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Canada doctor intro

  1. 1. Information for Health Care Professionals Cannabis (marihuana, marijuana) and the cannabinoids; 158 page PDF from Health & Welfare If you wish to download strains, growing, and other related material check out Objectives The objective of the proposed MMPR is to reduce the risks to public health, security and safety of Canadians, while significantly improving the way in which individuals access marihuana for medical purposes. To reduce the risks to public health, security and safety of Canadians, a new supply and distribution system for dried marihuana that relies on commercial production of marihuana for medical purposes would be established. Security requirements would be in place for the production site and key personnel of the licensed producer. Standards for packaging, transportation and record keeping would contribute to achieving security objectives. The process for individuals to access marihuana for medical purposes would no longer require applying to Health Canada. Individuals would be able to obtain marihuana, of any strain commercially available, with information similar to a prescription from an authorized health care practitioner (a physician or, potentially, a nurse practitioner). Quality and sanitation standards appropriate for a product for medical use will be in place. In line with other controlled substances, personal and designated production would be phased out. This would reduce the health and safety risks to individuals and to the public while allowing for a quality-controlled and more secure product for medical use. Health Canada would no longer receive and process applications or issue authorizations and licences, nor continue to produce and supply marihuana for medical purposes. Health Canada would not enter into future contractual arrangements for the production and distribution of marihuana for medical purposes. The new regulatory scheme returns Health Canada to its traditional role of regulator rather than producer and service provider, while striking a better balance between access and risks to public health and safety. Description The proposed Marihuana for Medical Purposes Regulations would authorize the following key activities: the possession of dried marihuana by individuals who have the support of an authorized health care practitioner to use marihuana for medical purposes; the production of dried marihuana by licensed producers only; and the direct sale and distribution of dried marihuana by specific regulated parties to individuals who are eligible to possess it.
  2. 2. The proposed MMPR would also allow individuals who hold an authorization to possess under the MMAR to transition to the new framework using their authorization for up to one year after its date of issue (unless a period of usage of less than 12 months has been indicated in the medical declaration). Individuals could also transition using a medical declaration issued under the MMAR. Licences to produce issued under the current MMAR would be phased out, while renewals would continue normally. New licences to produce would not be issued if the application is submitted after September 30, 2013, because there would not be enough time to produce a crop before the repeal of the MMAR on March 31, 2014. Licences to produce would also not be amended for a site change after September 30, 2013, for the same reason (see “Implementation, enforcement and service standards”). All licences to produce would end on March 31, 2014. 1. Possession of dried marihuana by individuals who have the support of an authorized health care practitioner Possession of dried marihuana Individuals would no longer have to apply to Health Canada for an authorization to possess dried marihuana for medical purposes. Instead, individuals who require marihuana for medical purposes would be able to legally possess dried marihuana if it was obtained under the proposed MMPR from a pharmacist or licensed producer with a supporting medical document from an authorized health care practitioner, or directly from an authorized health care practitioner. Similarly, an individual responsible for a person who requires marihuana for medical purposes would be able to legally possess dried marihuana under these circumstances. In both cases, individuals would be authorized to possess the lesser of 150 g or 30 times the daily quantity stipulated by the authorized health care practitioner. Under the proposed MMPR, individuals would be able to demonstrate that they are in legal possession of dried marihuana by showing a law enforcement official a client-specific label affixed to the product, or an accompanying client-specific document, as well as an appropriate piece of photo identification (see “Packaging and labelling”). Licensed producers would also be required to confirm to a member of a Canadian police force, in the context of an investigation, whether a named individual is a registered client or an individual responsible for a registered client. HEALTH CARE PRACTITIONERS Authorized activities 124. In addition to being authorized to possess dried marihuana in accordance with section 3, a health care practitioner may perform the following activities in regard to a person who is under their professional treatment: (a) sell, provide or administer dried marihuana; or
  3. 3. (b) provide a medical document. Medical document 125. (1) A medical document provided by a health care practitioner to a person who is under their professional treatment must indicate (a) the practitioner’s given name, surname, profession, business address and telephone number, facsimile number and email address, if applicable, the province in which the practitioner is authorized to practise their profession and the number assigned by the province to that authorization; (b) the person’s given name, surname and date of birth; (c) the address of the location at which the person consulted with the practitioner; (d) the daily quantity of dried marihuana to be used by the person, expressed in grams; and (e) the period of use. Period of use (2) The period of use referred to in paragraph (1)(e) (a) must be specified in the medical document as a number of days, weeks or months, which must not exceed one year; and (b) begins on the day on which the document is signed by the health care practitioner. Validity of medical document (3) A medical document is valid for the period of use specified in it. Attestation (4) The medical document must be signed and dated by the health care practitioner providing it and must attest that the information in the document is correct and complete. Labelling of dried marihuana 126. A health care practitioner who sells or provides dried marihuana to a person under their professional treatment must (a) sell or provide it in the immediate container in which it was sold or provided to the practitioner by a licensed producer and ensure that the immediate container carries the label required under section 60; (b) affix to the immediate container a separate label that contains the following information: (i) the given name and surname of the person under the health care practitioner’s professional treatment,
  4. 4. (ii) the health care practitioner’s given name, surname and profession, (iii) the daily quantity of dried marihuana to be used by the person, expressed in grams, and (iv) the date on which the dried marihuana was sold or provided; (c) ensure that the label required under paragraph (b) does not cover any portion of the label referred to in paragraph (a); (d) provide the person with a copy of the current version of the document entitled Information on the Use of Marihuana for Medical Purposes, published by the Department of Health; and (e) provide the person with a separate document containing the information referred to in paragraph (b).30-day limit 127. (1) A health care practitioner must not sell or provide to a person under their professional treatment in any 30-day period a total quantity of dried marihuana that exceeds 30 times the daily quantity referred to in subparagraph 126(b)(iii). Additional limit (2) A health care practitioner must not, at any one time, sell or provide to a person under their professional treatment a quantity of dried marihuana that exceeds 150 g. Return (3) If the person returns to the health care practitioner dried marihuana that the practitioner sold or provided to the person, the practitioner may, subject to subsection (2), replace the dried marihuana with an equal quantity. Exclusion (4) The quantity of any dried marihuana that the health care practitioner provides to the person to replace the returned marihuana is to be excluded for the purpose of calculating the total quantity referred to in subsection (1). Talking to Your Doctor 3.1_doctor with patient Persons who have an Authorization to Possess Marihuana for Medical Purposes, issued by Health Canada and signed by a medical practitioner, may legally obtain and use a designated amount for medical purposes. So the first step in getting medical marijuana is talking to your doctor. What will my doctor think? The Canadian Medical Association (CMA) recognizes and acknowledges the unique requirements of patients suffering from a terminal illness or chronic disease for which conventional therapies have not
  5. 5. been effective and for whom marijuana for medicinal purposes may provide relief. Among individual doctors, however, feelings are mixed. When the CMA surveyed physicians in May 2012, 70% said that they had been asked by patients to approve their use of medical marijuana. More than 20% of those physicians said that they would “never” support its use, while 12% said that they “usually” supported their patients. The majority of respondents to the CMA poll said that more information about the benefits and risks of medical marijuana would be useful. It is the CMA’s belief that further advancement of scientific knowledge about medical marijuana should be encouraged. To date, the sample sizes, duration of studies and the actual number of studies are too slight to make clear the evidence for the safety and efficacy of medical marijuana. Studies regarding safety, efficacy, proper dosage and delivery mechanisms for treating specific conditions should be conducted. The same safety and efficacy standards should apply to medical marijuana as to pharmaceutical products under the federal drug act (FDA). Suggestions for talking to your doctor How do you start the conversation with your medical practitioner about getting approved for medical marijuana use? Asking your physician about medical marijuana will likely be difficult and uncomfortable. A suggested start could be something as simple as: “Doctor, we’ve tried other drugs and I’m still not feeling well, can we talk about medical marijuana?” “I just can’t handle my symptoms (pain, nausea, etc.) anymore. Can we try medical marijuana?” “What are your thoughts on medical marijuana? Do you think it might help me?” “Can we try something different? Is medical marijuana an option that we can talk about?” “What are the pros and cons of medical marijuana? Do you think it could help?” Remember that you may meet with some resistance. Medical marijuana is a controlled substance that many physicians have little or no experience with and they may not be comfortable with it as a treatment. In addition, physicians are often reluctant to suggest a drug that hasn’t undergone rigorous studies on its efficacy and safety. You may want to get opinions and advice from more than one physician to find the treatment solution you’re both comfortable with. The decision tree below, suggested by Grant et al,1 provides a framework for physicians (in California) to consider authorizing medical marijuana to patients. Similarly, it provides a good checklist for you, as a patient, to assess the appropriateness of using marijuana for medical purposes. 3-1 Decision Tree_wp [Source:]
  6. 6. 1 I. Grant, J. Hampton Atkinson, B. Gouaux, B. Wilsey, “Medical Marijuana: Clearing Away the Smoke,” Open Neurol J. 2012. 6:18-25 Medical Marijuana If you are suffering from severe pain, chronic inflammation, or the nausea associated with chemotherapy, you may be wondering whether medical marijuana might alleviate your symptoms. Understanding the different types of marijuana, its active ingredients, and how it works will help you and your physician make the decision that’s right for you.
  7. 7. Marijuana is the common name for the Cannabis plant. In recent years, there has been mounting evidence of its usefulness for the treatment of pain, nausea, vomiting, inflammation, movement disorders and wasting syndrome or anorexia. In Canada, medical marijuana has been legally available by a physician’s medical declaration for more than a decade. There are two primary species of marijuana, which differ based on their physical properties, such as colour, taste, and smell. Different strains also have different chemical ingredients, which determine potency. Active ingredients The major active ingredients in medical marijuana are THC (delta-9-tetrahydrocannabinol), CBD (cannabidiol), and CBN(cannabinol). Other cannabinoids, more than 100 to date, have also been identified in lesser amounts in marijuana plants. Potency The strength of marijuana is indicated by the percentage of active ingredients in a sample, expressed by percent dry weight. For example: About THC (Delta-9-Tetrahydrocannabinol) THC is the best-studied ingredient of marijuana. This is the chemical that’s primarily responsible for marijuana’s physical and psychotropic effects. The average THC content of marijuana on the illicit market in Canada is 10% (ranging from 1% to 30%). In living plants, THC exists as an inactive acid. Heating or exposing the acid to ultra-violet light causes a chemical reaction that makes the THC active. Active THC also has certain medicinal properties:  Relieves pain (analgesic)  Helps prevent nausea (antiemetic)  Stimulates the appetite  Affects vision, hearing and sense of smell (psychotropic stimulant/relaxant)  Acts as a sedative About CBD (Cannabidiol) CBD is also found as an acid in living plants that becomes active when heated or exposed to UV light. Unlike THC, however, it is not psychoactive. Similar to THC, active CBD has a variety of medicinal properties:  Relieves pain (analgesic)  Helps prevent convulsions (antiepileptic)  Reduces inflammation (anti-inflammatory)
  8. 8.  Antipsychotic  Neuroprotective About CBN (Cannabinol) As THC oxidizes or degrades, cannabinol (CBN) is produced. CBN is psychoactive but much less so (about one-tenth) than THC. CBN is not associated with marijuana potency. What to Look for in a Licensed Producer 2.2-approved_DSC9107_smaller Production of medical marijuana in Canada is a highly regulated, controlled, commercial industry. To be legally licensed, producers must comply with extremely high standards of inspection across all areas of operations, from quality control to safety and security of distribution. Governing laws Health Canada provides licenses to medical marijuana producers who are inspected and found in compliance with applicable sections of the following Canadian acts and regulations: Food and Drug Act (FDA) Controlled Drugs and Substances Act (CDSA) Food and Drug Regulations (FDR) Natural Health Product Regulations (NHPR) Narcotic Control Regulations (NCR) Marihuana Medical Access Regulations (MMAR) (In effect until March 31, 2014) Marihuana for Medical Purposes (MMPR) (introduced June 19, 2013) Under MMAR, licensed marijuana producers must also abide by standards set in Good Manufacturing Practices (GMP), ensuring a controlled, procedure-driven cultivation, processing and testing systems. For instance, if a question of safety or potency is raised, a licensed, GMP-compliant grower should be able to fully trace a specific product or dose, and answer concisely to the medical community and patients. Scientifically trained staff A licensed producer employs personnel with advanced degrees in chemistry and pharmacology to manage production quality systems. The work depends on intelligent, reliable, trustworthy, creative staff who ensure that breeding, growing, drying, packaging, storage, testing and distribution of medical marijuana is robust, ensuring a consistent product for patients.
  9. 9. Keeping patients’ best interests in mind, licensed producers adhere to tight contamination and potency limits through validated analytical tests. Safety testing occurs at every stage of production, with full traceability, and the same standards used with common pharmaceutical products. Regulated potency ensures that patients know what to expect from the product and can measure the dosage required for their desired effect. Security with zero tolerance for abuse Marijuana is an illegal narcotic in Canada, and only legally cultivated by licensed producers. As such, it is imperative that everything produced, including all waste streams and distribution to patients can be accounted for, proving zero tolerance associations with illegal markets. Licensed producers are required to provide infallible security to the premises that produce and store medical marijuana. How Much Marijuana Will I Need to Take? 3.3_dosingSeveral surveys have shown that the average consumption of marijuana for medical purposes is 1 to 3 g per day.1,2,3 Currently, the maximum daily amount approved for patient use is 5 g/day. The optimal amount for you will be set out by your medical practitioner. (See Medical Marijuana Access) Precise dosages of inhaled cannabis have not been established. In one recent Canadian study, 25 mg of dried marijuana (THC (delta-9-tetrahydrocannabinol) 9.4%) smoked as a single inhalation 3x/day for five days, was effective in reducing intensity of pain, improved sleep and was well tolerated.4 Suggested guidelines for dosing medical marijuana are to “start low and go slow.” Patients who are new to cannabis are cautioned to start with a very low dose and to stop therapy if any undesirable or unacceptable effects occur. Patients should wait between puffs for a few minutes to gauge the strength of the effects. Delivery mechanisms Inhalation by smoking/vaporization is the most common delivery system for users to get the active ingredients, THC (delta-9-tetrahydrocannabinol), CBD (cannabidiol), and CBN (cannabinol), in marijuana. With this method, THC blood levels peak in just two minutes, while the medical effects peak at 15 minutes and may last as long as several hours. After approximately two hours, blood concentrations are reduced by half. This predictable behaviour (onset/half-life) for THC delivered by inhalation makes it easy for most patients to determine how much they need to take for the medical effect that they want. Since inhalation delivers the THC quickly, it is the system most suitable for treating acute symptoms such as nausea, seizures, sleep initiation, appetite stimulation, and for unexpected pain. Some people prefer to bake/cook with marijuana or use it to prepare tea. When ingested orally in these ways, the active ingredients are absorbed throughout the gastro-intestinal tract. Again, the recommendation is to start low and go slow. Wait 30 to 60 minutes between bites of baked goods to gauge the strength and effect.
  10. 10. This delivery system is slower to produce THC effects (one to two hours for onset) but lasts longer than inhalation (up to six hours). For chronic pain, multiple sclerosis spasticity or sleep maintenance, oral delivery may be preferred. However, since it takes effect more slowly, care must be taken not to take more while the ingredients are still being absorbed. Overdosing with cannabinoids, while not immediately life-threatening or toxic, can produce undesirable psychological side-effects and dosages above 5 g per day may increase the risk of health and psychological side effects. 1 G.T. Carter, P. Weydt, M. Kyashna-Tocha and D.I. Abrams. “Medicinal cannabis: rational guidelines for dosing,” IDrugs. (2004), 7:464-470. 2 A.J. Clark, M.A. Ware, E. Yazer, T.J. Murray et al. “Patterns of cannabis use among patients with multiple sclerosis,” Neurology. (2004), 62:2098-2100. 3 M.A. Ware, H. Adams, and G.W. Guy. “The medicinal use of cannabis in the UK: results of a nationwide survey,” Int.J.Clin.Pract. (2005), 59:291-295. 4 M. Ware, T. Want, S. Shapiro, A. Robinson et al. “Smoked cannabis for neuropathic pain: a randomized controlled trial,” CMAJ. (2010), 182:E694-701. Side Effects 3.2 approved shutterstock_116261065Like any drug, medical marijuana can have side effects. It’s important to be aware of these when deciding whether it’s an appropriate treatment for you. Because THC is psychoactive, its use may result in acute psychosis, including feelings of paranoia, delusions, and distorted sensory perceptions. Evidence suggests that individuals with schizophrenia have a higher likelihood of suffering adverse psychiatric effects. Precautions for the use of medical marijuana are based on evidence of potential side effects in affecting the following areas. Lungs Generally, it is not recommended that any medicinal product be smoked. However, smoking is a common delivery method for the THC and CBD found in medical marijuana. There are negative pulmonary side effects related to smoking marijuana. In vitro studies provide strong evidence that smoked marijuana is carcinogenic, although epidemiological evidence is inconclusive. Studies suggest that heavy marijuana smokers have decreased lung function and often experience symptoms of bronchitis and chronic coughs, implicating it as a long-term risk factor for chronic obstructive pulmonary disease. Heart Upon taking marijuana, some patients experience a rapid heart beat (tachycardia). This side effect can be problematic or even dangerous for patients who have angina or a pre-existing heart condition.
  11. 11. Smoking marijuana also causes blood vessels to expand (vasodilation), resulting in reddening of the eyes and affecting the body’s ability to counteract low blood pressure. Central nervous system Side effects to the central nervous system include intoxication-like symptoms such as drowsiness, dizziness, and getting a “high” sensation (elation and laughing). Cognitive impairment such as reduced short-term memory and difficulty concentrating have also been reported. In addition, marijuana use impairs psychomotor performance; driving under the influence is not advised. Liver Marijuana use has been implicated in chronic liver disease. A significant association has been seen between its use and severe liver fibrosis in patients with hepatitis C. Fertility Epidemiological, clinical and non-clinical studies agree that marijuana and THC have negative reproductive side effects on sperm count, motility, and morphology. Pregnancy and breastfeeding Use of marijuana should be avoided if you are planning a pregnancy, pregnant or breastfeeding because of potential risks to your fetus or child. Granny Storm Crow Lists 1000 Pages of Cannabis Research Links I’m proud to say that Granny Storm Crow is both a resident of California and a member of my generation. We may have come from different sides of the country, but we learned the same kind of moral code. She was taught “When the truth won’t do, then something is wrong!” I was taught “When something is wrong, let everyone know!” So together, we’re finding out what is wrong (and more importantly, what is right!) and letting everyone know. That’s why people like us want to share this information far and wide. Here is where you can download the latest copy of her list as of January 2013. It’s a ZIP file containing the list itself, plus a separate glossary and index. Enjoy…and share it with anyone who wants to learn more about what cannabis can really do as a medicine. If you wish to download strains, growing, and other related material check out