I would like to begin by acknowledging that we are on the ancestral grounds of the Beothuk people

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Baldric Franklin
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1 I would like to begin by acknowledging that we are on the ancestral grounds of the Beothuk people

2 Introduction to the Cannabinoid System And Medical Use Dr Alia Norman Radiation Oncologist Cannabinoid Medical Clinic Churchill Square

3 Disclosures: Employed by and receive speakers fees from CANABO

4 Objectives: THC vs CBD Delivery Routes Why it works What it works for Safer Use Research Opportunities

5 2752 publications in 2017

7 The Endocannabinoid System Neural development Immune function Inflammation Appetite Metabolism and energy homeostasis Cardiovascular function Digestion Bone development and bone density Synaptic plasticity and learning Pain Psychiatric disease Psychomotor behavior Memory Wake/sleep cycles Regulation of stress and emotional state Cancer Eat, Relax, Sleep, Forget, Repair Local action, Short duration

8 3 Main Drugs 3 Main Routes

9 Nabilone Synthetic THC mimic. Indication: nausea with chemo Most common use: chronic pain Most common side effect: cognitive dulling $ Covered, but not efficient Research Idea: Cost comparison of Herbal vs Meds Replaced including Nabilone

10 THC is the psychoactive component Side effects: impairment, racing heart, can trigger anxiety and even psychosis. Is more helpful for sleep and appetite Best pain relief combines THC+CBD and can reduce side effects from THC.

11 CBD (Cannabidiol) CBD has very minimal impairment Can reduce Anxiety Seizures Inflammation Pain Cravings

12 Oral very high CBD, very low THC Seizure trials Epidiolex

13 Lennox-Gastaut trial: reduction in monthly drop seizures

14 Herbal Cannabis Routes: Sprayed: Sativex THC:CBD, Elixer THC or CBD Inhaled: vapourized or smoked. Don t smoke salad oil. Eaten: Edibles, Canadian oils, decarboxylated Other: topical creams or patches, vaginal

15 Vapourizers: boil don t bbq

16 ½ a grain of rice is not a dose

17 It s important for seniors to understand the change in THC/CBD levels since the 60s Then: 10THC:5CBD Now 24THC: 0 CBD Medical can be either.

18 Strains or Chemovar

19 Turpenes -Smell and taste -Strain Differences -More reliable than Indica or Sativa Entourage Effect

20 Crowdsourcing Chemovar Selection

21 Seen individuals benefit so far... Replacing opioids/benzos Fibromyalgia PTSD nightmares Insomnia Anxiety (also common side effect) Cancer pain MS and spinal spasticity Crohn s and UC Seizures Autism behaviours Inflammatory arthritis Diffuse osteoarthritis Interstitial cystitis Parkinson s Nausea IBS Migraine Nerve pain from disk disease, chemo, diabetes Appetite loss Phantom Limb

22 Trial Evidence Replacing opioids/benzos Fibromyalgia *N PTSD nightmares *N Insomnia Anxiety Cancer pain*s (mixed results) MS and spinal spasticity *S Crohn s and UC Seizures *CBD Autism Behaviours Inflammatory arthritis *S Diffuse osteoarthritis Interstitial cystitis Parkinson s bradykinesia Nausea *N IBS Migraine Nerve pain from disk disease, chemo, diabetes Appetite *cannabis in AIDS Phantom Limb

23 Strong Trial Evidence Seizure in refractory epilepsy syndromes. Chemo nausea: similar efficacy to maxaran

24 Negative Trials Sativex cancer pain: didn t reach endpoint Very low dose THC for appetite in cancer patients.

25 Target Conditions Fibromyalgia CBD + trial Sleep Anxiety and Mental Health Opioid Replacement Exploring Cancer Responses

26 Trial challenges Hard to make THC placebo USA: schedule 1 Unusual dose response pattern

27 It works better for some people than others with the same disease.. Try any treatment on thousands of patients, some will hit a home run. 5-10% Super Responders

28 Cannabinoids and Pain Mechanisms: -reduce inflammation -reduce muscle spasm -block overactive nerve firing -central effects (mood, sleep, sensory alteration)

29 Chemical Circuit Breaker

30 Is Cannabis a Solution to the Opioid Epidemic? Can reduce the opioid dose needed for pain relief or replace opioids Doesn t suppress breathing Even at high doses

31 Examples of default styles

32 Therapeutic Index Ratio of physically harmful dose to Useful dose. Fatal overdose for cannabis is >1000 lbs. Cannabis 1000:1 Diazepam 100:1 Morphine 70:1 Cocaine 15:1 Alcohol 10:1 Digoxin 2:1

33 Can THC be addictive? Cannabis use disorder: 9%-15% Dopamine release Slow clearance reduces withdrawal but makes it harder to identify. Insomnia, Irritability, Low Appetite

34 Polypharmacy In medical practice, cannabis offers the opportunity to reduce multiple medications. Make a plan for which drugs to taper and when.

35 Adjunctive nabilone in cancer pain and symptom management: a prospective observational study using propensity scoring. Maida 2008 J Supportive Oncology n=112

36 Cannabis and Cancer? May be a balance between PRO and ANTI cancer effects. Clinical trials needed. My opinion: Avoid in curative cases and with immunotherapy

38 Patients trust something natural more than pharmaceutical... When a plant mimics something our body naturally produces, effects can be powerful. Many drugs are plant derived

39 but not all natural products are harmless or safe -morphine -cocaine -tobacco

40 Cannabis Best Health Practices Try CBD For Several Days We don t have good predictors for who will respond to CBD. Lowest side effects Reduces side effects of THC

41 Cannabis Best Health Practices Try CBD Don t Smoke! Joints have 5x the tar of cigarette Vapourizing offers rapid onset / tight control over dosing. Orals offer long lasting relief.

42 Cannabis Best Health Practices Try CBD Don t Smoke! THC is not for everybody. Use Responsibly Wait 4 hrs for driving. Mental health and development risks for heavy teen users. Rapid heart rate and blood pressure changes

43 Cannabis Best Health Practices

44 Questions? Cannabinoid Medical Clinic Stout: Drug Metab Rev 2014

CANNABIS LEGALIZATION: SUPPORT MATERIAL FOR MANITOBA PHYSICIANS

CANNABIS LEGALIZATION: SUPPORT MATERIAL FOR MANITOBA PHYSICIANS 1. GENERAL INFORMATION Cannabis 101 What is cannabis? Cannabis is a product derived from the Cannabis sativa plant. Cannabis contains hundreds