disease Associations References Schizophrenia, substance abuse AAT repeat disorders, Parkinson s disease, inverse relation between number of repeats and working memory performance CNR1 Trinucleotide repeat in 3 UTR Zhang et al., 2004; Comings et al., 1997; Ujike et al., 2002; Barrero et al., 2005, Ruiz- Contreras et al., 2013 CNR1 SNPs or Haplotypes rs ; rs806380; rs806377; rs ; rs806379; rs ; rs ;rs806368; rs806369; rs ; rs ; rs ; rs Substance abuse disorders, depression, anxiety and eating disorders, obesity, schizophrenia, attention deficit disorder CB2 SNPs rs , rs Low bone mineral density or osteoporosis associated in at least 3 distinct human populations Hopfer et al., 2006; Zuo et al., 2009; Zhang et al., 2004; Juhasz et al., 2009; Lazary et al., 2009; Ho et al., 2011, Okahisha et al., 2011, Mutombo et al., 2012, Marcos et al., 2012 Huang et al., 2009; Karsak et al., 2005; Karsak et al., 2009; Yamada et al., 2007

24 The Expanded Endocannabinoid System 5-HT1A receptors Adenosine A2A receptors GPR55 CB1 and CB2 receptors PLA2 Glutamate mglu5 receptor GPR18 5-lipoxygenase (5-LOX) CYP1, CYP3A Transient receptor potential (TRP) channels, Ion channels TRPA1,TRPM8 TRPV1, TRPV2, TRVP4 DAGLα, diacylglycerol lipase α DAGLβ, diacylglycerol lipase β FAAH, fatty acid amide hydrolase MAGL, monoacylglycerol lipase PLA2 Adenosine transporter, (SLC29) Glutamate transporter PPARγ (NR1C3) Glycine α3 receptors

25 Transient receptor potential of vanilloidtype 1 (TRPV1) channel An important component of the ECS, treating chronic and inflammatory pain Ionotropic cannabinoid receptor The effects TRPV1 and anandamide (AEA) have been reported by 100s of studies, activates and desensitizes Involved with physical stimuli - Temperature (42C), mechanical and osmotic stimuli, electrical charge, light, hypotonic cell swelling, and chemical stimuli (low ph). Cannabidiol (CBD) can activate and desensitize TRPV1, underlies part of CBD s analgesic and anti-inflammatory effects. - and less potently THCV, cannabigerol (CBG), cannabigerovarin (CBGV), and cannabidivarin (CBDV)

26 CBD Inhibiting THC (Non-CB Receptor) Antagonism of CB1 can arise when one drug diminishes the effect of another drug by targeting different receptors or enzymes. (Ex, Dry mouth and Cholinergic drugs) (McPartland 2015) CBD augments AEA levels, and both stimulatetrpv1 channels. Pre-synaptic TRPV1 channel activation enhances glutamate release in the spinal cord and brain. This may counteract or antagonize the inhibitory action of pre-synaptic CB1 receptors co-localizing on glutamatergic neurons (Campos, 2009; Di Marzo, 2010). CBD inhibits adenosine uptake. Pre-synaptic A2A receptors form heteromers with CB1 receptors on glutamatergic neurons, and A2A receptor agonism inhibits CB1 receptor-mediated effects CBD acts as a direct and indirect agonist at 5-HT1A receptors and facilitates 5-HT1A-mediated anxiolytic effects (Campos and Guimaraes, 2008; Gomes etal., 2011; Campos et al., 2013); inhibits tryptophan degradation.

27 CBD Enhancing THC (Non-CB1 Receptor) CBD inhibition of FAAH CBD reduces peripheral hyperalgesia via TRPV1 channels (Costa et al., 2004), may hypothetically potentiate THC central mechanisms via CB1 CBD reduces inflammation and inflammatory cytokines (e.g. TNF-α, IL-6, IL-1β) through TRPV1-, A2A and PPARγ mediated mechanisms. THC reduces inflammation through separate CB1- and CB2 receptor-mediated mechanisms. CBD acts as a positive allosteric modulator of glycine receptors, which contributes to cannabisinduced analgesia (Xiong et al., 2011) CBD is an antioxidant and ROS scavenger, more potent than ascorbate or α-tocopherol CBD suppression of ROS, TNF-α, IL-6, IL-1β to dampen NF-κB. THC may dampen NF-κB through a CB2-mediated mechanism CBD modulation of cytosolic Ca2+ levels via several mechanisms CBD inhibits cancer growth and induces apoptosis (Marcu et al. 2010) - Synergy

28 CBD Influencing THC in Humans Part 1 CBD decreased anxiety caused by THC (Karniol et al., 1974) CBD slightly increased time to onset, intensity, and duration of THC intoxication (Hollister and Gillespie, 1975) CBD attenuated THC euphoria (Dalton et al., 1976) CBD reduced anxiety provoked by THC (Zuardi et al., 1982) CBD improved sleep and decreased epilepsy (Cunha et al., 1980; Carlini and Cunha, 1981) CBD decreased cortisol secretion and had sedative effects (Zuardi et al., 1993)

29 CBD Influencing THC in Humans Part 2 CBD provided antipsychotic benefits (Zuardi et al., 1995) CBD reduces the appetitive effects of THC (Morgan et al., 2010) CBD plus THC imparted synergistic inhibition of human glioblastoma cancer cell growth and apoptosis (Marcu et al., 2010) Sativex compared to THC greater pain relief and improvement in sleep (Notcutt et al., 2004) Sativex compared to THC extract reduced cancer-related pain (Johnson et al., 2010) Sativex compared to THC reduced abnormalities in psychomotor performance associated with schizophrenia (Roser et al., 2009)

30 Studies combining THC and CBD Over 25 human and epidemiological studies Low ratio of CBD to THC (i.e.,1:4, 1:1) No studies of CBD to THC that were >1:1 2.7mg to 2.5mg (THC/CBD) Other concepts: - CBD fluidizes membranes, allowing more THC penetration into muscles, amplifying THC s muscle relaxant properties - CBD inhibits hepatic metabolism of drugs (pharmacokinetics)

31 CBD (and component interaction) Summary CBD can directly stimulate receptors, enzymes, and other proteins. CBD can indirectly stimulate receptors by altering EC components and other neurotransmitter levels. Synergy or additive effects occur due to interactions at the same target (i.e., CB1 receptors) or by triggering different pathways that converge on the same physiological effects (i.e., inflammation). - CBD inhibition of FAAH; THC & AEA synergy (Clapper et al., 2010) - CBD reduces inflammation through TRPV1-, A2A, and PPARγ mediated mechanisms. THC reduces inflammation through CB1 and CB2. - CBD acts at glycine receptors (AM), contributes to pain relief (Xiong et al., 2011)

32 New Research: CBD as an Allosteric Modulator of CB1 Diminished signaling from 2-AG and THC Orthosteric site mutation, loss of NAM activity igure 6. Cys-98 and Cys-107 coordinate the negative allosteric modulatory ac Q7/Q7

33 Summary: The ECS and its Modulation by Phytocannabinoids Example, acid phytocannabinoids (CBGA, THCA) inhibit FAAH Di Marzo et al. 2015

34 Terpenes and Phytocannabinoids Part 1 Terpenes can stimulate the expanded ECS to support phytocannabinoid activity Russo 2011

35 Terpenes and Phytocannabinoids Part 2 Russo 2011 Russo 2011

36 Terpenes and Phytocannabinoids Part 3 The essential oil of cannabis has analgesic, anti-inflammatory, and in some cases may even have antidepressant effects (, (Segelman et al Burstein et al. 1975,,Hall 2008; Russo et al. 2000). Terpenoids improve THC pharmacokinetics by increasing vasodilatation of alveolar capillaries (which permits more absorption of THC by the lungs), and by increasing blood brain barrier permeability (Agrawal et al. 1989). (Russo and McPartland 2014) Examples from Russo (2011): - β-myrcene is analgesic, anti-inflammatory, anti-convulsant, and a skeletal muscle relaxant. - β-caryophyllene is analgesic and anti-inflammatory, eases gut muscle spasms, - D-limonene is an antioxidant, antidepressant and anticonvulsant, and blocks carcinogenesis induced by benz[a]anthracene, one of the tars generated by the combustion of herbal cannabis. - D-linalool is sedative, anxiolytic, analgesic and anti-inflammatory, and induces apoptosis in cancer cells. -α-pinene is anti-inflammatory, aids memory as an acetylcholinesterase inhibitor, and causes bronchodilation.

37 The variables in synergy, and the entourage effect Dosing/Administration Inhalation topography Genetic Disease/conditions (i.e., elevated receptor levels) Lifestyle Diet

38 Metabolism (Dosing Vs. Concentration) Ex) MW 300 1M = 300g in 1 L 1mM = 300mg in 1 L 1uM= 300ug in 1 L 1nM = 300ng in 1 L MW of THC: g/mol MW of CBD: g/mol 34mg THC = ~140 ng/ml (i.e., 3.8% THC 1 gram NIDA) That s blood What about at the target site? i.e., From cancer research 1.7/0.4 um THC/CBD ng/ml THC ng/ml CBD

39 Metabolism THC bioavailability is 25% from smoking/inhalation Peak plasma 6-10min High intra- and intergroup variability due to many factors (i.e., smoking topography) THC THC-COOH (inactive, 30-45min [equal] to THC) & 11-OH-THC CBD & CBN not detected after 1hour of smoking

40 Clinical Trials for Appetite and CINV Since 1975, more than 40 clinical studies have examined the effectiveness of synthetic THC, Nabilone (THC derivative) or smoked Cannabis CINV and appetite stimulant Inhaled Cannabis - Typical Inhaled Dose in clinical research 1gram (2-5% THC) - Appetite 1-4 doses per day (2.5-10mg orally) (4-21 days) - CINV before or after treatment - Oral THC recommended dosage for nausea and vomiting induced by cancer chemotherapy are 5 15 mg/m 2 /dose, without exceeding 4 6 doses per day (CPA 2005)

41 Emerging Research: Diet and the ECS Humans cannot make AEA de novo Fish oils alter endocannabinoid levels (Balvers et al. 2012) High/low fat diet influences endocannabinoid genes expression (Engali et al. 2014) High-fructose diet (Lowette et al. 2015), increased CB1mRNA and decreases learning and cognition Omega-3 deficiency in mammals can abolish ECS functions in rats, GPCR uncoupling (Lafourcade et al. 2010)

42 Emerging Research: Diet and the ECS Humans cannot make AEA de novo Fish oils alter endocannabinoid levels (Balvers et al. 2012) High/low fat diet influences endocannabinoid genes expression (Engali et al. 2014) High-fructose diet (Lowette et al. 2015), increased CB1mRNA and decreases learning and cognition Omega-3 deficiency in mammals can abolish ECS functions in rats, GPCR uncoupling (Lafourcade et al. 2010)

43 Helpful References McPartland, J. M., Duncan, M., Di Marzo, V., & Pertwee, R. G. (2015). Are cannabidiol and Δ(9) - tetrahydrocannabivarin negative modulators of the endocannabinoid system? A systematic review. British Journal of Pharmacology, 172(3), Di Marzo, V., & Piscitelli, F. (2015). The Endocannabinoid System and its Modulation by Phytocannabinoids. Neurotherapeutics : the Journal of the American Society for Experimental NeuroTherapeutics, 12(4), Russo, E. B. (2011). Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. British Journal of Pharmacology, 163(7), Pertwee, R. (2014). Handbook of Cannabis. Oxford University Press.

44 Helpful References Visit Us Online to Learn More! PatientFocusedCertification.org