therapeutic use of medical cannabis Flashcards
definition of hemp as in the farm bill
THC </= 0.3% on a dry weight basis
what are the different cannabis markets
the pharmacy
medical programs
adult use (21+)
hemp market (farm bill)
illicit (dealer)
what is the degree of regulation of each of the cannabis markets?
pharmacy most regulated
medical programs highly regulated but fewer lab testing requirements than pharmacy
adult use has less stringent regulations and lab testing
hemp market has regulations but lots of grey area
illicit has absolutely no regulation and you have to trust your dealer
primary function of endocannabinoid system
regulatory/homeostasis
ex: memory, pain, sleep, mood, etc.
what are the ligands in the endocannabinoid system
endocannabinoids: anandamide and 2-AG
phytocannabinoids: THC, CBD, CBG, CBN, etc
pharmaceutical cannabinoids: dronabinol, nabilone, cannabidiol, nabiximols
what are the receptors in the endocannabinoid system
CB1, CB2
CB1 primarily in brain, nervous system
CB2 primarily in immune system
role of the cannabinoid receptors CB1 and CB2
to modulate release of neurotransmitters like 5-HT, DA, NE
the most abundant G protein coupled receptor in brain
how do the cannabinoids activate the receptors
RETROGRADE signaling: cannabinoids activate CB receptors pre-synaptically through feedback inhibition as opposed to post-synaptically
what are the endocannabinoids
anandamide (AEA) which is selective for CB1
2-arachidonylglycerol (2-AG) which is more abundant, full agonist at CB1/CB2
what are the pharmaceutical cannabinoids
dronabinol (marinol) for CINV
nabilone (cesamet) for CINV
epidiolex (cannabidiol) for seizures, undergoing trials for Huntington’s disease
nabiximols (sativex)– not in the US
THC has enhanced activity for ___
CB1
CBD also inhibits ____
FAAH enzyme
different major roles of the phytocannabinoids
THC: psychotoxic
CBD: anticonvulsant
CBN: sedative
CBG: analgesic, anti-inflamm
THCV: appetite suppressnat
what are some other MOAs of medical cannabis
there is also activity outside of the endocannabinoid system
such as COX1/COX2
and mu opioid receptors, alpha-2 adrenergic, G-protein coupled receptors, many more
what is the difference between psychoactive and psychotoxic
psychoactive means affecting the mind, consciousness, mood, and thoughts
psychotoxic means intoxicating or causes significant mood change
what is the precursor/mother cannabinoid
CBGa
what is the role of the terpenes
odorous– scent and flavor profile in cannabis, protection & attraction
what are the flavonoids and flavorants
flavnonoids: color, aroma
flavorants: flavor, aroma
what is the entourage effect theory
cannabinoids, terpenes, flavonoids, flavorants, and other naturally occurring compounds in cannabis act synergistically to enhance the overall effects
what are the trichomes
tiny little crystals that cover the leaves and buds– produce and store cannabinoids, terpenes, and flavonoids
what are the different ways to classify cannabis
genotypes (Strain names– indicates possible characteristics)
phenotypes (Sativa, indica, hybrid)
chemotype (grouped by most abundant cannabinoid)
chemovar (defined by chemical variety)
what are some differences between sativa and indica
sativa: tall, thin and lanky; leaves are thin; matures slower; effects are said to be uplifting and invigorating; daytime use
indica: short and stalky; leaves are broad/chunky; matures quicker; effects are said to be sedating and relaxing; nighttime use
what are some different chemotypes?
type 1: THC
type 2: balanced 1:1
type 3: CBD
type 4: CBG
what does isolate mean
contains one singular cannabinoid or terpene
what does broad spectrum mean
contains one main cannabinoid and other naturally occurring plant compounds but excludes a specific cannabinoid
what does full spectrum mean
contains all naturally occurring plant compounds
what are some possible dosage forms for medical cannabis
inhalation (cartridge, concentrates, dry leaf)
ingestion (capsules, oral liquid, tinctures and elixirs, rick simpson oil)
topical
transdermal
suppository
distillate syringe
true/false: you should hold in after you inhale
false
no evidence supports this
bioavailability, onset, and duration of inhaled dosage form
<50% bioavailable
onset in 5-10 mins
duration 2-4 hours
side effects from inhaled dosage form
throat irritation, coughing, bronchitis
which of the inhaled dosage forms are free of other excipients
concentrates, dry leaf
what was the cause of EVALI
additional excipients were used to thin out oil, leading to severe lung injury; toxic byproducts are formed (myrcene–methacrolein)
considerations for temperature
boiling points vary from ~300-450
vaporizing at a temp too low will not express the cannabinoid or terpene; vaporizing at a temp too high will obliterate the cannabinoid or terpene providing little therapeutic benefit
what are some factors that can alter the ingestion of cannabis
recent meals can delay the onset, prolong duration, and cushion the potency.
dose stacking can lead to overmedication
bioavailability, onset, and duration of ingested cannabis
bioavailability 10-20%
onset 1-3 hours
duration 6-8 hours, up to 24
counseling/dosing of ingested cannabis
start with a low dose, on an empty stomach
onset/duration of transdermal cannabis
onset is variable ~30 mins
duration is variable ~8-12 hours
onset/duration of suppository
onset 15-60 minutes
duration 2-8 hours
how are distillate syringes used
they can be either ingested or inhaled
combustion as a consumption method?
this is not approved in most medical programs due to harmful effects of inhaling carbon monoxide & tar production
an immediate loss of potency (30-60%) is noted upon incineration
describe cannabis withdrawal symptoms/duration
insomnia, vivid dreams, anxiety
may last for up to 45 days
what is a significant drug interaction to look out for
clobazam
pharmacokinetic vs pharmacodynamic drug interactions
PK: clobazam, phenytoin, beta blockers, CCBs, warfarin, buprenorphine, valproic acid, theophylline, antifungals, antiretrovirals, tacrolimus, tizanidine
PD: additive effects
-additive depressant: alcohol, barbiturates, benzodiazepines
-additive tachycardia, hypertension with sympathomimetics
-additive xerostomia and drowsiness with anticholinergics
what are the cardiac side effects
increased risk MI, stroke, heart failure
what is cannabis hyperemesis syndrome
cyclic episodes of nausea/vomiting with chronic cannabis use
excessive bathing in hot water provides relief
treatment is cannabis holiday, IV fluids, antiemetics, PPIs, topical capsaicin
contraindications
allergy to active drug or excipients
schizophrenia, psychosis, bipolar disorder
pregnancy, lactation
history of heart attack, stroke, angina
COPD, asthma
liver/kidney dysfunction
what is the correct dose
the lowest dose that provides therapeutic benefit without adverse effects
true/false: patient must experience psychoactivity to have effect
false
which preparations should be used for chronic conditions vs prn
chronic: long acting oral preparation
prn: vaporization
dosing for inhalation vs PO
inhalation: start with one inhalation and wait 15 minutes, may increase by 1 inhalation q15-30 minutes
oral: start with 2.5 mg at bedtime- increase to BID after 2 days- increase by 2.5 mg every 2 days
