Neuro/Psych Final - Lecture 2 Medical Marijuana

Dr. Vrabel: Slide Sledge Hammer Approach

Cannabis sativa was added to the U.S. Pharmacopeia in 1850, making it available over the counter. It was subsequently removed in:

1941, after years of declining use

The primary function of the endocannabinoid system (ECS) is:

Regulatory homeostasis across multiple body systems

CB1 receptors are described as the most abundant G-protein coupled receptor in the brain. Which statement best explains why cannabis cannot cause a fatal overdose via respiratory depression?

CB1 receptors have low density in the cardiovascular and respiratory control centers of the brain

2-Arachidonylglycerol (2-AG) differs from anandamide (AEA) in which important way?

2-AG is the more abundant endogenous ligand and acts as a full/potent agonist at both CB1 and CB2

A patient asks why CBD is considered non-psychotoxic despite acting on the same endocannabinoid system as THC. The best pharmacological explanation is:

CBD acts as an inverse agonist/allosteric modulator at CB1 (not a direct agonist) and also inhibits the FAAH enzyme

Epidiolex (cannabidiol) is FDA-approved for seizures associated with which conditions?

Lennox-Gastaut syndrome, Dravet Syndrome, and tuberous sclerosis complex

Which cannabinoid is considered the 'mother cannabinoid' because it is the biosynthetic precursor to all other cannabinoids?

CBGa (cannabigerolic acid)

The process that converts THCa into the psychoactive THC is called:

Decarboxylation

The Entourage Effect Theory proposes that the various compounds in cannabis (cannabinoids, terpenes, flavonoids) work together in what manner?

Synergistically, producing effects greater than the sum of the parts

A cannabis product classified as 'Type III chemotype' would be dominant in which cannabinoid?

CBD

When counseling a patient on inhalation technique, which statement is evidence-based?

There is no scientific evidence that prolonged breath-holding increases absorption; it only causes throat irritation

A patient ingests a high-THC edible. When orally consumed, THC undergoes first-pass hepatic metabolism primarily to:

11-OH-THC, which is 4–10 times more potent than THC itself

A patient reports no therapeutic effects after taking oral cannabis multiple times. Which of the following is the LEAST likely explanation?

The product contained too much CBD relative to THC

Which route of administration provides the longest duration of action and is most appropriate for chronic, persistent symptoms?

Oral ingestion (capsules, edibles, RSO)

Which EVALI-associated excipient was found in illicit market vape cartridges and caused severe lung injury?

Vitamin E acetate

The standard recommended starting oral THC dose for a cannabis-naive patient is:

2.5–5 mg THC, especially at bedtime, increasing by 2.5 mg every 2–4 days

Which condition represents an absolute contraindication for cannabis use?

Active schizophrenia or psychosis

Both THC and CBD inhibit which CYP enzymes, raising potential drug interaction concerns?

CYP 3A4, CYP 2C9, CYP 2C19, and CYP 2D6

A patient with a known citrus fruit allergy has an anaphylactic reaction to a cannabis tincture spray containing 2% limonene and MCT oil. What is the most likely cause of this reaction?

Allergic cross-reactivity between citrus and limonene (a citrus-derived terpene)

Which of the following is a qualifying condition for the Pennsylvania Medical Marijuana Program?

Post-traumatic stress disorder (PTSD)

Cannabis history: What milestone happened in 1850?

Added to U.S. Pharmacopeia — available OTC

Cannabis history: What milestone happened in 1937?

Marihuana Tax Act — prohibits non-medical use

Cannabis history: What milestone happened in 1941?

Removed from U.S. Pharmacopeia

Cannabis history: What milestone happened in 1970?

Controlled Substance Act — placed in Schedule I

Cannabis history: What milestone happened in 1996?

California becomes first state to legalize for medical use

Cannabis history: What milestone is going on today?

Many states fully legalized or medical programs; remainder may allow CBD with limited THC per the Farm Bill

Cannabis Markets: The Pharmacy

Most regulated. FDA-approved cannabinoid products (Marinol, Syndros, Cesamet, Epidiolex, Sativex*). Strict testing and barriers to entry.

Cannabis Markets: Medical Programs

Highly regulated; require laboratory testing, physician certifications, and state-specific supply chains. Lack reciprocity; limited 3rd-party reimbursement. Pharmacists are required in: CT, MN*, AR, LA, PA, NY, UT, VA, MD*.

Cannabis Markets: Adult use

Less stringent regulations, fewer lab testing requirements, highly taxed. Combustion, edibles, and beverages permitted. Must be 21+.

Cannabis Markets: Hemp Market (Farm Bill)

THC ≤ 0.3% on dry weight basis. Designer/synthetic cannabinoids (D-8, THC-O, THC-JD) are possible. Grey regulatory area. In PA, must be 18+ for CBD, 21+ for THCA or smokable products

Cannabis Markets: Illicit

No regulation, decriminalized in some states. Quality depends entirely on source.

What are the receptors associated with the Endocannabinoid system?

CB1 and CB2 (G-protein coupled receptors)

Terminal illness, ALS, Tourette syndrome, and Parkinson's disease are all classified as:

Pennsylvania qualifying conditions

Which of the following IS a Pennsylvania qualifying condition?

Glaucoma

Which neurologic condition IS a Pennsylvania qualifying condition?

Multiple sclerosis

Which of the following IS a Pennsylvania qualifying condition?

Severe chronic or intractable pain

Which of the following IS a Pennsylvania qualifying condition?

Huntington's disease

Which of the following is NOT a Pennsylvania qualifying condition?

Chronic migraine

Which of the following IS a Pennsylvania qualifying condition for medical marijuana?

PTSD

Cannabis combined with anticholinergic medications may produce additive:

Tachycardia, drowsiness, dry mouth, and dry eyes

Combining cannabis with sympathomimetics can cause:

Additive tachycardia and hypertension

Cannabis combined with alcohol, barbiturates, or benzodiazepines produces what type of pharmacodynamic interaction?

Additive CNS depression

Which of the following co-administered drugs would require monitoring due to pharmacokinetic interaction with cannabis?

All of the above

Which of the following is NOT on the list of drugs requiring monitoring when co-administered with cannabis?

Amoxicillin

The most clinically significant "exception" drug interaction noted with high-dose CBD is:

CBD + clobazam (a prodrug)

Smoked cannabis induces which CYP enzyme via polycyclic aromatic hydrocarbons?

CYP 1A2

Both THC and CBD inhibit which CYP enzymes, creating potential drug interactions?

CYP 3A4, CYP 2C9, CYP 2C19, and CYP 2D6

THC and CBD are primarily metabolized by which CYP enzymes?

CYP 2C9 and CYP 3A4

Cannabis should be used cautiously or avoided in patients with:

Liver or kidney dysfunction

Inhaled cannabis is specifically contraindicated in patients with:

COPD or uncontrolled asthma

Which cardiac history is a contraindication to cannabis use?

Prior heart attack, stroke, or angina

Cannabis is contraindicated in which population?

Pregnancy and lactation

Which of the following is considered a contraindication to cannabis use?

Schizophrenia, psychosis, or bipolar disorder

Which of the following is a potential serious adverse effect of chronic heavy cannabis use?

Cannabinoid hyperemesis syndrome

A patient allergic reaction to cannabis products could be caused by:

Any of the above

Cannabis Withdrawal Syndrome symptoms may last up to:

45 days

Cannabis Withdrawal Syndrome may include all of the following EXCEPT:

Hypertensive crisis

Constipation is most commonly associated with which cannabinoid, whereas diarrhea is associated with the other?

Constipation – THC; Diarrhea – CBD

High doses of which cannabinoid may also cause sedation?

CBD

Which of the following is a common side effect of cannabis?

Xerostomia (dry mouth)

A recommended patient self-monitoring strategy is:

Keeping a journal of effects, doses, and responses

"Clinical Endocannabinoid Deficiency Syndrome" is best described as:

A proposed condition relating to low endocannabinoid tone

"Endocannabinoid tone" is conceptually defined as:

(AEA + 2-AG levels) + CB receptor density

For daytime cannabis use, which cannabinoid can help attenuate THC side effects?

CBD

Oral cannabis is best suited for:

Chronic persistent conditions

The recommended oral cannabis starting dose for a naive patient is:

2.5–5 mg THC, especially at bedtime, increasing 2.5 mg every 2–4 days

The recommended dosing titration for inhalation is:

1 inhalation; wait 10–15 min; increase by 1 inhalation every 15–30 min PRN

During patient counseling, it is critical to distinguish:

Psychoactivity (psychotoxicity) from therapeutic effect

The correct cannabis dose is defined as:

The lowest dose providing therapeutic benefit without adverse effects

The core dosing principle for cannabis is:

"Start low and go slow"

Which of the following is NOT a primary goal of a cannabis patient consultation?

Guaranteeing third-party insurance reimbursement

Vaporizing at too high a temperature will:

Destroy the target compound

Cannabinoids and terpenes vaporize within what temperature range?

300–430°F

The most common base oil used in cannabis tinctures is:

MCT oil

Cannabis oral liquids/tinctures are typically supplied in what volumes?

12.5–30 mL dropper bottles

A disadvantage of capsule/tablet dosage forms is:

They are difficult to titrate because they cannot be cut

Cannabis capsules/tablets are commonly supplied in which strengths?

2.5 mg, 5 mg, 10 mg

Because RSO is very viscous, it is recommended to:

Warm the syringe before use

The recommended starting dose of RSO is:

A half grain of rice-sized portion

Rick Simpson Oil (RSO) is produced by:

Whole plant ethanol extraction

Dry flower should be stored:

Airtight with a humidity pack

Dry leaf/flower cannabis requires which type of vaporizer for optimal use?

Dry herb vaporizer, preferably with a ceramic chamber

The regulatory residual solvent threshold for concentrates is:

<5000 ppm

Concentrates should be stored:

In sealed glass at approximately 40°F

The recommended starting "dab" size for a concentrate is:

Sesame seed-sized

Cannabis concentrates are produced using:

Hydrocarbon extraction

A potential contaminant of concern in vape cartridge hardware is:

Heavy metals

EVALI (e-cigarette or vaping product use-associated lung injury) was linked to which excipient?

Vitamin E acetate in illicit market cartridges

Vape cartridges are typically produced using which extraction methods?

CO2 or butane extraction followed by distillation

For rectal absorption of THC to occur, the THC must be in which form?

THC hemi-succinate

Un-adulterated THC administered rectally is:

NOT absorbed rectally

The (debated) approximate bioavailability of suppository cannabis is:

~13.5%

Transdermal patches should be applied to:

Veinous areas of the skin

Transdermal cannabis penetrates:

All three skin layers, with possible systemic absorption

Topical cannabis is best used for:

Local pain and inflammation

Topical cannabis preparations have what depth of penetration?

Epidermis only, with no systemic absorption

A "true" tincture, by definition, contains at least:

20% alcohol

Proper sublingual tincture administration involves:

Holding under the tongue for 30 seconds, then swallowing

The onset of a sublingual tincture is approximately:

15–45 minutes

Through first-pass hepatic metabolism, THC is converted primarily to:

11-OH-THC, which is 4–10 times more potent than THC