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Medical Cannabis

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Cannabinoid Therapeutics is the therapeutic, or medical use, of cannabinoids for the management of medical conditions. There are a number of terms which are used for this including:

  • Medical Cannabis
  • Medicinal Cannabis
  • Cannabis Therapeutics
  • Cannabinoid Therapeutics
  • Cannabinoid Based Medicines (CBM)
  • Medical Marijuana

Cannabinoid Therapeutics refers to the use of pharmaceutical cannabis products approved by the Therapeutic Goods Administration (TGA) for prescription by a registered prescriber. They generally come in the forms of oils, liquids and sprays and also gels for application to the skin.

Cannabinoid Therapeutics is based on the effect that medical cannabis has on the human endocannabinoid system. The endocannabinoid system is a system within our bodies which produces and uses endocannabinoids. It is a biochemical control system involved in the regulation of numerous bodily processes. The system includes both endocannabinoids and cannabinoid receptors such as CB1 and CB2 receptors.

'Endocannabinoids and their receptors are found throughout the body: in the brain, organs, connective tissues, glands, and immune cells. In each tissue, the cannabinoid systems performs different tasks, but the goal is always the same: homeostasis, the maintenance of a stable internal environment despite fluctuations in the external environment.' Dr Dustin Sulak(1)

Cannabinoid receptors can be found in the brain, nervous system, gastro-intestinal tract, bone, immune system, skin, and nearly every other organ in the body. Experts are still trying to fully understand the endocannabinoid system but so far, we know it plays a role in regulating a range of functions and processes including:

  • Appetite
  • Bone health
  • Fertility
  • Immune function
  • Inflammation
  • Mood
  • Memory
  • Pain sensation
  • Skin health
  • Sleep
  • Stress response

CB1 and CB2 receptor function is to receive chemical signals to control cellular activity and play an important role in signal processing in the brain (2).

Cannabinoids have also been found to have effects outside the CB1/CB2 receptor system (5) and studies are attempting to identify and understand other potential receptors such as GPR18, GPR55, GPR119, TRVPV1, 5-HT3, GlyR, PPARa, PPARy and CBD3.

References:

1) Szafarski, J.P., Bebin, E.M., 2014, Cannabis, Cannabidiol and Epilepsy – From receptors to clinical response, Epilepsy & Behaviour, Vol.14, pp. 277-282

2) Lintzeris, N., 2016, Medical Cannabis Research at The Lambert Initiative, Presentation 2016 Nimbin Hemposium, Lambert Initiative for Cannabinoid Therapeutics, The University Sydney

3) Sulak, D., 2015, The Endocannabinoid System, Healer.com, viewed 29 March 2020 < http://healer.com/the-endocannabinoid-system/ >

4) Grzesiak M.H.B, Bultman, L., 2016, Cultivating Science & Weeding out Lore, Wrenchworks Reference Library Press, Minneapolis, p.71-78

5) Morales, P., Hurst, D.P.,Reggio, P.H., 2017, Molecular Targets of the Phytocannabinoids-A Complex Picture, Prog Chem Org Nat Prod, Vol.103,P.p.103-131.

Every human body has an endocannabinoid system where chemical compounds called endocannabinoids interact with receptors to maintain different functions of the body. However, the human body is not the only way cannabinoids can be produced.

Cannabinoids can be produced in one of three ways: 

  1. Naturally within the human body. These are called endocannabinoids because ‘endo’ means ‘within’
  2. Naturally from plants. These are called Phytocannabinoids because ‘phyto’ means ‘coming from a plant’
  3. Synthetically which include human made chemicals produced to mimic phytocannabinoids

For some people there are times when the endocannabinoid system does not work at its optimal level. At these times, or in the case of some illnesses or disease, the endocannabinoid system may benefit from cannabinoids from external sources such as from the cannabis plant.

The Cannabis Plant

The cannabis plant consists of more than 100 phytocannabinoids and over 400 trace compounds including terpenes which work synergistically and can be found in various ratios in the differing strains of the plant. Known as the entourage effect, these compounds work together, magnifying the therapeutic benefits of the plant’s individual components (1, 2).

Just a few of the compounds of interest and the focus of studies in disease specific animal models to uncover therapeutic potential include THC, CBD, CBDA, CBDV, THCA, THCV, CBG CBGA, CBN, CBC (3).

References:

1) Sulak, D., 2015, The Endocannabinoid System, Healer.com, viewed 29 March 2020 < http://healer.com/the-endocannabinoid-system/ >

2) Rosenberg, E.C., Tsien, R.W., Whalley, B.J., Devinsky, O., 2015, Cannabinoids and Epilepsy, Neurotherapeutics, Springer, DOI 10.1007/s13311-015-0375-5.

3) Neitzert, M., 2016, Media Release, viewed 12 May 2016, < www.dzne.de/en/about-us/public-relations/meldungen/2016/press-release-no-6.html >

4)Lintzeris, N., 2016, Medical Cannabis Research at The Lambert Initiative, Presentation 2016 Nimbin Hemposium, Lambert Initiative for Cannabinoid Therapeutics, The University Sydney

There is currently a lack of research evidence about the effectiveness of medical cannabis. For this reason the use of medical cannabis is only recommended when conventical treatments have been tried and proven unsuccessful in managing the person’s symptoms.

Multiple Sclerosis (MS)        

Multiple sclerosis (MS) is a neurological condition. It affects the central nervous system (CMS – brain and spinal cord) causing a wide range of symptoms depending on where the CNS is affected. These symptoms can include problems with vision, arm or leg movement, sensation or balance. There are different types of MS that can sometimes cause serious disability, although it can occasionally be mild. In many cases, it's possible to manage symptoms and slow the progression of the disease.

Medical Cannabis has been used in the management of symptoms of MS. There is some quality research suggesting pharmaceutical grade THC and some THC:CBD ratios are effective in treating spasticity and pain in some patient groups. Research findings have been mixed about the effect of medical cannabis on improving urinary issues, sleep quality and disturbances and quality of life.

References:

Australian Government, Department of Health, Therapeutic Goods Administration (2017). Guidance for the use of medicinal cannabis in the treatment of multiple sclerosis in Australia.  https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-cannabis-treatment-multiple-sclerosis-australia.pdf viewed April 2020.

Medicinal Cannabis and MS. Ms Research Australia  https://msra.org.au/medicinal-cannabis-ms/ viewed April 2020

Epilepsy

While up to 70 percent of people with epilepsy can obtain seizure control with medication, around about 30 percent continue to have seizures despite the availability of many antiepileptic drugs. This treatment gap has led people to seek alternatives, including medicinal cannabis. There is evidence that medical cannabis can be effective in epilepsy, especially for difficult to control seizures in syndromes such as Dravet Syndrome in children and Lennox-Gastaut Syndrome (LGS). Several studies have found low evidence for the use of medicinal cannabis products for the treatment of paediatric epilepsy, and for patients up to aged 25 years, especially when first-line treatments (anti-epileptic drugs) have been found to be ineffective.

The Therapeutic Goods Administration only recommends the treatment of epilepsy as an adjunct treatment in addition of existing anti-epilepsy medications.

Refer to C4E Cannabis for Epilepsy for further details. www.C4E.com.au

References:

Australian Government, Department of Health, Therapeutic Goods Administration (2017). Guidance for the use of medicinal cannabis in the treatment of epilepsy in paediatric and young adult patients in Australia.

https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-cannabis-treatment-epilepsy-paediatric-and-young-adult-patients-australia.pdf  viewed April 2020

Palliative care

Palliative care focuses on the quality of life of patients with life-threatening illness by providing relief from the symptoms, pain and stress. The use of medical cannabis products in palliative care is currently unclear. Cannabis as a palliative treatment for cancer patients seems to be well tolerated, effective and safe option to help patients cope with the malignancy related symptoms.

As there are very few studies on medicinal cannabis treatment in palliative care, it should be used only after standard treatments have failed. It is possible that medicinal cannabis will interact with chemotherapy and other medications used in palliative care.

Reference:

Australian Government, Department of Health, Therapeutic Goods Administration (2017). Guidance for the use of medicinal cannabis in the treatment of palliative care patients in Australia. https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-cannabis-treatment-palliative-care-patients-australia.pdf viewed April 2020

Chemotherapy induced nausea and vomiting

A small number of studies have found relief of nausea and vomiting in patients with cancer who are undergoing chemotherapy.

While several studies found that the medicinal cannabis products were as effective as the prescription medicine it was compared with, most of the research studies were carried out some years ago, and in recent years much more effective prescription medicines for nausea and vomiting have become available. For these reasons, medical cannabis products for chemotherapy induced nausea and vomiting should be prescribed only after standard approved treatments have failed.

There are several clinical trials currently underway in Australia to investigate the effects of medical cannabis in specific areas of cancer care including loss of appetite, nausea, insomnia and pain.

References:

Cancer Council of Australia and Clinical Oncology Society of Australia: Medical use of cannabis position statement https://www.cancer.org.au/policy-and-advocacy/supportive-care-policy/cannabis-for-medical-purposes.html viewed April 2020

Australian Government, Department of Health, Therapeutic Goods Administration (2017). Guidance for the use of medical cannabis of the prevention or management of nausea and vomiting in Australia. https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-cannabis-prevention-or-management-nausea-and-vomiting-australia.pdf viewed April 2020

Chronic non-cancer pain

There is moderate research confidence that patients with chronic non-cancer pain are likely to achieve and report reductions in pain rating compared with patients receiving a placebo.

The majority of the studies on the use of cannabinoids in pain have studied THC or THC-rich extracts. The studies are mainly where cannabinoids were used in addition to other pain medicines.

There is some evidence available for the treatment of neuropathic pain using medicinal cannabis products; however, the degree of effect is small. There is, however, insufficient information to make a conclusion about cannabinoids for the treatment of pain associated with arthritis and fibromyalgia.

There is much interest at present as to whether cannabinoids are "opioid sparing" – in other words, whether use of medicinal cannabis products for pain can result in a reduction of use of strong opioids. If this were the case, deaths and incapacity from opioid overdoses could be reduced, given that cannabinoids have fewer adverse outcomes. While some individuals with pain have reported that their use of opioids has been reduced when they also use medicinal cannabis, clinical studies in this area are still ongoing.

Reference:

Australian Government, Department of Health, Therapeutic Goods Administration (2017). Guidance for the use of medical cannabis in the treatment of chronic non-cancer pain. https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-cannabis-treatment-chronic-non-cancer-pain-australia.pdf viewed April 2020

Medical cannabis products are not registered on the Australian Register of Therapeutic Goods and, therefore, are not available as prescription medicines in the same way as other medications your doctor may prescribe. There is one exception to this in nabiximols for the treatment of specific symptoms in multiple sclerosis. There is no subsidy for the cost of medical cannabis products through the Pharmaceutical Benefits Scheme meaning the cost of these products is extremely high and must be completely borne by the patient.

Apart from the one approved product (nabiximols) medical cannabis products can only be accessed via the Special Access Scheme (SAS), a pathway for unapproved medicines. To access this scheme the patient must have a prescription from an Authorised Prescriber who meets both the Federal and State requirements.

In Australia, doctors are not permitted to advertise that they prescribe specific medications. This is in line with the Therapeutic Goods legislation and the professional and ethical standards of the Medical Board of Australia and Australian Health Practitioner Regulation Agency (AHPRA).

For privacy reasons the details of authorised prescribers, or doctors who are willing to prescribe medicinal cannabis products, are not publicly available. However, a number of private medicinal cannabis clinics have opened facilities in multiple locations across Australia, slightly easing access issues. The fees for consults, assessments and the application process vary between clinics.

A number of hospitals also have authorised prescribers for specific medicinal cannabis products, often linked to a compassionate access scheme or clinical research study.

Because the area of medicinal cannabis is reasonably new and changing rapidly, many medical practitioners have limited understating of, and experience with, cannabinoid-based therapeutics. Finding a doctor who is an Authoriser Prescriber of medicinal cannabis will ensure you are speaking with a medical professional with expertise and interest in cannabinoid-based therapeutics.

Refer to the Australia Government, Department of Health, Therapeutic Goods Administration (TGA) website for details on access in Australia  https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-australia-patient-information

For people who are using medical cannabis there are a number of considerations related to day to day life including travel, possession and driving.

Taking Medical Cannabis

Medical Cannabis comes in the form of tablets or capsules which are taken orally. Oils and liquids are also taken orally as is mouth spray, often taken under the tongue. Sprays can also be used in the nose. There are some medical cannabis products that can be applied to the skin in the form of patches, creams and gels. Raw cannabis can be vaporised for medical use. Prescribed medical cannabis is not smoked.

Your prescribing doctor will tell you which product is right for your situation.

Travelling with Medical Cannabis

Hear from Lanai, the mother of the first approved medical cannabis patient in Australia about travelling with medical cannabis.

Driving while using medical cannabis

Different cannabinoids affect the body differently. Therefore, different ratios of cannabinoids in medicinal cannabis products will have varying effects. 

Research is underway in some Australian universities to determine if there is measurable level of cannabinoids in the blood at which driving capability is adversely affected. Until the results are released, the law cannot begin to be reviewed and changed.

Currently the Royal Australasian College of Physicians advises that anyone taking medicinal cannabinoids should not drive.

While there are no legal driving restrictions for people taking prescription Cannabidiol (CBD) only medicines, these medicines can cause drowsiness, fatigue and sometimes lower blood pressure meaning extreme caution should be used if planning to drive.

There is zero tolerance for driving with the presence of Tetrahydrocannabinol (TCH) in oral fluid, blood or urine.

Medical Cannabis and other medications

It needs to also be considered that just about all chemical compounds, including prescription, over the counter and herbal formulations and some foods can potentially interact with each other. And cannabis-based products are no different. Before commencing any form of cannabinoid-based therapies it is vital to speak to your doctor about any potential drug to drug interactions with all your prescription, over the counter, herbal or supplemental products.

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