Reefer Madness version 3.0* Presenter Disclosure *Original Reefer Madness: FMF 2014 by R. Dubin, Sharon Cirone and Mel Kahan Update on Health Canada s MMPR and the use of cannabis for medical conditions with Additional Slides by Dr. Mike Allan Ruth Dubin, PhD, MD, CCFP, FCFP, DCAPM,DAAPM Faculty: Ruth Dubin Relationships with commercial interests: None Potential for conflict(s) of interest: I do prescribe medical cannabis for very carefully selected patients. I am concerned about the risks and harms of widespread access to cannabis especially for youth and pregnant women. CONFLICT OF INTEREST DISCLOSURE Dr. Ruth Dubin I tried it as a teenager all it did was make me cough I hate the smell and am smelling it more frequently on the streets of Kingston Presentation Objectives At the end of this session the participant will be able to: 1) Understand the evidence for use of Marijuana (dried cannabis) in of chronic pain 2) Be aware of the updated Health Canada summary of the evidence and regulations 3) Outline the risks of marijuana use Presentation Pearls In your clinical practice, please consider Offering non-pharmacological and non-cannabis pharmacological modalities to your patients before considering cannabis Consulting the CFPC s Preliminary Guidance Document for Authorising Medical Cannabis Be aware of the risks of cannabis and operating machinery Ensuring that cannabinoids are improving your patients function and quality of life CFPC: Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance Document Sept 2014. http://www.cfpc.ca/dried_cannabis_prelim_guidance/ http://www.cfpc.ca/cannabis_orientation_preliminaire/ 1
*60-110mg oral morphine per day Health Canada review of cannabinoids (animal and human evidence) Dystonia Huntington s Disease (less Chorea) ALS Parkinson s Tourette s Sleep PTSD Alzheimer s (nabilone reduces agitation) Migraine/cluster HA (or are pt s using it to reduce cannabis withdrawal?) Animal data > human data for inflammatory arthritis Anxiety? CBD effect? Maybe opioid sparing: animal studies - incr opioid peptide release and precursor gene expression in CNS Evidence for Cannabis in chronic pain Neuropathic pain conditions*: diabetic peripheral neuropathy, M.S., post-surgical pain, CRPS, Post-stroke pain, spinal cord injury, HIV neuropathy, arthritis, Cancer, fibromyalgia, Sickle Cell disease, Post herpetic neuralgia, Thoracic outlet syndrome, lumbosacral radiculopathy, arthritis Cannabinoids now 3 rd tier in Canadian Neuropathic Pain Guideline * Evidence for cannabis in neuropathic pain is limited STEPWISE PHARMACOLOGIC MANAGEMENT OF NEUROPATHIC PAIN (Moulin et al, 2014) Figure 2: Neuropathic Pain: Pharmacotherapy Treatment Outcome: Meaningful (~30%) Pain Improvement Ordered by decreasing Amitriptyline High Dose Opioids * estimated efficacy 18 Improve TCA Gabapentinoids SNRI Tramadol Opioid Analgesic Add additional Neuropathic Pain Venlafaxine 50 17 Improve agents Cannabinoids Fourth-line Agents* sequentially if partial but inadequate pain relief + Gabapentin 58 15 Improve * Topical lidocaine (second-line for postherpetic neuralgia), methadone, lamotrigine, lacosamide, tapentadol, botulinum toxin + Limited randomized controlled evidence to support add-on combination therapy Limitations 1. Based on indirect comparisons. 2. Timeframe ~4 to 12 weeks. 3. Details on methods available in online supplement. Cannabinoids 60 57 Pregabalin 16 Improve Benefit Comparison Duloxetine 59 13 Improve 62 Can Fam Physician 2018 Feb. 9 Improve 66 Improve Improve Mary D Case of PJ: 21 year old student 48 year old female History of colectomy for colon cancer complicated by wound infection/ostomy/multiple surgeries Developed severe post surgical pain No benefit from usual medications Tried medical cannabis: improved pain, improved appetite, back to work Severe chronic pain post compound fracture left leg with damage to peroneal nerve Age 18 psychiatric admission for suicidal ideation and self harm (slashing self with razor blade) Dx Adjustment Disorder?Borderline Personality Now smoking cannabis frequently, UDT + THC C/O severe anxiety, doing poorly at school 2
Can Fam Phys Sept 2014 60:801 Cannabis Use Disorder Symptoms: hypersomnia or insomnia, fatigue, anxiety, depression, and cravings Clinical indicators of problematic cannabis use Daily or almost daily use Reports relief of anxiety as primary reason for using cannabis Repeated unsuccessful attempts to reduce or stop use Medical, social, legal, or financial harms from cannabis use Expressions of concern from family or friends Oral cannabis Peak effect 2.5-3.5 hours - slower elimination Erratic, slow absorption oil/butter for absorption Lower peak level of THC but higher peak level of active 11-OH metabolite (oral 3X> inhaled) + last longer Small studies: more anxiety, perceptual changes, strange thoughts, hallucinations, confusion, disorientation, euphoria, nausea, headache, dizziness. http://weedchefs.com/cannab utter-cookies/ Cannabis hyperemesis syndrome : Mayo Clin Proc. 2012;87(2):114-119 All 98 patients were younger than 50 years of age. Most reported using cannabis for > than 2 years before symptoms (95%) used cannabis more than once weekly. (86%) reported abdominal pain. American Epilepsy Society * The recent anecdotal reports of evidence for CBD in resistant epilepsy give reason for hope in anecdotal reports..robust scientific evidence for the use of marijuana is lacking... We do not know if marijuana is a safe and effective, the long-term effects on learning, memory and behavior, especially in infants and young children."[15] *Dravet syndrome-severe Myoclonic Epilepsy of Infancy Intractible, i1:16,000 to 1:21,000 Breastfeeding and Cannabis Health Canada THC is excreted into breast milk Lethargy, sedation,less frequent feeding and poor sucking May show signs of decreased motor development and reduced muscular tone Infants will test positive in urine screens Worsened attentional behaviour, visual analysis + hypothesis and executive function in later years. No effect on IQ 3
Effects of Prenatal exposure to Cannabis CFPC Preliminary Guidance Document Neurocognitive Effects of Cannabis Use in Youth, Young Adults Newborns show increased startle and tremors and altered sleep patterns Increased risk of motor, social and cognitive disturbances Reduction in long and short term memory retrieval and retention Lower academic achièvement, deficits in problem solving skills and visual-motor coordination Hyperactivity and impulsivity Decreased IQ Neurocognitive damage Risk of addiction Increasing presentations of cannabis induced psychosis Harm Reduction Vaporize rather than smoke, and do not mix with tobacco to reduce potential risk of heart or lung disease. Avoid use of dried cannabis with alcohol or other sedating drugs. Consider cigarette smoking cessation Do not give or sell your cannabis to others it is both dangerous and illegal. Harm Reduction (con t) Lock up and hide your dried cannabis out of reach of children and hidden from visitors and from adolescents at home. Use it outside to limit exposure of family members to second-hand smoke. Do not drive: four hours after any use by any route, at least six hours after oral ingestion or at least eight hours after using cannabis any euphoria or sedation Do not use cannabis of any kind in pregnancy, planning to become pregnant, or breastfeeding. Last Thoughts: Smoked Prescribing guides recommend max 9% THC 1 inhalation ( drag ) = 100mg once a day Titrate up to QID = ~half a joint /day (400mg/day) What is being used: In Canada: 27% THC is maximum but many ~15%, Can smoke 5 grams/day (~6 joints ) Presently patients can easily attain 20x the recommended dose. Cost issues Cesamet (nabilone) is covered in Ontario Sativex (delta 9 THC and cannabidiol) costs $12/day, for 5 sprays (the average dose) Dried cannabis costs about $8/gram Typical medical cannabis user smokes 1-3 grams/day = $8-24 per day Can Fam Physician. 2014 Dec;60(12):1083-90. 4
Costs Drug Daily Dose 2 Approximate cost/month Nabilone* 1 2 to 6 mg $94 to $305 Nabiximols* Medical Marijuana Dried 4 to 12 sprays 1 to 3 g typical use $226 to $903 $250 to $750 Based on $8.37/g Manufacturer list price, does not reflect pharmacy dispensing fees. 1 Only generic nabilone covered by most provincial drug plans. 2 Studied doses: Nabilone 0.5mg to 8mg/day, nabiximols 4 to 48 sprays/day, smoked marijuana had THC concentrations ranging 1 to 8% up to three times a day as tolerated. Daily doses from drug monographs and Health Canada. Can Fam Physician 2018 Feb. Spasticity July 1, 2018 Vancouver The Morning Marijuana Becomes Legal for All 5