Medical Cannabis. Danial Schecter, MD, CCFP. Vocational Rehabilitation Association November 7th, Executive Director Cannabinoid Medical Clinic

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1 Medical Cannabis Danial Schecter, MD, CCFP Executive Director Cannabinoid Medical Clinic Vocational Rehabilitation Association November 7th, 2014

2 Conflict of Interest This program has not received financial support

3 Why Cannabinoid Medicine Became aware of the Endocannabinoid System Realization that traditional pharmaceutical agents had limited efficacy or intolerable side effects Listened to stories of patients who achieved real benefit with improved quality of life

4 My first observational study of Cannabinoids

5 Learning Objectives Understand why cannabinoids are considered a valid therapeutic choice Become aware of the medical cannabis regulations in Canada Recognize barriers encountered by workers (and employers) of patients who use medical cannabis and re-entering the workforce

6 The Endocannabinoid System Signaling system (similar to hormones) Important regulatory function in physiologic and pathophysiologic processes including: Neural development Immune function Inflammation Appetite Metabolism and energy homeostasis Cardiovascular function Digestion Bone development and bone density Synaptic plasticity and learning Pain Reproduction Psychiatric disease Psychomotor behavior Memory Wake/sleep cycles Regulation of stress and emotional state

7 The Endocannabinoid System

8 Distribution of CB1 Receptors

9 Pharmacologic action of Phytocannabinoids 9-THC is the only cannabinoid that is psychoactive

10 Commonly Cited Clinical Indications Chronic neuropathic or musculoskeletal pain Nausea and vomiting due to chemotherapy or HIV treatment Appetite stimulant Hypnotic Anticonvulsant Motor disorder (PD, Huntington, Tourettes) Spasticity due to MS Glaucoma Anxiety, PTSD Autism Other...?

11 Opioid Sparing Effects of Cannabis Cannabinoids exhibit analgesic effects and may potentiate the antinociceptive effects of opioids Cannabinoids may decrease the amount of opioids required, thereby decreasing negative side-effects

Importance to Vocational Rehabilitation Professionals Currently 40 50 000

12 Importance to Vocational Rehabilitation Professionals Currently people using medical cannabis. Projected to grow to people in 10 years.

Cannabinoids in Canada Dronabinol/THC 2.5 10 mg THC (Marinol) Nabilone 0.25 1 mg THC (Cesamet) Nabiximols 2.5 mg THC + 2.5 mg CBD (Sativex) Herbal Cannabis THC < 0.

5 mg qhs and increase up to 10 mg BID Approved for chemotherapy induced nausea and vomiting and anorexia associated with HIV/AIDS Oral capsule Start with 0.

13 Cannabinoids in Canada Dronabinol/THC mg THC (Marinol) Nabilone mg THC (Cesamet) Nabiximols 2.5 mg THC mg CBD (Sativex) Herbal Cannabis THC < 0.5 % to > 17 % CBD 0 % to 9 % Oral Capsule Start with 2.5 mg qhs and increase up to 10 mg BID Approved for chemotherapy induced nausea and vomiting and anorexia associated with HIV/AIDS Oral capsule Start with 0.5 mg qhs and slowly titrate to 1 mg BID as tolerated Maximum recommended dose is 6 mg/day Same indications as Dronabinol Oromucosal spray Start at 1 spray every 4 hrs to a maximum of 4 sprays on day 1 and increase as tolerated Average dose is 5 sprays/day; limited experience with doses higher than 12 sprays/day Approved for multiple sclerosis associated neuropathic pain and cancer pain Authorized use via Marihuana for Medical Purposes Regulations (MMPR Health Canada) Average 1-2 grams per day (~ 2 4 joints) Not formally approved as a prescription drug (no DIN) Availability and Cost: 2.5 mg capsule: $ 2.05 pd 5.0 mg capsule $ 4.10 No longer available in Canada Availability and cost: 0.25 mg capsule: $ 1.64 pd 0.5 mg capsule $ 3.29 pd 1.0 mg capsule: $ 6.58 pd Available via ODB, no LU code needed Availability and Cost: $ 3-5 per spray Not covered via ODB Availability and Cost: 3 $ - 12 $ per gram Available from Licensed Producers approved by Health Canada No coverage (Veterans Affairs)

Marihuana for Medical Purposes Regulations (MMPR) Effective as of June 2013 and replaced the MMAR regime as of April 1 st 2014 Can only obtain cannabis from a Licensed Producer (LP) Able

14 Marihuana for Medical Purposes Regulations (MMPR) Effective as of June 2013 and replaced the MMAR regime as of April 1 st 2014 Can only obtain cannabis from a Licensed Producer (LP) Able to access cannabis from an LP with a medical document (prescription) from an authorized health care provider Physician able to prescribe according to his/her judgment/clinical discretion

15 Licensed Producers License granted by Health Canada Strict quality control measures Tests every lot for contaminants and percentage of THC and CBD Listed on Health Canada s website Only able to sell herbal cannabis, no extracts (tinctures/oils) or edibles Can not have a store-front Only 13 listed on Health Canada s website although 22 approved

16 Barriers to Re-Entry to the Workplace

17 Barriers to Re-Entry to the Workplace Stigma associated with disclosure of disability requiring cannabis therapy Until now few medical cannabis users, companies able to have Zero Tolerance! Medical Review Officers (MRO) do not have strict guidelines to deal with lab results US DOT regulated employees not allowed to use cannabis (recreational or medical)

18 Employer s Responsibilities Become informed about the medical benefits of cannabis Must abide by human rights legislation and the duty to accommodate Develop company policies surrounding the use of potentially psychoactive medications Accommodate employees in safety sensitive positions

19 Employee Rights and Responsibilities Right to accommodation only if employee reports use of medical cannabis Respect smoking rules and regulations (consider vaporizer and edibles)

20 Issues to consider when reentering the workplace Does the employee hold a safety sensitive position? May require Independent Medical Assessment by Occupational Health MD Cannabis may not impair the employee may boost productivity

22 Why can t I find a physician to prescribe me cannabis? Physicians are not obliged to authorize the use of medical marijuana by patients The CMA still believes there is insufficient scientific evidence available to support the use of marijuana for clinical purposes.

23 Why can t I find a physician to prescribe me cannabis?

24 Why can t I find a physician to prescribe me cannabis?

25 Why can t I find a physician to prescribe me cannabis? 10/80/10 Rule No guidelines (conditions/dosage/titration) Smoked/inhaled Fear of abuse Fear of regulatory bodies Repeating mistakes of Oxycontin Time crunch

26 Cannabinoid Medical Clinic Doors opened July 14, 2014 First clinic seeing patients on a referral basis only No patient fees for ancillary services, no affiliations with specific LPs Focus on: 1) Patient care 2) Physician Education 3) Clinical Research

27 Cannabinoid Medical Clinic The patient experience: Plan to spend hours at the clinic Able to complete comprehensive questionnaire at home on proprietary EMR Sees nurse prior to MD, provides education about MMPR, THC:CBD, process Following MD sees a Cannabinoid Educator

28 Our Cannabinoid Educators Educate patients on safe usage, monitoring, titration and potential side effects Recommend Licensed Producer Helps with paperwork Demonstrate Vaporizers Available for questions

30 Take Home Messages Medical Cannabis is a valid treatment that is prescribed by physicians Effects of medical cannabis are often different than recreational cannabis Patients often achieve functional improvements that allows return to work Employers have a duty to accommodate Employees in safety sensitive positions may benefit from Independent Medical Evaluation (IME)

31 Questions

Use of Cannabinoids in Medical Practice

Use of Cannabinoids in Medical Practice Annual Scientific Assembly Family Medicine Review 2016 Murray Opdahl BSPE, MD, CCFP Objectives Briefly present: An overview of available cannabinoids Concerns voiced