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Medical Marijuana in Canada - January 22, 2015

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Throughout 2015 the Canadian Cancer Survivor Network (CCSN) will offer a series of webinars designed to provide you with information to help build your knowledge and understanding of medical marijuana use in Canada.

The first webinar in this series features a presentation and Q&A session with Dr. Paul Daeninck , MD, MSc, FRCPC.

Published in: Health & Medicine
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Medical Marijuana in Canada - January 22, 2015

  1. 1. Medical Marijuana in Canada A Practical Understanding of Its Use for Cancer Patients Paul Daeninck, MD MSc FRCPC Departments of Internal & Family Medicine University of Manitoba and CancerCare Manitoba
  2. 2. Objectives At the end of this event, participants will learn about: 1. The basic facts about medical cannibis 2. The role of medical cannabis for cancer patients
  3. 3. Ma-fen is used for waste diseases and injuries; it clears blood and…it undoes rheumatism. If taken in excess it produces hallucinations and a staggering gait. If taken over a long term it causes one to communicate with spirits and lightens one’s body Ancient Chinese Herbal, c. 2700 BC
  4. 4. Russo et al, 2008 Cannabis in History Food and oil (seeds) Fibre (stems) Drug / Medicine (flowers)
  5. 5. W.B. O’Shaughnessey, Irish MD observed use in India 1839 – found a “tincture of hemp” to be effective analgesic, muscle relaxant and anti- seizure treatment Provided cannabis to pharmacists in England in 1842
  6. 6. Cannabis in History Production by Lilly and others to 1930s 1937: US Tax Act 1970: Controlled substance 1970s-80s research supported July 2001: Cdn gov’t medicinal use Apr 2014: MMPR established
  7. 7. Medline-indexed publications on cannabis and cannabinoids 1962-2006 0 200 400 600 800 1000 1200 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year Numberofpapers Medline-indexed publications on cannabis & cannnabinoids 1962-2006
  8. 8. Cannabis sativa
  9. 9. Time Nov 22/2010
  10. 10. HOW DOES CANNABIS WORK?
  11. 11. Cannabis sativa Marijuana (dried leaves / flowering heads) Isolated pure compounds Non-cannabinoids Cannabinoids Psychoactive Δ9-THC Δ8-THC cannabinol (weak) Active, not psychoactive cannabidiol Inactive > 60 compounds > 400 chemical compounds > 70 types of cannabinoids Most potent psychoactive ingredient Marijuana: What’s in it? Kalant H. Pain Res Manage 2001;6:80-91
  12. 12. 1) Neurotransmitter (NT) released from vesicles within the presynaptic neuron activates the postsynaptic neuron 2) Activation of postsynaptic neuron leads to synthesis and release of endocannabinoid 3) The endogenous CB1 ligand diffuses back to and binds to the presynaptic CB1 receptor 4) The CB1 receptor activates a G-protein, which lead to presynaptic events that result in inhibition of NT release 5) Exogenous drugs directly activate CB1 receptors to stimulate the endogenous cannabinoid system, enhancing its function 5 1 2 4 3
  13. 13. Female flowers (“buds”) are rich in cannabinoids (e.g. THC) Smoked Herbal cannabis Joints, pipes Vaporized Herbal cannabis heated to release cannabinoids but prevent burning Oral / buccal Tinctures (alcoholic extracts) Edible products (cookies and brownies) Sublingual spray (nabiximols by prescription) Topical Balms, lotions and salves Use of medicinal cannabis
  14. 14. WHO IS USING CANNABIS?
  15. 15. Disease Prevalence Author(s) HIV/AIDS 15-40% Sidney 2001, Braitstein 2002, Ware 2002, Woolridge 2005, Prentiss 2006 Epilepsy 21% Gross 2004 Chronic noncancer pain (CNCP) 15% Ware 2003 Multiple sclerosis (MS) 10-12% Page 2005, Clark 2006, Chong 2006 Who uses cannabis as medicine?
  16. 16. Who uses cannabis as medicine? 2% use cannabis for medical purposes >37,000 people registered with MMAR No prospective prevalence studies done in: Cancer est 15-25% Pall Care unknown Ogborne, CMAJ 2000 Health Canada information
  17. 17. Hazekamp et al, J Psycho Drugs, 2013
  18. 18. Hazekamp et al, J Psycho Drugs, 2013
  19. 19. Hazekamp et al, J Psycho Drugs, 2013
  20. 20. WHY ARE PATIENTS ASKING FOR CANNABIS? WHAT IS THE EVIDENCE?
  21. 21. On-label indications: Nausea and vomiting from chemotherapy Chronic pain (neuropathic pain in MS and cancer) Anorexia associated with HIV / AIDS Off-label indications/emerging evidence for: Neuropathic/nociceptive/ mixed pain Chronic daily headache Fibromyalgia Anorexia and cachexia Spasticity Epilepsy Cannabinoid indications PTSD Anxiety Insomnia Spasticity (MS) Lower urinary tract symptoms (MS) Improving bladder symptoms associated with MS
  22. 22. Pharmacology of cannabis Izzo, 2009
  23. 23. Cannabinoid receptors and pain Cannabinoid receptors active in inflammatory and neuropathic pain models Cancer pain models involve both CB1 & CB2 receptors bone pain inflammatory pain neuropathic pain
  24. 24. Cannabinoids & cancer pain Farquhar-Smith WP Curr Opin Support Palliat Care 2009;3:7-13
  25. 25. Nabiximols in cancer pain Cannabis extract: THC 2.7 mg/CBD 2.5 mg per 0.1 mL minor CBs, terpenoids, sterols & plant components Used in several pain studies (MS, NP, RA) Conditional approval for use in Canada, UK (cancer/neuropathic pain)
  26. 26. Agent N= Indication Duration/Type Outcome/References Sativex GWCA0101 177 Intractable cancer pain 2 wks Improvements in NRS analgesia vs placebo (p=0.0142), Tetranabinex NSD (Johnson et al, 2010) Sativex GWCA0701 360 Intractable cancer pain 5 wks/DB CRA of lower & middle dose cohorts improved over placebo (p=0.006) (Portenoy et al, 2012) Adapted from: Russo EB, Hohmann AG. Role of cannabinoids in pain management. In: Deer T, Gordin V, editors. AAPM Textbook of Pain Medicine. New York: Springer; 2011. Nabiximols in cancer pain Nabiximols Nabiximols
  27. 27. Nabiximols: mean pain scores Johnson et al. JPSM 2010;39:167-179. Nabiximols
  28. 28. Portenoy et al. J Pain 2012: 13:438-449 Nabiximols: improvement in pain
  29. 29. Nabiximols: less sleep disruption Baseline Scores: Placebo=4.6 (n=91); 4 Sprays=4.1 (n=91); 4&10 Sprays=4.3 (n=178) Courtesy of Dr. Stephen Wright, GW Pharma
  30. 30. Cannabinoids in nausea 20 pts, RCT, P vs THC, X-over 10 or 15 mg/m2 po q4h x 3, various tumours Chemotherapy not specified Anti-emetic effect seen in 14/20 THC vs 0/22 P (p<0.001) No patients vomited while “high” Sallan et al, NEJM 1975 293: 795-797
  31. 31. Martin BR & Willey JL. J Support Onc 2004;2: 305-16 Cannabinoids in nausea
  32. 32. Inhaled marijuana Three studies, associated with chemo administration Some new users, many previous cannabis users All studies showed benefit, but high incidence of side effects 25-35% pts prefer marijuana Vinciguerra et al, N Y State J Med 1988 88:525 Chang et al, Ann Int Med 1979 91:819 Levitt et al, JCO 1984 abstract C-354
  33. 33. Jatoi A et al. J Clin Oncol 2002;20:567-573 Nelson K et al. J Pall Care 1994;10:14-18 Timpone JG et al. AIDS Res Hum Retroviruses 1997;13:305-15 Struwe M et al. Ann Pharmacother 1993;27:827-31 Beal JE et al. J Pain Symptom Manage 1995;10:89-97 Beal JE et al. J Pain Symptom Manage 1997;14:7-14 Appetite and weight loss
  34. 34. Cannabinoids and Anxiety Epidemiological studies demonstrate the most common reason for use of cannabis is to reduce feelings of stress, tension and anxiety Several reports suggest many individuals self medicate anxiety with cannabis Hollister, 1986; Tournier et al., 2003 Van Dam et al, 2012; Agosti et al, 2002 Hill et al, 2008; Dlugos et al, 2012
  35. 35. Cannabinoids and anxiety: clinical studies A small study examined efficacy of nabilone (1 mg nabilone, 3 times a day for 28 days) in neurotic anxiety. Significant benefit was seen after 4 days of treatment vs placebo Reduced somatic and depressive symptoms seen in these patients Fabre and McLendon, 1981
  36. 36. Cannabinoids and anxiety: clinical studies Oral preparations of very low dose cannabis could produce sedation and diminish anxiety independent of psychoactivity Cannabidiol, another constituent of cannabis has anti-anxiety effects, although seen experimentally- induced anxiety Graham and Li, 1976
  37. 37. Federal Government Signs Off On Study Using Marijuana To Treat Veterans' PTSD http://www.huffingtonpost.com/2014/03/17/ptsd-medical- marijuana-study_n_4980702.html Marijuana May Hold Promise As Treatment For PTSD http://www.huffingtonpost.com/2014/11/22/cannabis- ptsd_n_6199254.html
  38. 38. 20 Medical Studies That Prove Cannabis Can Cure Cancer http://www.collective-evolution.com/2013/08/23/20-medical-studies-that-prove- cannabis-can-cure-cancer/#sthash.H5ypYS6a.dpuf Cannabis Cures Cancer https://dl.dropboxusercontent.com/u/27713298/Web/cure/How_It_Works.html Run From The Cure: How Cannabis Cures Cancer And Why No One Knows Cannabis sativa hemp, the miracle plant, contains the cure for cancer and other ailments By Rick Simpson - Friday, March 7 2008 http://www.cannabisculture.com/articles/5169.html
  39. 39. MARIJUANA DOES NOT CURE CANCER
  40. 40. Cannabinoids as anticancer agents Guzman M. Nature Rev Cancer 2003:3;745-755
  41. 41. Enhancing the Activity of Cannabidiol and Other Cannabinoids In Vitro Through Modifications to Drug Combinations and Treatment Schedules October 2013 vol. 33 no. 10 4373-4380 KATHERINE ANN SCOTT, SINI SHAH, ANGUS GEORGE DALGLEISH and WAI MAN LIU
  42. 42. Cannabinoids and cancer treatment THC delivered to the tumour bed 3-6 days after resection cell growth effects noted no survival benefit (mean 24 wks) no psychoactive effects Treatment was safe, sets stage for further investigation
  43. 43. HOW DOES ONE OBTAIN MEDICAL MARIJUANA IN CANADA?
  44. 44. Why is authorizing cannabis so difficult? Multiple symptoms are affected by cannabis Pain Spasticity Sleep Anxiety Doses used are hard to quantify It is recreational drug with a great deal of stigma Data on risks and benefits do not meet regulatory standards No teaching in medical school or training programs
  45. 45. Prescription cannabinoids Dronabinol (Δ-9 tetrahydrocannabinol – THC) (2.5 - 10mg) Oral capsule Approved for chemotherapy-induced nausea and vomiting and anorexia associated with HIV/AIDS Nabilone (0.25 - 1.0mg) Oral capsule Approved for chemotherapy-induced nausea and vomiting Nabiximols (2.5mg THC + 2.7mg CBD) Oromucosal spray Approved in Canada for multiple sclerosis-associated neuropathic pain, spasticity and advanced cancer pain
  46. 46. http://www.cmpa-acpm.ca/cmpapd04/docs/resource_files/web_sheets/2013/com_w13_005-e.cfm “Physicians must be familiar with the existing program for patients currently accessing medical marijuana and must also familiarize themselves with the new regulations. Physicians are expected to know and comply with the regulations and policies of their College.”
  47. 47. Precautions and contraindications Contraindications: Psychosis/schizophrenia Unstable heart disease Ask about: History of legal issues/criminal charges Screening for other drug use Prior recreational cannabis use Validate that use of cannabis is‘medical’
  48. 48. Other concerns Psychosis Sedation Anxiety Dependence Cardiovascular effects Nausea Cognition Interactions Respiratory effects Pregnancy
  49. 49. Medical cannabis: Is it different than street marijuana? A System of Accountability: Grown under strict Good Production Practices (GPP) guidelines enforced by Health Canada Tested for the presence of microbials, mycotoxins, & metals as well as pesticide use Delivered to the patient in a safe manner (i.e. secure courier or XPressPost with proof of signature) Concentrations of cannabinoids require to be captured on the label (usually THC and CBD) Recall ability given lot designation
  50. 50. Health Canada website 14 Licensed Producers to date Patient confusion over who to choose What distinguishes one LP over another? Is the product safe? What does “Jack the Ripper” and “Green Kush” mean? Supply availability? http://www.hc-sc.gc.ca/dhp- mps/marihuana/info/list-eng.php
  51. 51. Cannabis Strains Thousands of cannabis strains exist 14 licensed producers listed >120 strains Most strains were developed for recreational use and still use common names high THC (15-20%) very low CBD (<1%) Varying amounts of minor cannabinoids (CBC, THCV, etc.) Page, 2014
  52. 52. Cannabis Strains Patients report that cannabis strains differ in their effects Patients and cannabis growers generalize into two types: Indica – sedative Sativa – stimulating The difference between Sativa and Indica may relate to species or subspecies of Cannabis Page, 2014
  53. 53. Summary Cannabis has been used for medical purposes for centuries Indications for cannabinoid use are varied, but evidence is still lacking Any physician can authorize the use of medical marijuana, but is not compelled to do so

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