MEDICAL CANNABIS QUICK REFERENCE GUIDE

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1 MEDICAL CANNABIS QUICK REFERENCE GUIDE

2 CANNABIS 101: MEDICINE MEDICAL CANNABIS QUICK REFERENCE GUIDE

3 HOW IT WORKS DEFINITIONS Cannabinoids Class of compounds that act on cannabinoid receptors in the human body (Internal or External) Endocannabinoids Cannabinoids that are naturally produced in the body (Anandamide & 2AG) Phytocannabinoids Cannabinoids produced by the cannabis plant (THC & CBD) Synthetic Cannabinoids Laboratory-synthesized compounds that bind to cannabinoid receptors (e.g. Nabilone) HOW IT WORKS 3

4 ENDOCANNABINOID SYSTEM ENDOCANNABINOIDS Cannabinoids are naturally produced in the body. The two most commonly known endocannabinoids are : 1. Anandamide 2. 2-arachidonoylglycerol (2AG) Endocannabinoids stimulate Cannabinoid receptors CB1 and CB2 Cannabinoid receptors are part of the receptor system in the brain involved in a variety of psychological processes including appetite, pain-sensation, mood and memory. THC s chemical structure is similar to the brain chemical anandamide. Similarity in structure allows drugs to be recognized by the body and to alter abnormal brain communication. BRAIN CHEMICAL DRUG ANANDAMIDE THC 4 MEDICAL CANNABIS QUICK REFERENCE GUIDE

5 ENDOCANNABINOID SYSTEM What can we do? By exogenously administering a cannabinoid one can potentially suppress abnormal pre synaptic firing and potentially control abnormal nerve transmission Why is this important? Gives rise to possible therapeutic effect of targeting CB1 as being able to supress abnormal firing in the instance of epilepsy, neuropathic pain MANAGING HUMAN HEALTH The goal in health is homeostasis to consistently keep things in balance The body makes endogenous cannabinoids naturally (anandamide & 2AG) to stimulate CB1 & CB2 Balance is managed through various receptors and endocannabinoids Exogenous cannabinoids with similar structures will also stimulate CB1 & CB2 HOMEOSTASIS is a key element in the biology of all living things. Best described as the ability to maintain internal conditions that are necessary for survival. DISEASE is simply a result of some aspect of failure in acheiving homeostasis, making the endocannabinoid system a unique target for medical applications. HOW IT IS CONSUMED 5

6 RECEPTORS Locations have different actions when CB1 receptors are stimulated The density and type of cannabinoid present will impact how the body will respond EG cannabis with high THC content activates CB1 receptors in the hypothalamus. This increases appetite and depending upon the person, it could be beneficial or create an adverse effect. DISTRIBUTION OF CB1 RECEPTORS cerebral cortex decision making, cognition & emotional behavior caudate nucleus learning & memory system putamen regulate movements & influence various types of learning globus pallidus regulate voluntary movements amyglada responsible for anxiety & stress, emotion & fear, pain hypothalamus body temperature, feeding, neuroendocrine function hypocampus memory & learning substantia nigra important role in reward, addiction & movement cerebellum motor control & coordination X no cannabinnoid receptors to cause central apnea dorsal vagal complex emesis CB1 receptors are located in the brain and spinal cord. CB2 receptors are located in the immune system. However, both receptors can be found all over the body. 6 MEDICAL CANNABIS QUICK REFERENCE GUIDE

7 CANNABIS SAFETY LD50-1:20,000 to 1: 40,000 In order to introduce death someone would have to smoke 20,000 to 40,000 as much cannabis as found in one marijuana cigarette. A smoker would theoretically have to consume nearly 1500 pounds of marijuana within fifteen minutes to induce a lethal response. IMPAIRMENT THC disolves in fat, whereas alcohol disolves in water. Because THC is fat suluble, it moves readily from water environments, like blood to fatty environments. You can still measure THC in the brain, even if its no longer measurable in the blood. IMPORTANT Explains why residual THC levels are in the body for a long time after use. HOW IT IS CONSUMED 7

8 HOW IT IS CONSUMED 8 MEDICAL CANNABIS QUICK REFERENCE GUIDE

9 MODES OF DELIVERY PRIMARY ROUTES OF ADMINISTRATION LUNGS INHALATION Diffusion into alveolar capillaries and then enters in the bloodstream Maximal onset occurs at min and lasts generally 2-3 hours (short-term relief) Interpatient variability # of inhalations Duration of inhalations Spacing of puffs Hold Time Inhalation Volume Metabolism occurs in the lung, liver, brain GUT INGESTION Metabolized in the liver and turned into 11 hydroxy THC Patient will see more sedation or euphoria Onset can be anywhere from 30 min to 2 hours and can last generally 5-8 hours (long-term relief) Interpatient variability Other food ingested/or lack of Individual variation in metabolism rates Frequency of use Variable absorption in the gut Low plasms THC levels 5 ngrams/litre High plasma levels 100 ngrams/litre HOW IT IS CONSUMED 9

10 INHALATION VERSUS INGESTION ENDOCANNABINOID SYSTEM Inhalation Versus Ingestion MEDICAL ASSESSMENT 10 MEDICAL CANNABIS QUICK REFERENCE GUIDE

11 THE MEDICAL ASSESSMENT History of Presenting Illness Current Medications Past Medications trials/therapy trials Risk Assessment (addiction potential, contraindications) Physical Examination KEY PRIORITIES Before physicians may authorize medical cannabis, many factors are carefully considered. Whether it is the most appropriate treatment for their patient The risks associated with the use of cannabis: - A risk of addiction (9%) - Symptoms of chronic bronchitis - Onset or exacerbation of mental illness If adequate pharmaceuticals for the primary condition have been trialed CONTRAINDICATIONS Under age 25 (relative) History of serious mental disorder (schizophrenia, psychosis, hallucinations) Active alcohol or drug abuse or substance dependence Serious liver, heart or lung disease Pregnancy Allergy to Cannabis MEDICAL ASSESSMENT 11

12 PATIENT DISCUSSION Review how cannabis works and the potential benefits and risks Understand how different formulations can have different effects on the body/mind Evaluate potential drug interactions as cannabis may interact with many medications (blood thinners, anti-epileptics, alcohol, opiates, insulin) Highest risks (side effects) are: At the onset of treatment During the titration phase Dosage change/strain change Method of delivery 12 MEDICAL CANNABIS QUICK REFERENCE GUIDE

13 SIDE EFFECT CONSIDERATION Cardiovascular Tachycardia, palpitations, hypertension/hypotension Respiratory (smoked) Coughing Wheezing Sputum production Neurologic Lethargy, (sedation, slowed reaction time, dizziness) Psychological dysfunction (paranoia/hallucinations) INTERACTIONS WITH OTHER DRUGS Co-Antagonistic Effect MEDICAL ASSESSMENT 13

14 THE SCRIPT AND DOSE 14 MEDICAL CANNABIS QUICK REFERENCE GUIDE

15 DOSING PROTOCOL 1 Can begin with synthetic cannabinoids 2 Start with the lowest effective dose of THC for their condition 3 Titrate up THC to effectiveness Dosing remains highly individualized and relies to a great extent on titration Prior cannabis experience can guide starting dosages (self-medicating patients) Start low, go slow Patient factors to consider: Preference for delivery of medicine Prior cannabis experience (tolerance) Lung capacity Pharmaceuticals THE MEDICAL DOCUMENT Dosage (per day) Length of time THC limit THE SCRIPT AND DOSE 15

16 SEED TO SALE Clones taken from mother plant and assigned barcode Clones are germinated Fully grown plants are dried Product gets packaged and labeled Patients profiles are verified before sending Product sent by Canada Post or Purolator Clones taken from mother plant ensures the genetics are identical in each plant. Allows for standardized label claims and product consistency. Clones grown in separate system until they can get transferred into standardized growing materials Each strain is provided with its own unique blend of nutrients until the flower is ready to be harvested. Trimmed and dried to an optimal moisture level. Our product is then labeled to display the THC and CBD percentages of the product. From there the product is heat and tamper proof sealed in child proof containers. Barcode for each strain is recorded throughout this entire process. The labeled and sealed product is then put in a discrete Canada Post or Purolator bag ensuring discretion and privacy. The patient is also provided with an official tracking number. A signature from the patient is required when accepting the package. 16 MEDICAL CANNABIS QUICK REFERENCE GUIDE

17 TREATMENT AGREEMENT 1 Treatment Agreement 2 Driving Safety Authorizing Physician (only one) To avoid using a motor vehicle within Avoidance of illicit drugs/ non-prescribed controlled substances four hours of inhalation, and possible 6 hours post inhalation with euphoria Avoidance of sharing medication, If ingesting one must be aware using other s, supplementing from illicit sources To be taken as authorized drowsiness may occur and should abstain if sedation, altered LOC (same warning as other medications such as narcotics, benzodiazepines, gabapentin etc.) 3 Harmful Smoking 4 Long Term Effects Patients should avoid using bongs, Science on cannabinoids is rapidly joints, blunts, pipes and should not combine with tobacco evolving and we may not yet appreciate long term effects of chronic use (motivation, mental health, IQ, memory) DOCUMENTS REQUIRED The following documents are required for a legal authorization in Canada: MD signed medical document Amount to be used daily, THC limit and duration of prescription Licensed Producer Form (downloadable form online) Cannabis remains a controlled substance and narcotic. Patients should be educated and sign an agreement. 17

18 HOW TO ACCESS CARE 18 MEDICAL CANNABIS QUICK REFERENCE GUIDE

19 ALEAFIA S PROCESS Pre-Doctor Assessment 1 Referral form received 2 Client contacted Intake package provided Completed packaged triaged Doctor selected Post-Doctor Assessment 3 Medical Authorization Management Licensed Producer selected 4 Patient monitoring Client Support Management 19

20 REFERENCE 20 MEDICAL CANNABIS QUICK REFERENCE GUIDE

21 For your convenience, we have compiled key points of interest from Health Canada s, Consumer s Information on Cannabis. Expanded information, education and training on use, administration and management of medical cannabis is available through Aleafia s Cannabis Resource Centre. Please contact for more information or to book a consult. WHAT THE PRODUCT MAY BE USED FOR? Your health care practitioner may have authorized the use of cannabis (marihuana, marijuana) for the relief of one or more of the following symptoms associated with a variety of disorders, which have not responded to conventional medical treatments. These symptoms (or conditions) may include: severe refractory nausea and vomiting associated with cancer chemotherapy; loss of appetite and body weight in cancer patients and patients with HIV/AIDS; pain and muscle spasms associated with multiple sclerosis; chronic non-cancer pain (mainly neuropathic); severe refractory cancer-associated pain; insomnia and depressed mood associated with chronic diseases (HIV/AIDS, chronic non-cancer pain); and symptoms encountered in the palliative/end-of-life care setting. This is not an exhaustive list of symptoms or conditions for which cannabis may be authorized for use by your health care practitioner. The potential therapeutic and adverse effects associated with cannabis use may vary depending on the amount of cannabis used and the concentration of cannabinoids in the cannabis product, the frequency of cannabis use, the patient's age and medical condition, previous experience with cannabis or cannabinoids, and the use of other prescription or non-prescription drugs. 21

22 POTENTIAL THERAPEUTIC USES LISTED BY HEALTH CANADA INCLUDE: Palliative Care Nausea and vomiting Wasting syndrome and loss of appetite in AIDS and cancer patients To stimulate appetite and produce weight gain in AIDS patients To stimulate appetite and produce weight gain in cancer patients Anorexia nervosa Multiple sclerosis, amyotrophic lateral sclerosis, spinal cord injury Multiple sclerosis Amyotrophic lateral sclerosis Spinal cord injury (or spinal cord disease) Epilepsy Pain Acute Pain Experimentally-induced acute pain Post-operative pain Chronic pain Experimentally-induced pain Neuropathic pain or chronic non-cancer pain Cancer pain Headache and migraine Arthritides and musculoskeletal disorders Osteoarthritis Rheumatoid arthritis Fibromyalgia Osteoporosis Other diseases and symptoms Movement disorders Dystonia Huntington s disease Parkinson s disease Tourette s syndrome Glaucoma Asthma Hypertension Psychiatric disorders Anxiety and depression Sleep disorders Post-traumatic stress disorder Alcohol and opioid withdrawal symptoms Schizophrenia and psychosis Alzheimer s disease and dementia Inflammation Inflammatory skin diseases Gastrointestinal system disorders Irritable bowel syndrome Inflammatory bowel diseases Diseases of the liver Metabolic syndrome, obesity, diabetes Diseases of the pancreas Anti-neoplastic properties WHAT THE ACTIVE INGREDIENTS MIGHT BE Tetrahydrocannabinol (THC) Cannabidiol (CBD) The type and amount of these ingredients may vary depending on the cannabis strain. WHAT THE OTHER INGREDIENTS MIGHT BE There are over 70 different cannabinoids as well as hundreds of other chemicals in cannabis. Many of the chemicals found in tobacco smoke are also found in cannabis smoke. 22 MEDICAL CANNABIS QUICK REFERENCE GUIDE

23 WHAT THE PRODUCT DOES: One of the principal active ingredients in cannabis (THC) acts on very specific targets found in the body known as cannabinoid receptors. Other cannabinoids, such as CBD, may also have targets other than the cannabinoid receptors. Cannabinoid receptors are found throughout the body, in most tissues and organs, but they are especially numerous in the brain and nervous system. Cannabinoid receptors are involved in the regulation of many bodily functions including: brain and nervous system activity, heart rate and blood pressure, digestion, inflammation, immune system activity, perception of pain, reproduction, wake/sleep cycle, regulation of stress and emotional state and many other functions. WHEN THE PRODUCT SHOULD NOT BE USED: Cannabis should not be used if you: are under the age of 25 are allergic to any cannabinoid or to smoke have serious liver, kidney, heart or lung disease have a personal or family history of serious mental disorders such as schizophrenia, psychosis, depression, or bipolar disorder are pregnant, are planning to get pregnant, or are breast-feeding are a man who wishes to start a family have a history of alcohol or drug abuse or substance dependence Talk to your health care practitioner if you have any of these conditions. There may be other conditions where this product should not be used, but which are unknown due to limited scientific information. INTERACTIONS WITH THIS PRODUCT Cannabis may interact with several drugs. Make sure to tell your health care practitioner which prescription drugs, non-prescription drugs or herbal products you are currently taking, particularly: Any drugs which slow down the central nervous system, causing drowsiness. These may include sleeping pills, tranquilizers, some pain medications, some allergy or cold medications, or anti-seizure medications. Other drugs may include antiretroviral drugs used in the treatment of HIV/AIDS, certain anti-depressants, stomach acid inhibitors, certain antibiotic and antifungal medications, certain heart medications, and Saint John's Wort. DOSING INFORMATION AND ROUTES OF ADMINISTRATION There is no scientifically defined dose of cannabis for any specific medical condition. If you have not consumed cannabis before, it would be prudent to have someone with you the first time you use it. Dosing remains highly individualized and relies greatly on titration (i.e. finding the right dose where potential therapeutic effects are maximized while adverse effects are minimized). The current available information suggests most individuals use less than 3 grams daily of dried marijuana, whether that amount is taken orally, inhaled, or a combination of both. Patients with no prior experience with cannabis or cannabinoids are cautioned to begin at a very low dose and to stop therapy if unacceptable or undesirable effects occur. 23

24 There are a small number of clinical studies of short duration with smoked/vapourized cannabis for therapeutic purposes. Smoking/vapourizing cannabis results in a more rapid onset of action (within minutes), higher blood levels of cannabinoids, and a shorter duration of acute effects compared to oral ingestion. While there are no established dosing guidelines for smoking/vapourizing cannabis for therapeutic purposes, it is prudent to proceed slowly and cautiously in a gradual fashion, waiting between puffs or inhalations for a minimum of 30 minutes to gauge for strength of effects or for possible overdosing. A dosing increase should be carried out slowly, only if required, and only until you reach a comfortable dose. In contrast to smoked/vapourized cannabis, there are no clinical studies of cannabis-based edible products for therapeutic purposes (e.g. oils, foods). Absorption of cannabinoids by the oral route is known to be slow and erratic, and the onset of acute effects is delayed with the acute effects generally lasting much longer compared to smoking/vapourizing. Furthermore, dosages for orally administered products are even less well-established than for smoking/ vapourization. These particularities have contributed to overdoses with some orally administered products. If ingesting cannabis orally (e.g. in oils, foods) wait a minimum of 2 hours between administration of single doses of oral products to gauge for strength of effects or for possible overdosing. Stop using cannabis right away and consult your health care practitioner if you begin to experience any side effects (see side effects section for additional information). OVERDOSE Symptoms of overdose may include: sleepiness, confusion, disorientation, clumsiness/ loss of coordination, fainting, dizziness, chest pain, fast, slow or pounding heartbeat, panic attacks, loss of contact with reality, and seizures. Seek immediate medical attention in case of overdose, and especially if experiencing chest pain, panic attacks, loss of contact with reality, or seizures. Cannabis should be used with caution in patients receiving concomitant therapy with other psychoactive drugs because of the potential for greatly enhanced effects on the brain and other parts of the nervous system. An overdose can also occur if a patient is smoking/vapourizing cannabis and at the same time consuming orally administered cannabinoids whether from prescription cannabinoid medications, or from consumption of oils, teas, baked goods or other products. HOW THE PRODUCT IS SUPPLIED Dried marijuana plant material, fresh marijuana plant material and products derived from fresh or dried marijuana. 24 MEDICAL CANNABIS QUICK REFERENCE GUIDE

25 HOW TO STORE THE PRODUCT Dried marijuana plant material and cannabis products should be stored in a cool place, preferably away from light and air. See manufacturer's instructions on the product label for recommended storage conditions. Keep any cannabis and cannabis products out of the reach of children and locked in a safe place to prevent theft, misuse and accidental ingestion by children. This product should not be shared with anyone else. ONSET, PEAK, AND DURATION OF EFFECTS With inhalation (smoking, vaporizing), effects may be felt within a few minutes of dosing and will generally peak within 30 mins., effects generally last between 2 and 4 hours but may be longer (e.g. 24 hours). With oral ingestion (e.g. oils, foods, capsules), acute effects may begin to be felt as quickly as 30 mins and as late as 3 or 4 hours after administration. This variability in timing depends on a number of factors (e.g. amount of food in stomach). It is prudent to wait a minimum of 2 hours between administration of single doses of oral products to avoid possible overdosing. Acute effects generally peak between 3 and 4 hours after dosing and can last up to 8 hours or longer e.g hours). With topical application, it is not known how long it takes for potential therapeutic effects to appear, nor how long they last. There have been reports of hypersensitivity reactions (e.g. rashes, itching) when skin has come into contact with cannabis. SIDE EFFECTS AND WHAT TO DO ABOUT THEM The information on side effects associated with therapeutic use of cannabis is limited. Some of the more well-known side effects are intoxication-like reactions including: dizziness, drowsiness, feeling faint or lightheaded, fatigue, headache; impaired memory and disturbances in attention, concentration and ability to think and make decisions; disorientation, confusion, feeling drunk, feeling abnormal or having abnormal thoughts, feeling "too high", feelings of unreality, feeling an extreme slowing of time; suspiciousness, nervousness, episodes of anxiety resembling a panic attack, paranoia (loss of contact with reality), hallucinations (seeing or hearing things that do not exist); impairments in motor skills and perception, altered bodily perceptions, loss of full control of bodily movements, falls; dry mouth, throat irritation, coughing; worsening of seizures; hypersensitivity reactions (contact dermatitis/hives); higher or lower blood levels of certain medications; nausea, vomiting; and fast heartbeat. 25

26 DOSING AMOUNTS Information obtained from a limited number of small and short-term clinical studies of cannabis for medical purposes indicate the daily doses of smoked or vapourized dried cannabis ranged from as little as 75 mg of dried cannabis 9.4% THC by weight) (i.e. 7 mg THC/day) to a maximum of 3.2 grams of dried cannabis (1 8% THC by weight; i.e. 32 to 256 mg THC). Doses of THC as low as mg of THC (and even lower) are associated with a therapeutic benefit and minimal psychoactivity. Various surveys published in the peer-reviewed scientific and medical literature have suggested that the majority of people using smoked or orally ingested cannabis for medical purposes reported using between grams of cannabis per week, or approximately 1 3 grams of dried cannabis per day. One study reported the average daily dose of dried cannabis (of various potencies) used by patients in the Netherlands Medical Cannabis program was 0.68 grams per day (range: grams per day) Another study suggests that regardless of route of administration (inhalation vs. oral), individuals reporting use of cannabis for medical purposes reported consuming equivalent amounts of cannabis per day and that amount averaged at around 3 grams per day. For smoking and vapourizing, the median reported dose was grams per day respectively. For edibles, the median reported dose was 1.5 grams per day. For teas, the median reported dose was 1.5 grams per day. There is no information available on dosing amounts for topically applied cannabis products (e.g. ointments, creams, lotions, oils, balms, salves), however one study suggests approximately 5% of individuals who use marijuana for medical purposes use such products. There is no information available on dosing amounts for fresh marijuana. In the absence of any clinical studies conducted with cannabis products, such as oils that are ingested orally, the following information has been provided as a reference to give some potential guidance around dosing. FOR PRODUCTS SUCH AS OILS THAT ARE INGESTED ORALLY The available clinical evidence for Marinol, an orally administered capsule that has received market authorization and that contains synthetic THC dissolved in sesame oil, indicates a dosing range from as low as 2.5 mg THC per day to a maximum dose of 210 mg THC per day. Doses lower than 2.5 mg (e.g. 1 mg) THC may further avoid incidence and risks of adverse effects. Average dose of Marinol is 20 mg THC per day. 26 MEDICAL CANNABIS QUICK REFERENCE GUIDE

27 Maximal recommended daily oral dose of Marinol is 40 mg per day. Preliminary information from an open-label clinical trial with Epidiolex (an orally adminis tered oil extract containing mainly cannabidiol (CBD) for treatment of certain types of childhood epilepsy not responsive to conventional treatment), suggests a daily dosing range between 5 and 20 mg/kg CBD. However, further clinical studies are required to substantiate this information. Important Note: EQUIVALENCY FACTOR The quantity of product other than dried marijuana (for example, fresh marijuana or cannabis oil) that is equivalent to one gram of dried marihuana ("the equivalency factor") must be determined. However, the equivalency factor depends on the production method, form of supply and the THC/CBD yield. The licensed producers will provide this information on the label. The information about the equivalency factor will also be available on the licensed producer's website. If the patient chooses to produce cannabis themselves or to have it produced by another person, the patient and the designated person, if any, are required to manage their possession or storage limit based on the quantity of fresh marijuana, cannabis oil or other products that are equivalent to a given quantity of dried marijuana. As such, five grams of fresh marijuana is determined to be equivalent to one gram of dried marijuana and the quantity of products that is equivalent to a given quantity of dried marijuana is calculated by taking into account the weight of fresh or dried marijuana that was used to make the products. DRUG SCREENING TESTS Because of the long half life of elimination of cannabinoids and their metabolites, drug tests screening for cannabinoids can be positive for weeks after last cannabis/ cannabinoid use depending on he sensitivities of the tests used. Step 1: Consult with a Health Care Practitioner Treatment decisions are best made in consultation with your health care practitioner. Under the ACMPR, an authorized health care practitioner includes physicians in all provinces and territories, and nurse practitioners in provinces and territories where supporting cannabis for medical purposes is permitted under their scope of practice. 27

28 Step 2: Obtain a Medical Document from your Health Care Practitioner You will need to obtain a medical document from your practitioner. The following information must be included on the medical document signed and dated by the health care practitioner: your full name; your date of birth; address where you consulted with the practitioner; daily grams of dried marijuana you are authorized to use, the period of use (i.e. number of days, weeks or months), which cannot exceed one year from the date the medical document is signed by the healthcare practitioner; the healthcare practitioner's name and, administrative information (profession, licence number, province of licence, business address, phone number, fax number and address, if applicable); and an attestation by the healthcare practitioner that the information contained in the document is correct and complete. This document may be completed by the applicant's health care practitioner as defined in the Access to Cannabis for Medical Purposes Regulations (ACMPR). A health care practitioner includes medical practitioners and nurse practitioners. In order to be eligible to provide a medical document, the health care practitioner must have the applicant for the medical document under their professional treatment. Regardless of whether or not this form is used, the medical document must contain all of the required information, (see in particular s. 8 of the ACMPR). Patient's Given Name and Surname: Patient's Date of Birth (DD/MM/YYYY): Daily quantity of dried marihuana to be used by the patient: _ g/day The period of use is day(s) week(s) month(s). NOTE: The period of use cannot exceed one year Health care practitioner's given name and surname: Profession: Health care practitioner's business address: Full business address of the location at which the patient consulted the health care practitioner (if different than above): Phone Number: Fax Number (if applicable): Address (if applicable): Province(s) Authorized to Practice in: Health Care Practitioner's Licence number: By signing this document, the health care practitioner is attesting that the information contained in this document is correct and complete. Health Care Practitioner's Signature: Date Signed (DD/MM/YYYY): 28 MEDICAL CANNABIS QUICK REFERENCE GUIDE

29 NOTE: The medical document can be submitted from the health care practitioner's office to the licensed producer by secure fax. If you choose to submit the medical document by secure fax, initial the statement below to acknowledge agreement. I, the health care practitioner, acknowledge that the faxed medical document is now the original medical document and that I have retained a copy of this document for my records only. Initial here: Step 3: Register and Order with a Licensed Producer Once you have obtained a medical document from your authorized healthcare practitioner, you can register as a client with the licensed producer of your choice. To register, you will need to submit certain information, including the original medical document. Please contact the licensed producer for further information regarding application requirements. After registering as a client, you will be able to order cannabis for medical purposes from the licensed producer. Do not send your medical document to Health Canada. Step 4: Shipping of your Cannabis for Medical Purposes Your cannabis will be sent to you directly by the licensed producer. The Controlled Drugs and Substances Act (CDSA) prohibits possession, trafficking, import and export, and production of controlled substances, including marijuana, unless authorized by regulations. Neither the ACMPR nor any other Health Canada regulations authorize licensed producers to provide cannabis for medical purposes through a storefront. POSSESSION OF CANNABIS FOR MEDICAL PURPOSES: The amount of dried marijuana you can possess is the lesser of thirty times the daily amount stipulated by your healthcare practitioner or 150 grams. For example, if your healthcare practitioner recommends 3 grams per day, you would be allowed a maximum of 90 grams at any one time (30 days 3 grams). However, if your healthcare practitioner recommends 6 grams per day, you would be allowed to possess a maximum of 150 grams at any one time, which would therefore be less than a 30-day supply. SHOWING PROOF OF LEGAL POSSESSION OF CANNABIS FOR MEDICAL PURPOSES: If asked by law enforcement, you can demonstrate that you are in legal possession of cannabis for medical purposes obtained from a licensed producer by showing either the label on the package containing your specific client information or the separate document containing the same information, which accompanied your shipment of cannabis. INFORMATION FOR HEALTHCARE PRACTITIONERS If you are a licensed health care practitioner and you want to know more about the use of cannabis for medical purposes (for example, pharmacology, potential therapeutic uses, contraindications, adverse reactions etc.) the following resources will provide you with scientific and medical information to help you inform patients. 29

30 INFORMATION FOR HEALTHCARE PRACTITIONERS (continued) Health care practitioners should consult their provincial or territorial health care licensing authority's guidelines and policies before authorizing the use of cannabis for medical purposes. In addition, the College of Family Physicians of Canada has published preliminary guidance on authorizing dried cannabis for chronic pain and anxiety, which can be found here: If you and your patient conclude that cannabis for medical purposes is an appropriate option for her/him, you will need to complete a medical document (or other document containing the same information). For additional application requirements, you can direct your patient to the section When you discuss daily amount of cannabis with your patient, it is useful to remember that the recommended daily amount dictates the total amount the patient will be authorized to possess or produce. Various surveys published in the peer-reviewed scientific and medical literature have suggested that the majority of people using smoked or orally ingested cannabis for therapeutic purposes reported using the equivalent of up to three (3) grams of dried marijuana per day. While there are no restrictions under the Access to Cannabis for Medical Purposes Regulations on the daily amount that you may authorize, there is a possession limit of the lesser of the equivalent of 150 grams or 30 times the daily amount of dried marijuana. DAILY AMOUNT EXPRESSED IN GRAMS OF DRIED MARIJUANA You must indicate on the medical document the daily amount that you authorize expressed in grams of dried marijuana. If the patient chooses to access either fresh marijuana or cannabis oil, from a licenced producer, the producer will determine the amount of fresh marijuana or cannabis oil that is equivalent to a given amount of dried marijuana by taking into account the dried marijuana equivalency factor established by the licensed producer. If the patient chooses to produce cannabis him/herself or to have it produced by another person, the patient and the designated person, if any, are required to manage their possession or storage limit based on the amount of fresh marijuana, cannabis oil or other products that are equivalent to a given amount of dried marijuana. As such, five (5) grams of fresh marijuana is determined to be equivalent to one (1) gram of dried marijuana and the amount of products that is equivalent to a given amount of dried marijuana is calculated by taking into account the weight of fresh or dried marijuana that was used to make the products. For fresh marijuana and cannabis oil sold or provided by licensed producers, information about the equivalency in dried marijuana will appear on the product label. The information is also available on the licensed producer's website. 30 MEDICAL CANNABIS QUICK REFERENCE GUIDE

31 The courts in Canada have ruled that the federal government must provide reasonable access to a legal source of marijuana for medical purposes. The legal sources of cannabis for medical purposes are licensed producers, personal production and designated production. A complete list of licensed producers can be found on the Health Canada website. Cannabis is not an approved therapeutic product and the provision of this information should not be interpreted as an endorsement of the use of cannabis for therapeutic purposes, or of marijuana generally, by Health Canada. This leaflet is designed by Health Canada for patients authorized to possess cannabis for medical purposes. It is based on the document "Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the Cannabinoids", and is a summary only - it will not provide you with all the facts about cannabis for medical purposes. Contact your health care practitioner if you have any questions. SERIOUS WARNINGS AND PRECAUTIONS Keep any fresh or dried marijuana and cannabis oil out of reach of children. Cannabis (marihuana, marijuana) contains hundreds of substances, some of which can affect the proper functioning of the brain and central nervous system. The use of this product involves risks to health, some of which may not be known or fully understood. Studies supporting the safety and efficacy of cannabis for therapeutic purposes are limited and do not meet the standard required by the Food and Drug Regulations for marketed drugs in Canada. Smoking cannabis is not recommended. Do not smoke or vapourize cannabis in the presence of children. Using cannabis or any cannabis product can impair your concentration, your ability to think and make decisions, and your reaction time and coordination. This can affect your motor skills, including your ability to drive. It can also increase anxiety and cause panic attacks, and in some cases cause paranoia and hallucinations. Cognitive impairment may be greatly increased when cannabis is consumed along with alcohol or other drugs which affect the activity of the nervous system (e.g. opioids, sleeping pills, other psychoactive drugs). 31

32 32 Aleafia Inc Jane MEDICAL Street, 2 ND Floor CANNABIS Concord, QUICK ON L4K REFERENCE 2M9 office: GUIDE aleafiainc.com

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