The “Budding” of Medical Cannabis use in Floridaweb.brrh.com/msl/IM2018/Day-2_Saturday/Saturday...
Transcript of The “Budding” of Medical Cannabis use in Floridaweb.brrh.com/msl/IM2018/Day-2_Saturday/Saturday...
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The “Budding” of Medical Cannabis Use in Florida
Dr. Matthew Soff, MD
Gastroenterology
Plantation FL
It’s taking off like a weed!!!
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Faculty Disclosure
I have no financial disclosures
I am certainly not disclosing my personal, intense study of the affects of Marijuana in college students
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Agenda
Review of the historical use of Marijuana in medicine
Explore and understand the Endocannabinoid system
Discuss the chemistry and physiologic affects of the compounds from the Cannabis plant (Phytocannabinoids)
Describe the current legal status of Cannabis in FLA
How Medical Marijuana is used today
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The “Original Medical Cannabis”
1850-1936 used for 100’s of indications
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A Brief Medical History of Marijuana
1830: British physician in India (Wm O’Shaugnessy) experiments with Cannabis……. And was knighted by Queen Victoria
1854: Cannabis entered The Dispensatory of the United States of America
1880: Sir William Osler, “a most satisfactory remedy for migraine”
1936: “Reefer madness” (FBN)
1937: Marijuana Tax Act
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A Brief Medical History of Marijuana
1942 : Cannabis removed from US Pharmacopoeia
1945: La Guardia Committee
1964: THC and CBD isolated by Israeli scientists
1971: Shafer commission & Controlled Substance Act
John Mitchell and Richard Nixon
1996: California passes Compassionate Use Act (Prop 215)
1998: Institute of Medicine report
Barry McCaffrey, Janet Reno and Bill Clinton
2012: Colorado and Washington legalize recreational marijuana
8/8/13: Dr. Sanjay Gupta goes on air to say, “I mistakenly believed the DEA listed Marijuana as Class1 because of scientific proof. The DEA has no proof…… (Marijuana) has very legitimate medical applications.”
2014: Rohrabacher-Farr amendment
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A Brief Medical History of Marijuana
1942 : Cannabis removed from US Pharmacopoeia
1945: La Guardia Committee
1964: THC and CBD isolated by Israeli scientists
1971: Shafer commission & Controlled Substance Act
John Mitchell and Richard Nixon
1996: California passes Compassionate Use Act (Prop 215)
1998: Institute of Medicine report
Barry McCaffrey, Janet Reno and Bill Clinton
2012: Colorado and Washington legalize recreational marijuana
8/8/13: Dr. Sanjay Gupta goes on air to say, “I mistakenly believed the DEA listed Marijuana as Class1 because of scientific proof. The DEA has no proof…… (Marijuana) has very legitimate medical applications.”
2014: Rohrabacher-Farr amendment
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Endocannabinoid System
1. Endocannabinoids (endogenous)
1. AEA: Anandamide
2. 2-AG: 2-arachidonylglycerol
2. Cannabinoid Receptors
1. CB1
2. CB2
3. Regulatory Enzymes
1. Synthesize
2. Catabolize
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Endocannabinoid System
An internal homeostatic regulatory system
Modulates
Pain perception
Seizure threshold
Appetite
Digestion
Mood
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Endocannabinoid System
Modulates Immune System
Tumor surveillance
Fertility
Bone physiology
Intraocular pressure
Hypothalamic-pituitary-adrenal axis
Retrograde system Paracrine hormone – acts locally
Inhibits release of other neurotransmitters
Excitatory or inhibitory
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Endocannabinoid System
Modulates Immune System
Tumor surveillance
Fertility
Bone physiology
Intraocular pressure
Hypothalamic-pituitary-adrenal axis
Retrograde system Paracrine hormone – acts locally
Inhibits release of other neurotransmitters
Excitatory or inhibitory
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Receptors?
Retrograde system Paracrine hormone – acts locally Inhibits release of other neurotransmitters
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It’s all about the receptors
CB1 and CB2: GPCRs (G protein-coupled receptors)
CB1 located in the CNS (Central Nervous
System)
CB2 located on immune cells
Found in all vertebrates
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CB1 Receptor
Highly expressed throughout the brain
Ten times more prevalent than narcotic receptors
Primary Psychoactive CB Receptor
Basal Ganglia Hippocampus Cerebral Cortex
Cerebellum Amygdala Hypothalamus Brain Stem
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CB2 Receptor
Highly expressed Immune Cells B cells
T cells
Macrophages
Inhibits Immune Cell activation
Inhibits Proinflammatory cytokine production
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Neurotransmitter Deficiency Syndromes
Deficiency
Acetylcholine
Dopamine
Serotonin
Norepinephrine
Endocannabinoids
Alzheimer's
Parkinson's
Depression
Depression
Endocannabinoid Deficiency Syndrome
Syndrome
e
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Endocannabinoid Deficiency Syndrome
Lower pain threshold
Failure to inhibit pain
Sleep disturbances
Mood disorders
Digestive disorders
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Endocannabinoid Deficiency Syndrome
Possible associations (hyperalgesia)
IBS (Irritable Bowel Syndrome)
Migraine
Fibromyalgia
Chronic Fatigue
Dysmenorrhea
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Endocannabinoid System
Cannabinoid receptors respond to:
Endocannabinoids (endogenous)
AEA (Anandamide)
2AG (2-arachidonylglycerol)
Phytocannabinoids (exogenous)
From Cannabis sativa
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80-100 Cannabinoids in Marijuana
“Phytocannabinoids”
THC: Δ9-tetrahydrocannabinol
CBD: Cannabidiol
CBC: Cannabichromene
CBG: Cannabigerol
CBN: Cannabinol
THCA: Tetrahydrocannabolic Acid
THCV: Tetrahydrocannabivarin
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80-100 Cannabinoids in Marijuana
“Phytocannabinoids”
THC: Δ9-tetrahydrocannabinol
CBD: Cannabidiol
CBC: Cannabichromene
CBG: Cannabigerol
CBN: Cannabinol
THCA: Tetrahydrocannabolic Acid
THCV: Tetrahydrocannabivarin
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THC: Δ9-tetrahydrocannabinol
CB1 Affects in the CNS
especially in the brain
Most psychoactive
GI
Reproductive tissues
Adrenal
Heart
Lung
Bladder
CB2 Affects immune cells
Agonist of CB1 and CB2 receptors
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CBD: Cannabidiol
Attenuates the “High” feeling caused by THC
CBD inhibits:
convulsions
anxiety
Insomnia
neuropathic pain.
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Cannabinoid Effects
Euphoria and relaxation – THC
CBD modulates the psychoactive effects
Stimulates appetite
Decreases nausea
Decreases pain perception
Somnolence – helps with sleep
Intensifies sensory experiences
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Cannabinoid Side Effects
Anxiety*
Paranoia*
Panic attacks*
Impairs cognitive function
Time distortion
Somnolence
Impairs short term memory
*Treat with benzodiazepines or antipsychotics No lethal dose: does not suppress respiration
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Over the last few years, 8 states and Washington, D.C., have legalized Marijuana for recreational use;
Medical Marijuana is legal in 29 states plus D.C
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The Beginning of Medical Cannabis in Florida
2014: SB1030
Compassionate Medical Cannabis Act
Legalized under STATE law – Low THC
Plant of the Genus Cannabis
Contains less than 0.8% THC
More than 10% CBD
Cancer related symptoms
Persistent seizures
Persistent muscle spasms
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The Beginning of Medical Cannabis in Florida
2016: “Right to Try Act” - HB307
“Permitted” use of Medical Cannabis
All parts of any of the genus Cannabis
Any part of the Plant
Flowers, Leaves, Seeds or Resin
Terminal, progressive disease
Significant functional impairment
Less than one year prognosis even with all available medical treatment
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Status of Medical Marijuana Florida 2018
November 8, 2016
Amendment 2 passes with 71% of Florida voters approving
Mandates the state legislature to broaden indications
June, 2017 – Senate Bill 8-A passes in special legislative session.
Broadens the indications for Medical Cannabis
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Current Indications - 2018
Crohns Disease
Cancer
Multiple Sclerosis
Parkinson's Disease
Seizures/Epilepsy
Spasticity/Muscle Spasm
Terminal Condition/Illness
PTSD
HIV/AIDS
Glaucoma
ALS
Chronic pain *
Physician determination * *
*Pain due to one of the other conditions * * Another condition similar in nature to one of the above specified conditions
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What can Medical Cannabis Do for Patients?
Helps with pain
Improves appetite
Improves disease related nausea and vomiting.
Help with sleep
Decreases anxiety
Improves sense of well being
Cancer-related symptoms
Euphoria
Combines the Benefit of THC and CBD
Entourage Effect
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What can Medical Cannabis Do for Patients?
Helps with pain
Improves appetite
Improves disease related nausea and vomiting.
Help with sleep
Decreases anxiety
Improves sense of well being
Cancer-related symptoms
Euphoria – a feeling of well being or elation
Combines the Benefit of THC and CBD
Entourage Effect
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Affects of Phytocannabinoids Depends on:
Dose
Ratio of cannabinoids
Route of administration
Timing of onset
Health status
Age of patient
Hx of cannabis use
Co-administration of meds
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Dose related affects
CBD
Low dose: Sedating
High dose: Stimulating
THC:
Low dose: Less anxiety
High dose: Increased anxiety
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The Strain Matters
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Mode of Administration
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Which Patients are Eligible
Florida resident
Age 18 (or needs a guardian)
Patient must have a clinical relationship with the prescribing physician for 3 months
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Which Patients are Eligible
Florida resident
Age 18 (or needs a guardian)
Patient must have a clinical relationship with the prescribing physician for 3 months
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Which Patients are Eligible
Florida resident
Age 18 (or needs a guardian)
Have an approved medical condition
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Current Indications
Crohns Disease
Cancer
Multiple Sclerosis
Parkinson's Disease
Seizures/Epilepsy
Spasticity/Muscle Spasm
Terminal Condition/Illness
PTSD
HIV/AIDS
Glaucoma
ALS
Chronic pain *
Physician determination * *
*Pain due to one of the other conditions * * Another condition similar in nature to one of the above specified conditions
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How Does the Doctor Do It
1) Initial in office evaluation
1) Document the Diagnosis and Symptoms
2) Confirms Pregnancy, Mental Illness and Abuse history
3) Patient signs informed consent
4) Patient signs ABN
2) Registers the patient with FL DOH Department of Medical Marijuana
1) Patient needs to respond to the E-mail
1) $75 check – now can be done electronically on web site
2) Passport photo – connected to Motor Vehicle Bureau
3) Copy of Fla License or ID Card
2) Approval takes 1-3 months
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How Does the Doctor Do It
After the patient is approved:
1. On the Department of Medical Marijuana Website
1. Certifies the patient for up to 70 days
2. Places an order for CBD and/or THC
1. Can order up to 2 forms of each
1. Capsule
2. Sublingual
3. Vape
4. Topical
2. Needs to specify mgs/dose and doses/day
3. Needs to specify Sativa or Indica
2. Patient gets the Cannabis from an approved dispensary
3. Regular follow up visits to monitor benefits, adverse affects and dosing needs
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What Does the Patient Get
No smoking…. No Joints…. No Bongs
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What Does the Patient Get
Oil for under the tongue or swallowed
Oil in a capsule
Oil to be “Vaped”
No smoking…. No Joints…. No Bongs
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Important Items to Remember
Medical Marijuana is not legal with regards Federal Law
No insurance will cover Medical Marijuana or the required office visits
Do not fly with Marijuana….. Ever!!
Do not drive with Marijuana across state borders.
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How NOT to think of Medical Cannabis
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We need to consider Medical Cannabis as a Medical Treatment
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We need to consider Medical Cannabis as a Medical Treatment
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The END
Thank you for your attention