HOLOS HEALTH ACHIEVING BALANCE WITH GOOD MEDICINE

Transcription

1 HOLOS HEALTH ACHIEVING BALANCE WITH GOOD MEDICINE Joe Cohen D.O., Medical Director Holos Health & Journey2Life Boulder and Denver Colorado

2 CANNABIS PRACTITIONERS Joseph Cohen, DO Jia Gottlieb, MD Lisa Rittel, DO Katherine Golden, RN Natali Murdock, RN

3 Learning Objectives Basic understanding of the Endocannabinoid System (ECS) Learn how cannabis integrates with Functional Medicine Yin and Yang- the relationship between THC & CBD Why cannabis can treat a wide variety of disorders Examples: Cannabis use in autoimmune disease, neurodegenerative disease, pain & addiction Make appropriate recommendations to patients

4 The Doctor Visit at Holos Medical history Physical exam- including body composition test Consultation (30 or 60 minutes with physician) Specific to medical condition & encourage wellness How cannabis can be used as a treatment In office completion of CDPHE online forms with guidance Referral to other practitioners when warranted Cannabis nurse follow-up (optional) Renewal visit in 1 year 100% compliant with all state guidelines

5 Yin and Yang In Chinese philosophy, yin and yang describe how seemingly opposite or contrary forces may actually be complementary, interconnected, and interdependent in the natural world, and how they may give rise to each other as they interrelate to one another. The relationship between CBD and THC follows this philosophy

6 The Endocannabinoid System (ECS)

7 The Endocannabinoid System Animals have had an endocannabinoid system for over 600 million years. The cannabis plant, with its phytocannabinoids, was introduced million years ago. Anandamide and 2AG, the 2 primary endocannabinoids- discovered in early 1990 s Endocannabinoids provide us with balance and homeostasis- an adaptogen. They moderate the flow of of neurotransmitters, keeping our nervous system running smoothly.

8 The Endocannabinoid System

9 The Human Endocannabinoid System

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11 The Endocannabinoid System Receptors are found throughout our body: CB1 receptors most concentrated in brain & CB2 in the immune system. Lock and key- receptors and cannabinoids must be a perfect fit Activation of CB1 receptor is responsible for psychoactive and physical effects commonly associated with cannabis consumptions Activation of CB2 receptor control the release of cytokines that promote inflammation and immune function. Very complex regulatory system with broad and diverse functions. Due to its ubiquitous activity it provides a bridge between body and mind. One of the most significant receptor systems in the human bodynot taught in many medical schools.

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13 Raw, Activated & Aged Cannabis

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15 Among the many benefits of CBD: Anti-inflammatory, Neuroprotective, Immunosuppressive

16 TERPENES

17 Terpenes Give cannabis both flavor and odor 200+ are found in cannabis plant Modulate the effects of cannabinoids which modulate the effects of neurotransmitters May be responsible for the different effects of indica and sativa dominant cultivars β-caryophyllene, a terpene, binds to CB-2 receptors

18 Actions of CBD Unlike psychoactive THC, CBD does not attach to the same binding site on the CB1 or CB2 receptors. THC binds to orthosteric binding sites and CBD binds to allosteric binding sites on the same receptor. CBD opposes some actions of THC at the CB1 receptor, decreasing the psycho-activity, anxiety and tachycardia caused by THC.

19 Actions of CBD CBD indirectly stimulates endogenous cannabinoid signaling by suppressing the enzyme fatty acid amidehydroxylase (FAAH). FAAH breaks down anandamide, therefore CBD allows anandamide to remain for longer duration, hence enhancing endocannabinoid tone by suppressing FAAH. CBD stimulates the release of 2-AG, an endocannabinoid that activates both CB1 & CB2 receptors. CB2 receptors are predominantly found in the immune system and peripheral nervous system. CBD INCREASES ENDOCANNABINOID TONE!

20 METHODS OF USE-TOPICALS Topical cannabis includes salves and creams and is used to treat local areas of pain Used in small amounts-usually non-psychoactive Massage well into effected area Combine with heat to treat muscle spasm Can be used on joints and other tender areas Often combined with other ingredience to reduce pain and inflammation Recently found to be effective in treating rashes Topical concentrates may treat skin cancer

21 METHODS OF USE- INHALATION Fast onset short duration Inhalation includes the categories following: Smoking flower Joint, pipe, bong Side effects include carcinogens, smoke, odor, cough, congestion, sinusitis, carbon monoxide, butane inhalation

22 METHODS OF USE- INHALATION Vaporizing flower The preferred method of inhalation Eliminates carcinogens, smoke, cough, congestion, sinus problems, odor, carbon monoxide, butane Often have ability to set temperature All cultivars (strains) available Plug-in and portable THE PREFERRED INHALATION METHOD

23 METHODS OF USE- INHALATION Vape pens for use with concentrate Often have to purchase pre-loaded cartridge Limited choice of cultivars Cartridges may have potential toxins (propylene glycol= antifreeze) Concentrated pesticides and fungicides used in grow May have poor temperature control Potential for increased tolerance Not recommended for new users CONVENIENT AND DISCREET

24 METHODS OF INHALATION- DABS Extremely high level of THC (75-90%) Likely to cause significant tolerance issues causing receptors to go into hiding Increased risk of addiction and dependency Recommend drug holiday to allow return to normal tolerance Need for studies into any long-term harm WHEN CANNABIS USE BECOMES ABUSE

25 METHODS OF USE- INTRAORAL Intermediate onset and duration Tinctures and sprays Easy to dose by counting drops or # of pumps Keep under tongue 1 minute before swallowing Comes in a variety of ratios of CBD:THC Start with a low dose and increase as needed EXCELLENT FOR INEXPERIENCED USERS

26 METHODS OF USE: TRANSDERMAL Intermediate onset and long acting Systemic (not local) use Transdermal patch is most common method Very convenient- can last 8-12 hours Applied to dorsal wrist or ankle (vascular area) Can cause local reaction (rash) Not always absorbed Expensive Transdermal cream Applied to same area as patch

27 METHODS OF USE- INGESTABLES Delayed onset and long lasting Start low and go slow 4X stronger and 4X longer lasting than inhaling Onset in minutes, duration 6-8 hours Includes capsules, pills, oils, edibles and drinks Delta-9-THC converts to 11-OH THC in liver Inconsistent results depending upon absorption in small intestine and liver conversion (CYP-450)

28 METHODS OF USE- INGESTABLES Ideal for sleeping through the night New users should start at 2.5 to 5mg dose Dabbers often need 100mg or more due to tolerance A small percentage of patients have no effect from ingesting ( absorption or liver CYP450) BE CAREFUL WHEN RECOMMENDING THC DOMINANT INGESTABLES TO NEW USERS

29 Juicing METHODS OF USE- OTHER The acid form of the plant may have anti-inflammatory and ant-cancer effects May cause diarrhea Hard to obtain due to need for large quantity Rectal suppositories May be helpful for prostate and colo-rectal cancer Many patients are finding positive results without the psycho-activity associated with ingestables Vaginal applications May help with painful menses, cervical dysplasia, orgasm

30 Cannabis as a Functional Medicine

31 Cannabis and Functional Medicine Functional Medicine The prevention, early assessment and management of chronic disease by correcting core imbalances to restore health to the greatest possible extent. This may require the elimination of triggers of disease, such as toxins in our food, our air and our water.

32 Cannabis and Functional Medicine Food is your medicine- food is your poison Gluten, toxins and inflammatory foods Hybridized wheat with increased levels of gliadin and glyphosate GMO s, Monsanto and Dow The medical/industrial complex Medical school education includes pharmacology and procedures, and lacks training in nutrition and ECS The average doctor visit is 7 minutes in the US Diagnosis code, prescriptions and procedure recommendations Look at the whole patient It all starts in the gut

33 Cannabis and Autoimmune Disease Pathophysiology of AI disease (it starts in the gut) Autoimmune disorders respond well to CBD & THC Sativex (GW Pharmaceuticals) Whole plant- 1:1 ratio CBD:THC for treating MS Fibromyalgia, SLE, Rheumatoid and other AI arthritic conditions, Crohn s and Inflammatory Bowel Disease, etc. Combining cannabis & functional medicine are effective in treating autoimmune disorders

34 Triggers, Genes & Leaky Gut = Autoimmune Disease

35 Genetics

36 Leaky Gut

37 How Leaky Gut Effects Autoimmune

38 Cannabis & Autoimmune Disease Studies with Sativex reveal whole plant 1:1 CBD:THC sublingual spray treats MS symptoms (autoimmune & neurodegenerative) CBD:THC in balance may be best results for AI CBD, along with the entourage of THC, other cannabinoids and terpenes, works via a variety of mechanisms to influence CB2 receptors. CBD is immunosuppressive, anti-inflammatory, neuroprotective, anti-spasmotic, etc. CBD tightens junctures via claudin-1

39 Autoimmune Disease: Treatment Remove triggers of disease Foods, physical & emotional stress, heavy metals and other environmental toxins, compromised microbiome, etc. Gut healing elimination diet Gut healing supplements Healthy microbiome Cannabinoids: 1:1 CBD:THC (tinctures 3x/d)) Immunosuppressive Anti-inflammatory Gut healing

40 Cannabis as Mind / Body Medicine

41 Cannabis as Body/Mind Medicine Cannabis can lower stress, therefore having a positive effect on adrenals (neuroendocrine). Improves mood Cannabis may treat the following: ADD/ADHD, OCD, Autism, PTSD, Seizures, Depression, Anxiety, CTE, Alzheimer s

42 PTSD and Anxiety Disorders

43 Cannabis and Sleep THC, especially indica dominant strains, 1 hour before bed for best results Metabolites of THC enhance sleep CBD may inhibit sleep (except pain or anxiety) CBN, from oxidized THC, enhances sleep Inhale to fall asleep, ingest to stay asleep Low to moderate dose for sleep, otherwise too stimulating

44 Neurodegenerative Disease

45 Cannabis and Neuroprotection Neuroprotection: mechanisms and strategies used to protect against neuronal injury, degeneration or death in the CNS. Neuroprotection prevents the onset of neurodegenerative disease. Acute: Traumatic Brain Injury, Stroke Chronic: Alzheimer s, MS, Parkinson s, ALS, Huntington s, Tourette s, Chronic Traumatic Encephalopathy (CTE) etc. CANNABINOIDS ARE NEUROPROTECTIVE

46 Cannabis and Neuroprotection Glutamate Excitotoxicity (GE) Excitotoxicity: Nerve cells are damaged or killed by excessive stimulation from neurotransmitters such as glutamate. GE is found in all acute and chronic neurodegenerative diseases. GE is also seen in those weaning from ETOH, Narcotics and Benzodiazepines. Since cannabis may prevent GE it shows promise in both the prevention and treatment of acute and chronic neurodegenerative conditions.

47 Glutamate Excitotoxicity Cannabis is an ideal medicine to help patients wean off of benzodiazepines, narcotics and alcohol. It reduces the need for these substances while easing withdrawal symptoms and protecting the brain Prescription drugs- a leading cause of death in US

48 Cannabinoids and Neuroprotection Scientific information disseminated by governmental organizations that promote and enforce cannabis prohibition laws would have you believe that consuming cannabis has no benefit for your brain and nervous system, and in fact has severely detrimental effects, with no exceptions. This must be the case, right? After all, how else can we account for the draconian penalties meted out for some violators of the cannabis prohibition laws? Clearly cannabis use must insidiously rot away one s brain, right? Wrong. Nothing could be farther from the truth. Although inhaling cannabis smoke may acutely stimulate the brain s natural forgetting faculty by no means does this imply that cannabis is causing brain damage. Rigorous peer-reviewed scientific work has consistently demonstrated that chemicals in cannabis, especially the cannabinoids, are actually neuroprotective and can be used to prevent and treat neurotoxicity and neuroinflammation. As your head begins to stop spinning, prepare to be startled by many other ground-breaking discoveries coming out of the emerging field of cannabinoid medicine. Sunil Aggarwal, M.D., PhD and Gregory Carter, M.D. The Pot Book Ch. 25, pg.295

49 Cannabis and Neuroprotection Cannabinoid receptors in the CNS, when activated, trigger signals in the brain that are linked to neuronal repair and cell maintenance, and the release of other compounds that further activate neuroprotective responses. Phytocannabinoids can enhance the protection provided by our endocannabinoid system.

50 CBD and THC have been shown to decrease amyloidbeta plaque found in Alzheimer s Cannabinoids prevents destruction of brain cells (GE) Cannabis shows great promise in treating a variety of neurodegenerative disorders Cannabinoids are anti-inflammatory & antioxidant

51 Pain and Addiction Pain is the most common symptom for which patients report using medical cannabis. Table II: Conditions (CDPHE August 2014) (**Does not add to 100% as some patients report using medical marijuana for more than one debilitating medical condition.) Reported Condition Number of Patients Reporting Condition Percent of Patients Reporting Condition** Cachexia 1,085 1% Cancer 3,648 3% Glaucoma 1,234 1% HIV/AIDS 686 1% Muscle Spasms 16,928 15% Seizures 2,497 2% Severe Pain 108,157 93% Severe Nausea 11,267 10%

52 Pain and Addiction Pain is by far the most common symptom for which patients report using medical cannabis. 93% of CO patients report pain as an indication. The key to effective use for pain is finding the sweet spot. Dose is critical Higher dose does not equate to more pain relief THC is a biphasic drug- less is more

53 Pain and Addiction Types of pain include acute, chronic and neuropathic. Cannabis works best for chronic and neuropathic pain Terpenes such as beta-caryophyllene, myrcene, etc. enhance the antiinflammatory and pain relieving effects of cannabinoids. Combining CBD and THC are most effective There may be an endocannabinoid deficiency in those who suffer from migraines. Low dose prophylaxis with any cannabis cultivar may be effective Durban Poison inhaled via vaporizer at onset (THCV?) CBD increases endocannabinoid tone

54 Pain and Addiction Cannabis is an ideal medication to give to patients wanting to wean off of narcotics, benzodiazepines and alcohol. Narcotics Cannabis can be used as an adjunct treatment for opioid pain medications. Potentiates the effect of narcotics therefore many patients can immediately reduce their opioid dose by one half. Narcotics, especially when combined with benzodiazepines, is a leading cause of death in the US. Overdose deaths have declined by 25% in MMJ states according to a report in JAMA Internal Medicine.

55 Public Health Impact of Opioids 44 Americans die daily from an overdose of prescription opioids. Emergency rooms treat 7000 people daily for misuse of prescription opioids. 1 in 20 Americans used prescription painkillers nonmedically in Opioid sales quadrupled between 1999 and Death rates quadrupled from opioid overdose from % of heroin users report using prescription opioids prior to using heroin.

56 Cannabinoid-Opioid Synergy Both opioid and cannabinoid receptors are present in pain signaling regions of the brain and spinal cord. Opioid and cannabinoid signaling pathways interact with each other. Administering cannabinoids with opioids results in a greater than additive anti-pain effect.

57 Medical Cannabis Law & Opioid Abuse States with medical cannabis laws saw the following: 24.8% reduction in opioid overdose deaths. 23% fewer hospitalizations from opioid abuse 13% fewer hospitalizations from opioid overdose

58 Cannabis as a Treatment for Symptoms of Opioid Withdrawal Nausea, vomiting, diarrhea, cramping Muscle spasm Anxiety, agitation, restlessness Insomnia Runny nose, sweating

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60 Prescription Opioids in America Although the US has 5% of the world s population, we consume 80% of the world s opioid supply. 50% of patients who took opioids for more than 1 month the first year continued to use them for 3 years or longer.

61 Benzodiazepines vs. Cannabis VS.

62 Pain and Addiction Benzodiazepines Benzodiazepines: used primarily to treat anxiety & insomnia Anxiety: CBD is an excellent antianxiety medicine CBD mitigates side effects of THC such as anxiety & paranoia Do not recommend THC dominant sativas as these can increase anxiety, cause panic attacks and paranoia. Insomnia: THC and CBN (oxidized THC) CBD may actually keep people awake Cannabinoid profile, dosage, timing, and delivery method are critical when treating insomnia.» THC initially stimulates and its metabolites are sedativetherefore inhaling cannabis is recommended 1 hour prior to going to bed. (short acting)» Edible cannabis is best for those who awaken during the night. (long acting)

63 Pain and Addiction Benzodiazepine addiction Benzos are highly addicting Slow weaning over time Withdrawals can last up to 2 years Cannabis can not only be used to replace the need for benzos, but can ease withdrawal symptoms and protect the brain Benzos, when combined with opioids, can slow or stop respirations and heart rate, while cannabis does neither

64 Pain and Addiction Alcohol Abuse Cannabis can replace alcohol as a recreational drug Since legalization in CO, highway fatalities are at near historic lows. Alcohol abuse has devastating effects on individuals and society. Cannabis can help treat withdrawal symptoms from alcohol abuse. We see many patients at Holos who have successfully weaned off of alcohol with help from cannabis.

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66 Cannabis for the Cancer Patient Treatment of Neuropathy, Nausea & Anorexia after Chemotherapy, Radiation and Surgery Use as a Chemotherapy Agent

67 Treatment of cancer related side effects Pain Relief Works centrally with the CB1 receptors as well as peripherally with both CB1 and CB2 receptors Also has anti-inflammatory effects (CB2) Most effective treatment: combination THC/CBD Neuropathy Seen in cancer patients, especially those given certain chemotherapy agents. Also seen in AIDS patients Studies show cannabis significantly reduces neuropathic pain

68 Treatment of cancer related side effects Cannabinoid: Opioid interactions= synergy Patients can reduce the dose of opioids in half when using cannabinoids. Reduce dose of opioids= decreased side effects Antiemetic effect Marinol (THC) Anxiety, depression and sleep can be positively effected by use of cannabinoids One medication can treat anorexia, nausea, pain, depression, anxiety and insomnia.

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70 Cannabinoids as Anticancer Agents In addition to the treatment of neuropathy, nausea & anorexia after chemotherapy, radiation and Surgerycannabis may be a chemotherapy agent. THC, when used in combination with chemotherapy agents may improve outcomes. (GBM) CBD, when combined with THC reduces the growth of several types of tumors and is more effective than THC alone. Therefore, less THC is needed resulting in less psycho-activity. Whole plant cannabis, with well over 100 cannabinoids (plus terpenes), may further reduce side effects of THC and further increase therapeutic effects. We see this with the balancing effect that CBD has on THC (orthosteric, allosteric)

71 Cannabinoids as Anticancer Agents Until recently, studies have been done on laboratory animals and in the test tube. Since we do not have adequate human trials, we cannot claim that concentrated oils can cure cancer. We should never recommend that patients forego or postpone conventional medical therapy in favor of self-medicating with highpotency cannabis oils. Potentially treatable cancers may become incurable in some cases. Since cannabinoids might improve anti-tumor activity of conventional chemotherapy while reducing side effects, oncologists should not discourage their use. It s about the whole plant

72 Cannabinoids as Anticancer agents Lots of anecdotal information about curative effects of cannabis. We have seen many patients in our practice that have had significant improvement We need to have human trials before we can make any claims Many providers would frown on the use of a relatively benign inhaled psychotropic agents while freely writing prescriptions for pharmaceutical agents with significantly greater cost, potential for addiction or abuse, and more negative societal impact overall

73 Pregnancy and Breastfeeding Cannabis is not recommended for use in neither pregnancy nor while breastfeeding Risk- benefit (CBD vs. anti-seizure meds) Endocannabinoids are needed for implantation and are necessary for breastfeeding. There s a paucity of studies on the use of cannabis in pregnancy and breastfeeding Endocannabinoids are involved in fetal implantation and breastfeeding. CBD increases endocannabinoid tone

74 CLINICAL PEARLS Cannabis can lower blood pressure The Rush = orthostatic hypotension Cannabis + heat = syncope (hot tub) CBD can be used as an antidote for too much THC Less is more Drug holidays should be used to lower tolerance. The greater the tolerance, the longer the holiday When recommending edibles for new users, start at 2.5 to 5 mg and prime the pump

75 CLINICAL PEARLS Start new users with inhaled flower or tincture Ask patients if they have issues with anxiety Do not recommend sativa dominant cultivars unless they are high in CBD CBD is a great anti-anxiety drug Develop a relationship with an MMJ doctor who can advise your patients

76 Carl s Story Carl: 2011 Obesity Type 2 Diabetes CVD (hypertension and hyperlipidemia) Several years of heavy opioid use after severe MVA w/ addiction (disabled due to s/p injuries) Several years of heavy benzodiazepine use w/ addiction Feeling depressed and hopeless Care with our clinic including: Nutritional and exercise support Nutritional supplementation Medical cannabis Counseling while weaning off addictive meds

77 Carl s Story Normal Body Composition Off all medications with reversal of diabetes, hyperlipidemia, hypertension and depression Off all narcotics and benzodiazepines His only medication is grown in his garden Writing children s books In love! Carl 2013

78 Carl s Garden