The challenge- dealing with a medicine that is not approved by Health Canada and in the US, is still classified by the federal government as a Schedule 1 drug, devoid of any legitimate medical value.

Is CTP alternative medicine or just medicine?

How do we integrate a dried leaf into practice?

Objective of talk. To help integrate cannabis into practice, or even to understand what your patients are getting from their use.

The endocannabinoid sysem is evolutionarily ancient, over 500 million years old and is found in all vertebrates, plus some invertebrate forms of life. This system is densely wound around homeostasis and is intertwined with many other systems. The endocannabinoid system helps to regulate pain, metabolism, memory, appetite and immune function. The cannabinoid
receptors are distributed widely through the body, though there are few in the medulla oblongata, so the effects of basal cardiorespiratory functions are minimal.

Endocannabinoids are naturally occurring chemicals within our brains that stimulate this system. Anandamide (from the Sanskrit, "Bliss")

There are broadly two types of receptors CB1 and CB2. CB1 receptors are found predominantly in the CNS, while CB2 receptors are in the PNS, hematopoeitic cells and immune system, particularly macrophages, B and T cells.

CB1 receptors trigger psychotropic "high", modify pain signals at the spinal cord and also produce effects on memory Blocking the CB1 receptor with rimonibant causes decrease in appetite, but can also bring about anxiety and depression.

The effect of CB2 receptor activation is on the immune system, with particularly large effect on the GI tract.

Paraphrasing Dr. William Mallon.

THC is a partial agonist of both the CB1 and CB2 receptor. it is the dominant cannabinoid in almost all forms of cannabis and is used for the treatment of pain and inflammation

THC causes the "high" that comes with cannabis, as well as sedation, cognitive and physical impairment,

There are full agonist research chemicals that are able to fully stimulate the CB1 and CB2 receptors. These have escaped the laboratory and are now being sold as legal highs, such as K2 and Spice.

http://www.vox.com/2014/10/15/6974843/synthetic-pot-weed-spice-k2-smacked-b...

Cannabidiol is the missing link for many physicians and most of the public in understanding cannabis for therapeutic purposes. When dealing with herbal cannabis, most are familiar with looking at THC percentages, but are less comfortable with evaluating cannabidiol (CBD) content, or using high CBD strains.

(Sativex is a 50:50 blend of THC and CBD)

In the last few decades most cannabis strains have been bred for high thc content, resulting in a low cbd content. It is unclear exactly how cbd work but its effect appears to not to be based on the CB1 or CB2 receptors. Some studies point to a decreased effect of THC caused by CBD. CBD has anxiolytic and anti-psychotic properties. While many psychiatric patients are warned off of using cannabis, there may be some who could benefit from a high CBD strain. In addition, those who have a family history of schizophrenia or otherwise at risk for mental illness should stay clear of cannabis strains that have a high THC:CDB content

CBD is widely promoted for antiinflammatory and neuroprotective effects

Cannabidiol has promising anti-seizure qualities. These were publicized with the "Charlotte's Web" strains for use in Dravet's syndrome

How much is enough? Or too little? With a paucity of information, the mantra of start low and go slow is generally recommended. An average joint contains about 0.5 g of cannabis, but the effect is obviously very dependent on the concentrations of THC and CBD contained in the sample. Health Canada reports that most CTP patients in Israel use approximately 1.5 g/day

The rate of addiction is often quoted as 9% or higher, though this is based on papers with significant methodologic issues.

http://www.huffingtonpost.com/sunil-kumar-aggarwal/cannabis-depedency-drug-...

As with the evidence surrounding brain development, risks of addiction have to be taken into context with the severity of the illness being treated and the side effects of the usual therapies involved, in order to reach a clinical decision.

The role of cannabis in schizophrenia remains unclear.

A reasonable recent discussion of the topic can be found here:
http://scottsworlds.blogspot.ca/2014/11/cannabis-use-and-psychosis-still.ht...

While some will still argue that schizophrenia can occur as a direct result of cannabis use, this view is turning in favor of cannabis more likely causing a worsening of psychotic symptoms or exacerbating an underlying vulnerability to psychosis. There has also been a study favorably comparing cannabidiol to an atypical antipsychotic.

http://www.nature.com/tp/journal/v2/n3/full/tp201215a.html

There are certainly people who can experience anxiety and potentially psychotic features
when using cannabis. For patients who have concerns around anxiety issues or a family history of schizophrenia, should either refrain from use, or choose a strain that is relatively high in cannabidiol.

There is poor evidence that smoking cannabis causes COPD, but from a harm reduction perspective, vaporization is a much more acceptable way for patients to ingest cannabis, either for recreational or medical use.

The use of cannabis can be accompanied by hypotension and tachycardia. Both of these tend to be mild and transient problems, though they can account for dizziness or other symptoms that patients may tolerate. These side effects are rarely clinically important in the younger patient, but justifies cautious use in the elderly.

There have been a few case reports of myocardial infarction and sudden death in those using cannabis recreationally. These are usually associated with confounding drugs or preexisting cardiac conditions.

As with any psychoactive agent, cannabis use should not be followed by driving or other activities requiring high levels of cognitive function. The degree of impairment brought on by cannabis is relatively mild, resulting in a doubling of the risk of causing an accident. This increase in risk is similar to the risk brought on by texting and is far smaller than the risk brought on by drinking alcohol before driving.

Physicians should take into account the consumption method and tolerance level of a patient and counsel them on driving in the same manner as they would counsel them on starting an opiate prescription

http://www.huffingtonpost.com/dr-carl-hart/oregon-measure-91_b_6063162.html

Treating pain from arthritis is one of the most common reasons for Canadians to use CTP. Patients may benefit both from analgesia and anti-inflammatory effect, but full clinical trials for cannabis and arthritis are still wanting.

Trial of Sativex for arthritis pain http://www.ncbi.nlm.nih.gov/pubmed/16282192

Neuropathic pain is a common chronic pain complaint. The medications available for neuropathic pain have generally been poorly studied for this indication and come with significant side effects of their own - addiction issues in the case of opiates; neuropsychiatric side effects, pharma malfeasence and abuse potential in the case of gabapentin.

On top of much anecdotal evidence, Ware, et al showed that smoked cannabis was effective in treating this type of pain. http://www.ncbi.nlm.nih.gov/pmc
/articles/PMC2950205/

Open access: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3566631/

The American Academy of Neurology has found that oral cannabis extracts and THC can be effective in treating pain and spasticity in multiple sclerosis.

http://www.neurology.org/content/82/12/1083.full

Institutional access to vaporizers remains an issue in acute and residential care. Edibles can be more variable in absorption, but are easier to manage in practice.

Early human studies are showing promise in relieving Crohn's disease. There is a heavy distribution of cannabinoid receptors in the GI immune system, that may play a role over and above using cannabis for analgesia.

http://www.ncbi.nlm.nih.gov/pubmed/23648372

Cannabidiol has shown promising results in the treatment of Dravet's syndrome and other pediatric seizure disorders. Families with children suffering from this disorder have been moving to Colorado in order to have access to high-CBD strains.

http://www.vancouversun.com/health/Epileptic+Okanagan+girl+illegal+cannabis...

http://www.herbal-ahp.org/documents/press_releases/AHP%20Therapeutic%20Comp...

A patient survey found that CTP was rated much more effective than the three FDA approved drugs available.


Formal studies are still needed to establish the usefulness of CTP for this condition.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080871/

http://onlinelibrary.wiley.com/doi/10.1002/acr.22267/abstract;jsessionid=83...

From an individual standpoint, cannabis is often chosen by patients as a substitute for other pain medications, both legal and not. There is a current opiate overdose crisis in Canada and increased use of cannabis for chronic pain might help to decrease the mortality from the overuse of narcotics.

http://www.harmreductionjournal.com/content/pdf/1477-7517-9-1.pdf

http://carbc2300.wordpress.com/2013/11/28/cannabis-the-exit-drug/

http://www.medicaldaily.com/states-medical-marijuana-laws-see-fewer-opioid-...


From a societal perspective, there have been signs of improvement in public health measures in US states that have legalized medical marijuana. These states have seen falls in traffic fatalities and in suicide rates, most dramatically in young men.

Many veterans report improvement of PTSD symptoms with CTP. Several US states support this diagnosis in their programs and there has been some preliminary research carried out in Israel. Impairment or disruption of memory by THC may be helpful in this condition

http://www.sciencedaily.com/releases/2014/05/140522104850.htm

A larger, blinded RCT trial of cannabis for PTSD symptoms is pending.

The role of cannabis in residential care. the inevitable response is - you want to get granny stoned.? The unfortunate reality is that there is heavy off-label use of atypical antipsychotics to control agitation or insomnia

http://www.thestar.com/news/canada/2014/04/15/use_of_antipsychotics_soaring...

Isreal has had some positive experience with CTP in nursing homes.

http://www.sciencedaily.com/releases/2013/01/130124123453.htm

http://www.globalpost.com/dispatch/news/regions/middle-east/israel-and-pale...

Twitter: @travels2little
email: drivmitchell@gmail.com