Medical Cannabis: A Patient Primer This primer is meant for documented patients who are using medicinal cannabis or considering using it in the future. The information provided about this medication in general, its effects and how to take it. Sanjeev Sharma, MD FACS 1
What is medicinal cannabis? Cannabis is a dioecious, or either male or female-gendered, plant. The male plant will produce hemp, with flowers having < 1% δ-9-tetrahyrdocannabinol (THC); whereas, the female plant will produce flowers consisting of a number of active substances, such as THC, cannabidiol (CBD), cannabigerol (CBG), and terpenoids. THC is mainly responsible for the psychoactive effects of cannabis, but others like CBD, CBG, and terpenoids will influence the effectiveness of the drug. Therefore, the chemical composition of any cannabis strain determines its effects and side effects. Cannabis provided by growers, manufacturers, and dispensaries should undergo testing to assure chemical make-up, and the absence of bacteria, mold, pesticides and solve The flowering male cannabis plant The flowering female cannabis plant Varieties Medical cannabis is several hundreds of varieties which have different compositions and strengths, therefore Sanjeev Sharma, MD FACS 2
different effects. Variety THC content CBD content What variety is best depends on your symptoms. For example: inhaling or ingesting cannabis with a high CBD content (like AC/DC) provides effective relief for pain and muscle spasms in patients with multiple sclerosis (MS). Because of the anti-inflammatory properties of CBD, this variety may be more effective than others for patients with inflammatory conditions. Cannabis with high levels of THC (like OG Kush) may be preferred for disorders such as Gilles de la Tourette syndrome, therapy-resistant glaucoma and symptoms like weight loss, nausea and vomiting. In case of chronic neural pain, Cannatonic is often suggested. Medical cannabis effects not only depend on your symptoms, but individuals will have wide variation in relief depending on their tolerance or the method of delivery (i.e., inhalation, ingestion, topical use). Figure 1: Medicinal cannabis varieties examples AC/DC THC/CBD ratio 1%/20% OG Kush THC/CBD ratio 24%/0.3% Cannatonic THC/CBD ratio 7%/12% Quality Medicinal cannabis should meet certain quality criteria. It must not contain any pesticides, heavy metals, fungi or bacteria. This is should be monitored, but sadly in the US, unlike Canada and the Netherlands, it is not regulated so. Sanjeev Sharma, MD FACS 3
Which medical disorders? There is sufficient reason to believe that medicinal cannabis can help in cases of: muscle spasms or cramps associated with multiple sclerosis or spinal cord damage; nausea, loss of appetite, weight loss and wasting syndrome due to cancer or AIDS; nausea and vomiting associated with chemotherapy or radiotherapy used in the treatment of cancer, hepatitis C or HIV infection and AIDS; chronic pain (mainly pain associated with the nervous system, for example that caused by a damaged nerve, phantom pain, facial neuralgia or chronic pain which remains after the recovery from shingles); glaucoma neurologic disorders, such as seizure disorders, migraines, agitation from Alzheimer s Disease, tremors in Parkinson s Disease A-Z symptoms where cannabis may be used: ADHD, alcohol or drug dependency, alcohol or drug withdrawal, Alzheimer's disease, angioedema (swelling under the skin), ankylosing spondylitis (inflammation of spine joints), anxiety, arthritis (caused by psoriasis), asthma, autoimmune diseases, bipolar disorder, blood pressure control, burns, cancer, claudication (leg pain from clogged arteries), constipation, cough, depression, detoxification (narcotic), Diabetes Mellitus, digestion, immune system problems, improving blood flow, inflammation, inflammatory bowel Sanjeev Sharma, MD FACS 4
disease, interstitial cystitis (chronic bladder inflammation), lichen planus (itchy mouth rash), menopause, menstrual pain, migraine, mood, movement disorders, muscle relaxation, nausea, nervous system disorders, osteoporosis (weakening of the bones), pain from nerve disorders, paralysis after stroke, pregnancy and labor, psoriasis (skin redness and irritation), Raynaud's disease (blood vessel disorder), saliva production control, sedative, sexual performance, skin conditions (cracked skin and nails), spinal cord injury, stomach disorders (increase stomach acid), stomach spasms, stress, spasticity from neurologic conditions, tendonitis (tendon inflammation), vomiting, wound healing. Sanjeev Sharma, MD FACS 5
Side effects Patients generally tolerate medicinal cannabis well. A low dosage often provides sufficient relief, so that side effects rarely occur. When they do, it is usually the result of a high dosage or combined use with a substance such as alcohol that intensifies the side effects. Known side effects of medicinal cannabis are moodaltering effects, insomnia and heart palpitations. Other effects are: relaxation, fits of laughter, feeling hungry, heightened sensitivity to the perception of e.g. color and music, lethargy and distorted temporal and spatial awareness. Your reaction time may also be slower, especially during the first hours after use. If you take a large dose, you may get high. This is a feeling of euphoria which slowly subsides into feeling satisfied, peaceful and calm. The altered perception may cause you to feel confused. These effects usually disappear after a few hours. If you have a genetic predisposition to psychosis (family or personal history of schizophrenia) or other mental health problems, please consult your specialist before using medicinal cannabis. You should also consult your doctor if you are a cardiac patient. Continuous use of cannabis during pregnancy can affect the fetus. Also, certain components of cannabis - like THC - end up in breast milk. That is why the use of medicinal cannabis is not advisable during pregnancy and while breastfeeding. For more information, consult your doctor or pharmacist. Smoking Smoking cannabis may damage the lungs and could lead to infections of the nose, throat and lungs. For this reason, Sanjeev Sharma, MD FACS 6
inhaling medicinal cannabis through the use of a vaporizer is recommended. Addiction Addiction is unlikely when cannabis is used as a medicine. The recommended dose is usually lower than that for recreational use. You should take particular care, however, if you have been addicted in the past. Quitting may cause withdrawal symptoms, such as mild forms of restlessness, irritability, insomnia and nausea. Institute of Medicine, Marijuana and Medicine: Assessing the Science Base, 1999 Cannabis is the least addictive of all drugs. Using medicinal cannabis Your doctor should determine, in consultation with you: Which variety would be most suitable What dosage you need How to take the medicinal cannabis Sanjeev Sharma, MD FACS 7
Best practice is to use lowest dose, titration method for medical cannabis use. That is, start with the lowest dose to attain symptom relief. If not successful, you may increase the dose. However, the mode of use (i.e., inhalation, ingestion, topical) it will effect how and when to use an increased dose. You can take medicinal cannabis in various ways. When inhaled, the active components of cannabis are absorbed quickly by the body. The maximum effect occurs within 30 minutes, and slowly wears off over three to four hours. It is quite easy to adjust the dose when inhaling. If the effect is insufficient, you can choose to inhale more. You can also stop when you achieve the required effect or when you start feeling side effects. When medicinal cannabis is ingested, it takes at least 30 minutes before any effects occur. The maximum effect is usually achieved after two or three hours, and it takes four to eight hours to wear off. Eating high-fat food with the medical cannabis can improve the absorption of the active substances. Sanjeev Sharma, MD FACS 8