Medical Marijuana/Cannabis - PowerPoint Presentation

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Medical Marijuana/CannabisHow, when, why should it fit

 

Kimberly Angelia Curseen, MD

Associate Professor of Internal Medicine

Emory Palliative Care

Center; Emory

School of Medicine

Director of Emory Outpatient Supportive/Palliative Care Clinic

kacurseen@emory.edu

Vinita Singh MD

Assistant Professor of Anesthesiology; Emory School of Medicine

Emory Pain Management

Director of

Winship

Cancer Institute Interventional Pain Management

Vinita.singh@emory.edu

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Disclosures

I have no relevant disclosures

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Objectives

Explore why patients may consider medical cannabis as an option

Better understand why medical cannabis may be affective in symptom management particularly for pain

Identify side effects

Identify how patient may use medical cannabis

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Case

Mrs. K is 59

yro

with stage IV metastatic breast cancer diagnosed originally in 2009.

She has metastasis to bone, liver, and lungs. She is currently being treated with

Afinitor

and

Aromasin

which she

is responding to, but has chronic nausea with treatment.

She

was referred to supportive/palliative care clinic for symptom management.

Primary

complaints:

Severe

pain in RUQ, chest, and back

Chronic

nausea

Constipation

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Case

Co-morbidities

Type II Diabetes with symptoms suggestive of gastroparesis

CKD Stage II baseline creatinine 1.8

Hypertension

Medications

Oxycodone 10mg every 4 hours as needed for pain

Odansetron

4mg every 4 hours as needed for nausea

Prochlorperazine

10mg every 8 hours as needed for nausea

Naproxen 500mg twice a day

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Case

She presents with her husband and appears very uncomfortable. She complained that her pain is very poorly controlled and she is struggling to keep up the every 4 hour dosing because of nausea and fatigue. She is constipated and the Naproxen gives her indigestion.

I asked her

“How can I help you?”

“My son gave me marijuana, I just wanted to know if you can help me. It was first time I was not nauseated and my severe pain stopped for a while. I don’t want to do something wrong but I can’t take it anymore…does it really help… I am suffering”

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What is suffering?

The state or an instance of enduring painIs an experience of unpleasantness and aversion associated with the perception of harm or threat of harm in an individualCan be defined as the bearing of pain, inconvenience, or loss; as pain endured; as distress or loss; or as pain or sorrowDr. Eric Cassell: The Nature of Suffering and the Goals of Medicine“A state of severe distress associated with events that threaten the intactness of personhood or the interconnected physical, social, spiritual, an psychological aspect of self”

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Marijuana: What your patients want and need to know

Why is it so hard to get?What are pros and cons of using it?Why does it work?Why does the ratio of THC to CBD matter?I know it helps with nausea and appetite but what about pain?What are the side effects?What should I use?

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marijuana

Was legal in USA until 1937 and was on the US Pharmacopoeia until 1942: this was doneAGAINST the advice of the AMA (then known as the American Medical Society)• Harry Anslinger – responsible for “Reefer Madness”: thus opiates became the pathway for pain managementUS DEA lists as Schedule I high abuse potential, no currently accepted medical use in US and lack of accepted safety for use under medical supervision)Cannot legally be prescribed under federal lawSome synthetic cannabinoids are not scheduled I

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marijuana

Pros

Marijuana is effective at relieving nausea and vomiting, caused by chemotherapy.Marijuana can relieve the spasticity of the muscles that is sometimes associated with multiple sclerosis and paralysis.Marijuana can help treat appetite loss associated with HIV/AIDS and certain types of cancers.Marijuana may help relieve certain types of pain.Marijuana can be safer than other medications prescribed to treat the same symptoms for certain pts.Studies show that smoking marijuana alone (without the concurrent use of tobacco) does not increase the risk of lung diseases.Marijuana has been used for centuries as a medicinal agent to good effect.

Cons

Smoking anything, whether it's tobacco or marijuana, can seriously damage your lung tissue.Not enough evidence supports marijuana as an effective pain relieving agent.Marijuana carries a risk of abuse and addiction.Smoked marijuana can contain cancer-causing compounds and fungal contaminates.Smoked marijuana has been implicated in a high percentage of automobile crashes and workplace accidents.Frequent marijuana use can affect short-term memory.Frequent use can impair cognitive ability.

https://www.verywell.com/alternatives-to-smoking-medicinal-marijuana-1132343

Institute of Medicine Division of Neuroscience and Behavioral Health report "Marijuana and Medicine: Assessing the Science Base". Accessed from procon.orgAbrams, DI. "Cannabis in Painful HIV-Associated Sensory Neuropathy: A Randomized Placebo-Controlled Trial" Neurology Vol. 68, Pages 515-521. Feb. 2007

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Marijuana: Cannabidiol (CBD) and tetrahydrocannabinol (THC) are the two main ingredients in the marijuana plant. Both CBD and THC belong to a unique class of compounds known as cannabinoids

Over 100 different cannabinoids & >60 cannabinoids in marijuanaEffects cannabinoids depends on plant strain and how it is grownTHC effects are modulated by other cannabinoidsReceptors mainly in hippocampus, cerebellum, and peripheral nervesBrainstem receptors inhibit nausea, NOT respirationPharmacology different preparations have different bioavailabilityAnandamide- endocannabinoid

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Gregory T. Carter, M.D.,

M.S. Professor

of Rehabilitation Medicine,

University of

Washington School

of Medicinehttps://www.nabp.net/events/assets/Carter_Aggarwal.pdf

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Gregory T. Carter, M.D., M.S. Professor of Rehabilitation Medicine, University of Washington School of Medicinehttps://www.nabp.net/events/assets/Carter_Aggarwal.pdf

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Marijuana: THC vs CBD; Delta-9-tetrahydrocannabinol/∆9-THC/THCCannabidiol(CBD)

THC

SedatingAnxiety inducingPsychoactiveIllegalRelaxationAltered senses of sight, smell, and hearingFatigueHungerReduced aggressionAnti-inflammatory, & Antioxidant properties

CBD

ActivatingAnxiety reducingnon-psychoactive, CBD seems to have antipsychotic propertiesLegalRelief from convulsions and nausea Decreased inflammationLow affinity for CB1 and CB2 , can antagonize at low conanalgesic effects

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Marijuana: What is it good for?

THC

SE of chemotherapy – Reduce nausea and vomiting while increasing appetiteMultiple sclerosis – Improve spasticity and bladder function while reducing painful spasms and central pain Glaucoma – Reduce pressure inside the eyeAIDS – Alleviate symptoms by stimulating appetite and eating Spinal injury – Lessen tremors

CBD

Schizophrenia – Reduce psychotic symptomsSocial anxiety disorder – Lower anxietyDepression – Reduce depressive symptomsSide effects of cancer treatment – Decrease pain and nausea while stimulating appetite

Questions and Answers about Cannabis. Retrieved from http://www.cancer.gov/cancertopics/pdq/cam/cannabis/patient/page

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marijuana

Pain reliefCannabinoid receptors (molecules that bind cannabinoids) have been studied in the brain, spinal cord, and nerve endings throughout the body of animals to understand their roles in pain relief. Cannabinoids have been studied for anti-inflammatory effects that may play a role in pain relief.Animal studies have shown that cannabinoids may prevent nerve problems (pain, numbness, tingling, swelling, and muscle weakness) caused by some types of chemotherapy.Smoked marijuana on experimentally induced pain: improved pain tolerance; decreased pain sensitivity and intensity

http://www.cancer.gov/about-cancer/treatment/cam/patient/cannabis-pdq#link/_13Milstein SL, MacCannell K, Karr G, Clark S. Marijuana-produced changes in pain tolerance. Experienced and non-experienced subjects. Int Pharmacopsychiatry. 1975;10:177-182.Cooper ZD, Comer SD, Haney M. Comparison of the analgesic effects of dronabinol and smoked marijuana in daily marijuana smokers. Neuropsychopharmacology. 2013;38:1984-1992. Greenwald MK, Stitzer ML. Antinociceptive, subjective and behavioral effects of smoked marijuana in humans. Drug Alcohol Depend. 2000;59:261-275

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marijuana

Smoked or vaporized marijuana better than placebo at relieving neuropathic painVaporized marijuana may have a better side effect profileMedium dose decrease pain, higher dose increase pain (hyperalgesia similar to opioids)

Ware MA, Wang T, Shapiro S, et al. Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ. 2010;182:E694-E701.Wilsey B, Marcotte T, Deutsch R, Gouaux B, Sakai S, Donaghe H. Low-dose vaporized cannabis significantly improves neuropathic pain. J Pain. 2013;14:136-148.Abrams DI, Couey P, Shade SB, Kelly ME Benowitz NL. Cannabinoid-opioid interaction in chronic pain. Clin Pharmacol Ther. 2011;90:844-851.

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Marijuana: Is it all good? Side effects

Tachycardia and hypotension, dizzinessMuscle relaxation, Sedation, ApathyBloodshot eyesSlowed digestion and GI transient Depression, Hallucinations, ParanoiaWithdrawal: Irritability, sleep disturbance, hot flashes, restless, nausea & crampingstudies suggest that 9 % of people who use marijuana will become dependent on it, rising to about 17 % in those who start using young (in their teens).

Anthony JC. The epidemiology of cannabis dependence. In: Roffman RA, Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treatment. Cambridge, UK: Cambridge University Press; 2006:58-105.; Hall WD, Pacula RL. Cannabis Use and Dependence: Public Health and Public Policy. Cambridge, UK: Cambridge University Press; 2003.Center for Behavioral Health Statistics and Quality (CBHSQ). Treatment Episode Data Set (TEDS): 2003-2013. National Admissions to Substance Abuse Treatment Services. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. BHSIS Series S-75, HHS Publication No. (SMA) 15-4934.ElSohly MA. Potency Monitoring Program Quarterly Report Number 124. Reporting Period: 12/16/2013-03/15/2014. Bethesda, MD: National Institute on Drug Abuse; 2014.

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Pharmacokinetics

OralAbsorption-slow and erratic-> low and irregular plasma levels; extensive first pass metabTHC Peak- 60-120min, can take > 4hrsPyschotropic effects: 30- 90min, peak- 2-4hr, decline->6hrBioavailability-6%SublingualPeak-100-130 minBioavailability- increased if oral spray during fed state

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Pharmacokinetics

Inhaled marijuana THC peak: 6-10minMax psychotropic effect- after 20-30min, continue for > 45-60minBioavailability-10-30%- varies based on depth of inhalation, puff and breath-holding durationMarijuana smoke contains human carcinogens and toxicants as NH3, hydrogen cyanide & tar

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Approved Cannabinoids

Dronabinol(Schedule III)-Trans isomer of THC dissolved in sesame oil within a gelatin capsule-FDA approved forNausea 2/2 chemoAnorexia and weight loss in AIDSNabilone (Schedule II)- Synthetic cannabinoid(mimics THC)-FDA approved forNausea 2/2 chemoNabiximols-whole plant extract of marijuana, contains THC & CBD; oral mucosal spray- available in US thru clinical trials onlySpasticity 2/2 to MSPain

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Case

We discussed the benefits vs the burdens of using it. Georgia has decriminalized a low THC <5% version of the oil. Based on her symptoms I decided she would be an appropriate candidate to try the oil.

Impaired renal function limit NSAIDS

Opioid contributing to nausea, anorexia, depression, and constipation with underlying gastroparesis

Many

antiemetics

cause further constipation

May help with neuropathic pain, renal function will limit titration of many common neuropathic agents

She had patient buy in, which she has lost with some conventional treatments

Treatment consistent with goals of patient setting realistic expectation

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Summary

Medial Cannabis is reasonable tool to consider in patients requiring palliative management of symptoms: pain, nausea, anxietyIt is important that patient be counseled and educated not just on the benefits but also the side effectsMedical Cannabis should be treated like a medication, patients should have informed consent (patient should have realistic expectations of outcomes)Studies are not strong in the US 2nd to legal restrictionsPatients should be medically supervised during use to monitor for SEMore provider education is required

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