227 Medical Cannabis

A physician's prescription for medical cannabis needs to document the following four pieces of information:

.Patient’s name and date of birth.

Cannabis strain or product details (including THC and CBD content).

Dosage and frequency of use.

The physician's license number and signature.

Cannabis Act (Bill C-45)

Legislation that came into effect on October 17, 2018.

Laws for Medical and Recreational Cannabis

Medical cannabis requires a prescription, while recreational cannabis is available to adults over the age of 18 or 19 without a prescription.

Bringing Prescribed Cannabis Across Borders

Canadians cannot bring their prescribed cannabis across international borders due to legal issues in other countries.

Cannabis

A plant that contains cannabinoids, used both recreationally and medicinally.

Cannabinoids

Chemical compounds in cannabis that interact with specific receptors in the body to produce effects.

CB1 receptors

Cannabinoid receptors found primarily in the brain and central nervous system.

CB2 receptors

Cannabinoid receptors located in the immune system and peripheral tissues.

CBD (Cannabidiol)

A non-psychoactive compound in cannabis with anti-inflammatory, analgesic, and anxiolytic properties.

THC (Tetrahydrocannabinol)

The primary psychoactive compound in cannabis responsible for producing a 'high'.

THC and Blood-Brain Barrier

THC can cross both the blood-brain barrier and the placenta, affecting the brain and developing fetus.

Elimination Half-Life for THC

Varies depending on usage; typically 1-2 days for occasional users, up to 30 days for chronic users.

THC's Routes of Administration

Includes smoking, vaping, edibles, and oils or tinctures.

Clearing THC from Fatty Tissues

For steady users, it can take several weeks (often up to 30 days) to clear THC from fatty tissues.

Elimination Half-Life for CBD

Ranges from 18-32 hours, which is much shorter than THC's half-life.

CBD Psychoactive Properties

CBD does not have psychoactive properties; it is non-intoxicating and does not cause a 'high'.

CBD's Routes of Administration

Includes oils or tinctures, capsules or edibles, and topicals.

Nabiximols

A medication made from a combination of CBD and THC used to treat symptoms of multiple sclerosis and chronic pain.

Nabilone

A synthetic cannabinoid similar to THC used to treat nausea and vomiting associated with chemotherapy.

Inhaled Route for Medical Cannabis

The recommendation for inhaled routes such as smoking or vaping is questioned for people using medical cannabis.

Inhaled route

Generally not recommended due to the potential for respiratory harm.

4-6-8 Rule

Refers to the dosage guideline for medical cannabis: 4 hours for a single dose, wait at least 4 hours before taking another dose; 6 hours to reassess symptoms and adjust dosage every 6 hours; 8 hours for better safety, cannabis should be used no more than every 8 hours.

Strategies for Safer Cannabis Use

Consider educating the client about the risks of cannabis use and its effects, monitoring the dosage to minimize the risk of overconsumption, and encouraging the use of alternative routes instead of smoking or vaping.

Signs of Acute Cannabis Intoxication

Impaired coordination and motor skills, altered perception of time and space, increased heart rate, dry mouth and red eyes, anxiety, paranoia, or panic attacks, euphoria or an altered state of consciousness.

4 Primary Principles of Trauma-Informed Practice

Safety: Ensuring both physical and emotional safety for clients; Trustworthiness: Building trust with clients by being reliable and consistent; Choice: Empowering clients to make decisions regarding their treatment; Collaboration: Working together with clients to identify goals and needs.

OARS Technique

A key method in motivational interviewing consisting of Open-ended questions, Affirmations, Reflective listening, and Summarization.

6 Levels of Validation

1. Being present with the person; 2. Accurate reflection of the person's feelings; 3. Normalizing the person's experience; 4. Understanding the person's perspective; 5. Deepening understanding of their internal experience; 6. Acknowledging and respecting the person's autonomy.

Cannabinoids as Treatment

Considered when other treatment options are ineffective or inappropriate, used for chronic pain, nausea, vomiting (e.g., from chemotherapy), and certain neurological conditions.

Conditions for Cannabinoids as Third-Line Therapy

1. Chronic pain; 2. Multiple sclerosis spasticity; 3. Chemotherapy-induced nausea and vomiting; 4. Appetite stimulation in conditions like cancer or AIDS.

Reasons for Limited Evidence of Medical Cannabis

Lack of rigorous clinical trials due to legal and regulatory restrictions, variability in cannabis strains, formulations, and dosages, and limited understanding of the long-term effects of cannabis use.

Evidence for Cannabis Use in Conditions

Anxiety: Some studies show that CBD may reduce anxiety, but results are mixed; Depression: Limited evidence, though CBD may show promise for depression relief; Epilepsy: Strong evidence supporting CBD for treatment of certain types of epilepsy; Glaucoma: Cannabis may lower intraocular pressure, but effects are short-lived; Insomnia: Some evidence suggests that cannabis, especially THC, may help with sleep disorders; Parkinson's Disease: Cannabis may help with symptoms such as tremors and muscle stiffness, but evidence is still limited; PTSD: CBD has shown promise in reducing symptoms of PTSD, especially anxiety and hyperarousal, but more research is needed.

Adverse Events/Side Effects of Medical Cannabinoids

CNS Effects: Sedation, dizziness, impaired memory, cognitive function, fatigue, and euphoria.

CNS Effects

Sedation, dizziness, impaired memory, cognitive function, fatigue, and euphoria.

Gastrointestinal Effects

Nausea and vomiting, especially with high doses.

Cardiovascular Effects

Tachycardia, orthostatic hypotension.

Psychiatric Effects

Anxiety, paranoia, and risk of triggering or worsening psychosis.

Respiratory Effects

Chronic bronchitis, coughing, and wheezing, especially in people who smoke or vape.

Respiratory Complications

Smoking cannabis can lead to respiratory issues like coughing, wheezing, and chronic bronchitis due to irritation from inhalation of smoke.

Vaping Effects

Vaping may also cause respiratory irritation, but it is considered less harmful than smoking.

Cardiovascular Complications

Cannabis use can cause tachycardia (increased heart rate) and orthostatic hypotension (low blood pressure when standing up).

Heart Attack Risk

It may increase the risk of heart attacks in individuals with pre-existing cardiovascular conditions.

Cannabis Use and Psychosis

Chronic cannabis use, especially in individuals with a predisposition to mental illness, may increase the risk of psychosis or exacerbate existing mental health disorders, including schizophrenia.

Groups Not Recommended to Use Cannabinoids

People with a history of or at risk for psychosis, schizophrenia, or other serious mental health disorders; pregnant and breastfeeding women due to the risk of fetal exposure and potential harm to the infant.

Groups to Use Cannabinoids with Caution

People with cardiovascular diseases, respiratory issues (especially those who smoke cannabis), or a history of substance use disorder; elderly individuals, due to the potential for side effects like dizziness and cognitive impairment.

Impact of Patient Characteristics

Patient age, pre-existing medical conditions (e.g., cardiovascular disease), mental health status, and history of substance use disorder can all influence the likelihood and severity of adverse events.

Elderly Patients

Elderly patients may be more susceptible to sedation and cognitive effects.

Psychiatric Conditions

Those with psychiatric conditions may have an increased risk of psychosis.

Impact of Route of Delivery

The method of delivery affects the onset, duration, and intensity of effects. Inhalation routes (smoking or vaping) may have quicker onset but are associated with respiratory issues, while oral routes have a delayed onset but a longer duration of effects.

Cannabis Use Disorder (CUD) Criteria

Includes symptoms such as increased use, inability to cut down, cravings, time spent obtaining and using cannabis, and continued use despite negative consequences. It also includes tolerance and withdrawal symptoms.

Risk Factors for CUD

Early onset of use, frequent use, genetic predisposition, and a history of other substance use disorders or mental health conditions.

Questions for Clients

Frequency of use, methods of consumption, reasons for use (recreational or self-medication), and any history of cannabis use disorder or mental health concerns.

THC Detection in Urine Drug Test

Once: THC may be detectable for 1-3 days; Every weekend: THC may be detectable for up to a week; Chronic, heavy use: THC may be detectable for several weeks or even up to 30 days.

Screening Tools for CUD

Cannabis Use Disorder Identification Test (CUDIT), Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).

Psychological Interventions for CUD

Cognitive-behavioral therapy (CBT), contingency management, motivational interviewing, and motivational enhancement therapy.

Medications for CUD

Currently, there are no medications approved by Health Canada specifically for the treatment of Cannabis Use Disorder.

Cannabis Replacement Therapy for CUD

There is limited evidence on the effectiveness of cannabis replacement therapy, but it may help reduce withdrawal symptoms and cravings for cannabis.

Prevention

Prevent the initiation or continuation of risky behaviors.

Safer Use

Encourage practices that reduce harm (e.g., using vaporizers instead of smoking).

Managed Use

Help individuals maintain control of their use and reduce risks associated with heavy use.

Abstinence

Some individuals may benefit from complete abstinence from cannabis.

Harm Reduction Strategies for Frequent Cannabis Use

Educate on safer methods of consumption (e.g., vaporization), monitor usage patterns, encourage moderation, and promote regular check-ups.

General Approach to Cannabis Dosage

Start with low doses, gradually increase, and assess the patient's response to minimize adverse effects.

Mainstay of Treatment for Chronic Conditions

For chronic conditions, oral cannabis preparations are often the first-line choice, especially for conditions like pain, insomnia, and spasticity.

Dose for Inhaled Cannabis Route

If inhaled, start with 1-2 inhalations, and wait for about 15-30 minutes before deciding to take more, adjusting based on response.

Need for Euphoric Effects in Medical Cannabis

No, it is not necessary for the client to experience euphoric effects for the medical cannabis to be effective in symptom control. The goal is therapeutic relief, not a 'high.'

Avoiding THC Side Effects

To reduce side effects such as fatigue, tachycardia, and dizziness, users should start with a low dose, use non-THC products (CBD), and avoid operating heavy machinery.

Follow-up Appointments

Follow-up appointments should occur every 3-6 months to evaluate effectiveness, adjust dosage, and monitor for side effects.

High THC Medical Cannabis Products

High THC products are not recommended due to the higher risk of psychoactive effects and increased likelihood of adverse effects such as anxiety or paranoia.

Oral Cannabis Bioavailability

Fatty food can increase bioavailability, making the effects stronger. Holding an oil extract in the mouth can increase absorption due to the mucous membranes, enhancing bioavailability.

Inhaled Cannabis Route (Smoking/Vaping)

Smoking or vaping cannabis is not recommended due to the respiratory risks associated with inhaling smoke or vapor.

Effect on Blood Pressure

The inhaled route affects blood pressure, often causing a drop in blood pressure after a rise in heart rate.

Peak Effects Duration

Peak effects are felt within minutes, with effects lasting 2-4 hours.

Effectiveness and Safety of Topical Cannabis

Topical cannabis products are generally considered safe for localized pain relief but have limited systemic effects.

Drug-Drug Interactions with THC/CBD

THC/CBD can interact with medications such as antidepressants, anticonvulsants, benzodiazepines, blood thinners (e.g., warfarin), and sedatives.

Drugs That Increase Serum Levels of THC and CBD

Drugs that increase THC and CBD serum levels: CYP450 inhibitors such as ketoconazole, itraconazole, fluconazole, grapefruit, and verapamil can inhibit the enzymes that metabolize THC and CBD, increasing their serum concentrations.

Drugs Whose Serum Concentration is Increased by CBD

CBD can inhibit the metabolism of drugs metabolized by the CYP450 enzyme system, particularly those that use CYP3A4 and CYP2C19.

Increased Levels of Antiepileptics

Increased levels of antiepileptics like clobazam and valproate can occur due to CBD.

Increased Levels of Anticoagulants

Increased levels of anticoagulants like warfarin can occur due to CBD.

Increased Levels of Antidepressants

Increased levels of antidepressants like fluoxetine and sertraline can occur due to CBD.

Increased Levels of Benzodiazepines

Increased levels of benzodiazepines like diazepam can occur due to CBD.

Increased Levels of Immunosuppressants

Increased levels of immunosuppressants like cyclosporine can occur due to CBD.

Increased Clearance with Inhaled Cannabis

Inhaled cannabis (smoking or vaping) may induce CYP1A2 and other enzymes, potentially increasing the clearance of caffeine, theophylline, and warfarin.

Red Flag Interactions with Cannabis

Red flag interactions include CYP450 inhibitors/inducers and central nervous system depressants (e.g., benzodiazepines, alcohol), as combining cannabis with these can lead to excessive sedation and respiratory depression.

Central nervous system depressants

Combining cannabis with these can lead to excessive sedation and respiratory depression.

Anticoagulants (warfarin)

Cannabis can affect the anticoagulant effect.

Antidepressants/antipsychotics

Potential for serotonin syndrome or exacerbation of psychiatric symptoms.

Pros of Purchasing Medical Cannabis from a Licensed Producer (Mail)

Convenience, quality control, wide range of products, discreet.

Cons of Purchasing Medical Cannabis from a Licensed Producer (Mail)

Delayed delivery, lack of personal interaction, shipping costs, limited ability to assess products.

Pros of Purchasing Medical Cannabis from a Licensed Walk-In or Authorized Retail Outlet

Immediate access, in-person consultation, variety of products.

Cons of Purchasing Medical Cannabis from a Licensed Walk-In or Authorized Retail Outlet

Limited privacy, geographic limitations, lineups.

Can Clients Grow Their Own Medical Cannabis?

Yes, clients authorized to use medical cannabis may be allowed to grow their own cannabis at home, regulated by the Cannabis Act.

Risks Associated with Purchasing Cannabis from an Illegal Dispensary

Unregulated products, lack of dosage information, legal consequences.

Maximum Amount of Cannabis a Person Can Possess and Share

Under Canadian law, an adult can possess up to 30 grams of dried cannabis or its equivalent in other forms.

Difference Between a Prescription for Medical Cannabis and Being Authorized to Use Medical Cannabis

Prescription: Patients are authorized to use medical cannabis by a healthcare provider, who provides a medical document.

Authorization

Being authorized means a healthcare provider has evaluated the patient and issued a medical document confirming the need for medical cannabis.

4 Steps for a Client to Be Authorized to Use Medical Cannabis

1. Consult a healthcare provider. 2. Receive a medical document. 3. Register with a licensed producer. 4. Obtain the cannabis.

Guidelines for Titrating Medical Cannabis

Start low and go slow: Begin with a low dose and gradually increase to find the minimum effective dose while minimizing side effects.

Monitor side effects

Observe for signs of sedation, dizziness, or cognitive impairment and adjust accordingly.

Regular follow-ups

Frequent check-ins with healthcare providers to assess effectiveness and safety.

Withdrawal Symptoms from Stopping Cannabis

Symptoms typically begin within 1-3 days after stopping and may last 1-2 weeks.