Ravikanepi ABC ja tulevik Eestis
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1 Ravikanepi ABC ja tulevik Eestis Siim Erik Siimut Visioonikonverents
2 Teemad, mida täna käsitlen: Mis see (ravi)kanep on? Endokannabinoidsüsteemi ABC Ravikanepi olukord mujal maailmas Ravikanep Eestis?
3
4 Kanep (Cannabis sativa, Cannabis indica)
5 Lahksuguline üheaastane õistaim Narkootiline kanep ja tööstuslik kanep (hemp) 2 eristuvat fülogeneetilist populatsiooni (Cannabis Sativa, Cannabis Indica) Sawler, Jason, et al. "The Genetic Structure of Marijuana and Hemp." PloS one10.8 (2015): e
6 Sativa Indica
7 Vaigunäärmed emasel kanepitaimel (trichomes)
8 Kanepi peamine psühhotroopne toimeine CB 1 ja CB 2 osaline agonist Antipsühhootiline CB 1 ja CB 2 agonistide antagonist Endokannabinoidsüsteemi modulaator Pertwee, R. G. "The diverse CB1 and CB2 receptor pharmacology of three plant cannabinoids: Δ9 tetrahydrocannabinol, cannabidiol and Δ9 tetrahydrocannabivarin." British journal of pharmacology (2008):
9 Kanepisaadused Kanepiõisikud - marihuaana Kõrge THC : madal CBD ~1:1 THC:CBD Madal THC : kõrge CBD Hašiš kanepivaik Traditsiooniline: THC <10%, 1-5% CBD Nüüdisaegne: 30%+ THC, CBD<1% kanepiõli herbaalse kanepi ekstrakt 50-90% THC (CBD?)
10 Endokannabinoidsüsteemi ABC
11 EKS: lipiidne signaalivõrgustik Retseptorid (CB 1, CB 2 jt) Ligandid (anandamiid, 2-arahhidonoüülglütserool jt) Sünteesi- ja laguensüümid (FAAH, MAGL jt)
12 Alhouayek, Mireille, and Giulio G. Muccioli. "The endocannabinoid system in inflammatory bowel diseases: from pathophysiology to therapeutic opportunity." Trends in molecular medicine (2012):
13 EKS-i funktsioon? Homöostaasi hüpotees Funktsioon Rahune Puhka Unusta Kaitse Söö Stimuleerimise efekt Ärevuse, valu, lihastoonuse, kehatemperatuuri ja vererõhu langus Une esilekutsumine, rahusti (sedation), füüsilise aktiivsuse vähenemine Ebameeldivate kogemuste ja hirmutunnete unustamise soodustamine Neuroprotektiivne stressi põhjustavate stiimulite korral, antiinflammatoorne Söögiisu suurenemine McPartland, John M., Geoffrey W. Guy, and Vincenzo Di Marzo. "Care and feeding of the endocannabinoid system: a systematic review of potential clinical interventions that upregulate the endocannabinoid system." PloS one9.3 (2014): e Di Marzo, Vincenzo. " Endocannabinoids and other fatty acid derivatives with cannabimimetic properties: biochemistry and possible physiopathological relevance." Biochimica et Biophysica Acta (BBA)-Lipids and Lipid Metabolism (1998):
14 Aga mis see ravikanep siis ikkagi on?
15 Ravikanep (medical cannabis, medical marijuana) kitsamas mõttes on standardiseeritud toimeainetega, kontrollitud kvaliteediga kanepiürt (mis hoolimata ekspertide arvamusest siiski eksisteerib) Ravikanep (cannabinoid medicines) laiemas kontekstis hõlmab füto- või sünteetiliste kannabinoidide kasutamist ravivõttena
16 Standardiseeritud toimeainete sisaldus (THC, CBD, CBN) Terpenoidide profiili analüüs Garanteeritud puhtus raskemetallidest, herbi- ja pestitsiididest Ürt kiiritatud gammakiirgusega, et hävitada bioloogiline kontaminatsioon 6 erinevat ravikanepi sorti ISO-9001 sertifitseeritud Hea põllumajandustava järgimine (GAP Good Agricultural Practice) Regulaarne järelvalve/audit (teostab Hollandi Tervishoiuministeerium)
17 Milles siis probleem on?
18
19 Teaduspõhisusele eelneb kasutamine ravivõttena Rahvusvaheline regulatsioon Botaaniline substants (droog, Ravimiseadus 8 (3)) tänapäeva meditsiinis?!?!
20 Ravikanepi olukord maailmas
21 ÜRO aasta narkootiliste uimastite ühtne konventsioon: kanep I ja IV nimekirjas ÜRO aasta psühhotroopsete ainete konventsioon: Δ9THC I nimekirjas Δ9THC (dronabinol) -> II nimekiri. Mitu WHO ekspertkomiteed soovitanud lahterdada ümber III või IV nimekirja
22 WHO Expert Committee on Drug Dependence : thirty-fifth report. Conventions allow the CND to decide differently from a WHO recommendation, based on considerations other than the medical and scientific ones considered by the ECDD. CND - Commission on Narcotic Drugs WHO World Health Organization ECDD Expert Committee on Drug Dependence
23 Prognoositud kanepi kogus, esitatud INCB-le (International Narcotics Control Board ) Riik 2010 (kg) 2016 (kg) Kanada Iisrael N/A 7700 Saksamaa Itaalia Prantsusmaa Holland Hispaania Norra Tšehhi Soome Eesti 0,002 6,5
24 Milleks seda kõike kasutatakse?
25 Hazekamp, Arno, et al. "The medicinal use of cannabis and cannabinoids an international cross-sectional survey on administration forms." Journal of psychoactive drugs 45.3 (2013): Muud 26 % Krooniline valu 31 % Unetus 5 % Depressioon 6 % 953 patsienti 31 riigist Isutus/kaalukaotus 12 % Ärevus 20 %
26 Meditsiinilise kanepi näidustused Austrias (2014) Neuroloogiline/ psühhiaatria 10% Spastilisus (MS) 10% Muud 5% Krooniline valu 55% Anoreksia 15% 4500 patsienti Iiveldus ja oksendamine 5% Dr. Eberhard Pirich Praha,
27 Holland 5540 patsienti 56,8% naised, 42,7% mehed Keskmine vanus 55,6a Kõik eelnevalt tarvitanud retseptravimeid: Rahusteid (45.5 %) valuvaigisteid (44.3 %) Haavandilise koliidi vastased ravimed (35.9 %) NSAID-e ehk mittesteroidseid põletikuvastaseid ravimeid (30.7 %) Hazekamp, Arno, and Eibert R. Heerdink. "The prevalence and incidence of medicinal cannabis on prescription in The Netherlands." European journal of clinical pharmacology 69.8 (2013):
28 Ravikanep Eestis
29 Narkootiliste ja psühhotroopsete ainete meditsiinilisel ja teaduslikul eesmärgil käitlemise ning sellealase arvestuse ja aruandluse tingimused ja kord ning narkootiliste ja psühhotroopsete ainete nimekirjad NARKOOTILISTE JA PSÜHHOTROOPSETE AINETE I NIMEKIRI Kanep (v.a Euroopa Liidu ühtsesse põllukultuuride sordilehte võetud sordid, mille tetrahüdrokannabinooli sisaldus ei ületa 0,2%) ja selle töötlemisproduktid (hašiš, marihuaana, vaik, ekstraktid, tinktuurid jne) Tetrahüdrokannabinool (THC), isomeerid ja nende stereokeemilised teisendid
30 Üks patsient on saanud loa kasutada Sativexit Üks taotlus tagasi lükatud
31 Mida teha? Parandada arstide teadlikkust kannabinoidide kasutamise võimalustest ja ohtudest Lihtsustada legaalset ligipääsu kannabinoidide tarvitamiseks meditsiinilistel eesmärkidel
32 Konkreetsemalt: Liigutada THC II nimekirja (nagu see on 1971 konventsiooni nimekirjades) 3 1. Narkootiliste ja psühhotroopsete ainete nimekirjad (1) Narkootiliste ja psühhotroopsete ainete nimekirjad kehtestab valdkonna eest vastutav minister määrusega. Narkootiliste ja psühhotroopsete ainete nimekirja tehakse muudatused ja täiendused Ravimiameti ettepanekul. Narkootiliste ja psühhotroopsete ainete nimekirjade koostamisel lähtutakse ÜRO aasta narkootiliste ainete ühtsest konventsioonist ja ÜRO aasta psühhotroopsete ainete konventsioonist või arvestatakse narkootiliste ja psühhotroopsete ainete kuritarvitamise ja sõltuvuse tekitamise riski suurust. Lisada opioidide kõrvle erand teatud tingimustel THC-d sisaldavatele preparaatidele 3 (2) Narkootilisteks ja psühhotroopseteks aineteks ei loeta ravimpreparaate, mida kasutatakse ainult meditsiinilisel või teaduslikul eesmärgil ning mis sisaldavad käesolevas lõikes esitatud tingimustel järgmisi I, II, III ja IV nimekirjas loetletud aineid:
33 Tänan tähelepanu eest! Küsimusi?
34
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