Medical Marijuana and Clinical Oncology in 2022"The Good the Bad and the Potentially Ugly"
Marijuana/cannabinoids are particularly appealing for oncology patients offering the possibility of a single medication to encompass a variety of problems, such as pain, nausea, anorexia, sleep disorders , and anxiety.
Dr. Malcolm Brigden - University of Calgary - Canada.
Cannabis and Psychedelics – Leanna Standishwwuextendeded
Cannabis and Psychedelics – Leanna Standish, PhD, ND, LAC, FABNO
Presented at the 2015 Palliative Care Summer Institute conference at Bellingham Technical College
The world is watching as Canada becomes one of the first countries to legalize recreational cannabis, and there's still much we don't know about how this huge social change will affect our lives.
In this webinar, Dr. Chris Wilkes, MD, from UCalgary's Cumming School of Medicine reviews what the research to date tells us about the impact of cannabis on the brain, and what needs further study. Dr. Fiona Clement, PhD, whose team compiled the Cannabis evidence series for the Alberta provincial government, looks at the factors informing government policy, including evidence from other jurisdictions that have legalized marijuana.
Watch the full webinar recording at https://go.ucalgary.ca/2018-07-11URNAP-WhatdoeslegalizedcannabismeanforCanadians_LPRegistration.html
Cannabis and Psychedelics – Leanna Standishwwuextendeded
Cannabis and Psychedelics – Leanna Standish, PhD, ND, LAC, FABNO
Presented at the 2015 Palliative Care Summer Institute conference at Bellingham Technical College
The world is watching as Canada becomes one of the first countries to legalize recreational cannabis, and there's still much we don't know about how this huge social change will affect our lives.
In this webinar, Dr. Chris Wilkes, MD, from UCalgary's Cumming School of Medicine reviews what the research to date tells us about the impact of cannabis on the brain, and what needs further study. Dr. Fiona Clement, PhD, whose team compiled the Cannabis evidence series for the Alberta provincial government, looks at the factors informing government policy, including evidence from other jurisdictions that have legalized marijuana.
Watch the full webinar recording at https://go.ucalgary.ca/2018-07-11URNAP-WhatdoeslegalizedcannabismeanforCanadians_LPRegistration.html
7 Famous Myths About CBD oil And Marijuana - HemproveHemprove
Hemprove is a health care company in Canada. Here, hemprove shows some great and famous myths about CBD OIL and Marijuana, which are most famous right now among people.
Now that medical cannabis is available in Maryland as well as DC, patients are looking for guidance from clinicians – who have received little or no information about this substance in their formal training. Furthermore, much of the information being offered about the dangers and benefits of cannabis tends to be distorted positively or negatively according to the philosophical orientation of the source.
Vad är CBD-olja? Fördelar Laglighet Biverkningar Risker Hur man använder
Cannabidiololja används för hälsoändamål, men det är kontroversiellt. Det finns viss förvirring om vad det är och effekten på människokroppen.
Cannabidiol (CBD) kan ha vissa hälsofördelar, men det kan också finnas vissa risker. Det är inte heller lagligt i varje stat.
Hash It Out: The Role of Medical Marijuana in GIPatricia Raymond
Marijuana's side effect of Cannabinoid Hyperemesis Syndrome is well known to us, as is use of Marinol to enhance appetite in the chronically ill, but are there other high points in the use of medical marijuana? What about the possible use of CBD oil for chronic pancreatitis or intractable abdominal pain?
Studies have shown cannabis' effect on GI motility, inflammation and immunity, intestinal and gastric acid secretion, nociception and emesis pathways, and appetite. Let's weed through the available data on the medical use and side effects of medicinal cannabis in gastroenterology.
Please share this slideshow with anyone who may be interested!
In this webinar:
● Marijuana for Medical Purposes Regulations (MMPR)
● Statistics on cannabis usage and results of the CCSN medical cannbis survey
● Differences between licensed producers and dispensaries
● Basic information on medical cannabis usage, adverse effects, potential use and contraindications
● Cannabis varieties
● How to legally access medical cannabis
Contact the presenter:
● Kaivan Talachian: ktalachian@canntrust.ca
View the YouTube video:
http://youtu.be/ZB9-z-pqqTc
Follow our social media accounts:
Twitter - https://twitter.com/survivornetca
Facebook - https://www.facebook.com/CanadianSurvivorNet
Pinterest - https://www.pinterest.com/survivornetwork
YouTube - https://www.youtube.com/user/Survivornetca
This presentation will review the current research around medical marijuana and discuss the issues around the recent legalization of recreational use. We will explore common clinical questions regarding marijuana use including testing and concurrent controlled substance use.
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7 Famous Myths About CBD oil And Marijuana - HemproveHemprove
Hemprove is a health care company in Canada. Here, hemprove shows some great and famous myths about CBD OIL and Marijuana, which are most famous right now among people.
Now that medical cannabis is available in Maryland as well as DC, patients are looking for guidance from clinicians – who have received little or no information about this substance in their formal training. Furthermore, much of the information being offered about the dangers and benefits of cannabis tends to be distorted positively or negatively according to the philosophical orientation of the source.
Vad är CBD-olja? Fördelar Laglighet Biverkningar Risker Hur man använder
Cannabidiololja används för hälsoändamål, men det är kontroversiellt. Det finns viss förvirring om vad det är och effekten på människokroppen.
Cannabidiol (CBD) kan ha vissa hälsofördelar, men det kan också finnas vissa risker. Det är inte heller lagligt i varje stat.
Hash It Out: The Role of Medical Marijuana in GIPatricia Raymond
Marijuana's side effect of Cannabinoid Hyperemesis Syndrome is well known to us, as is use of Marinol to enhance appetite in the chronically ill, but are there other high points in the use of medical marijuana? What about the possible use of CBD oil for chronic pancreatitis or intractable abdominal pain?
Studies have shown cannabis' effect on GI motility, inflammation and immunity, intestinal and gastric acid secretion, nociception and emesis pathways, and appetite. Let's weed through the available data on the medical use and side effects of medicinal cannabis in gastroenterology.
Please share this slideshow with anyone who may be interested!
In this webinar:
● Marijuana for Medical Purposes Regulations (MMPR)
● Statistics on cannabis usage and results of the CCSN medical cannbis survey
● Differences between licensed producers and dispensaries
● Basic information on medical cannabis usage, adverse effects, potential use and contraindications
● Cannabis varieties
● How to legally access medical cannabis
Contact the presenter:
● Kaivan Talachian: ktalachian@canntrust.ca
View the YouTube video:
http://youtu.be/ZB9-z-pqqTc
Follow our social media accounts:
Twitter - https://twitter.com/survivornetca
Facebook - https://www.facebook.com/CanadianSurvivorNet
Pinterest - https://www.pinterest.com/survivornetwork
YouTube - https://www.youtube.com/user/Survivornetca
This presentation will review the current research around medical marijuana and discuss the issues around the recent legalization of recreational use. We will explore common clinical questions regarding marijuana use including testing and concurrent controlled substance use.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
3. Some disclaimers
No financial or other intellectual conflicts of interest to report
Slides/materials have been derived from the internet and various other educational resources-special
thanks to Dr Kerba University of Calgary
To paraphrase our current prime minister “Some may have
smoked but of course they never inhaled!”
3
4. What we hope to exploretoday
• History
• Biology, pharmacology, and neuropharmacology of cannabinoids
• Individual products and their mechanism of effect
• Some of the current evidence for use
• Potential concerns : drug interactions, college and provincial recommendations,
other possible issues
• Some Considerations: If you do take the endorsement plunge
4
6. History of cannabisasamedicine for cancer
• First reported medical use>3000 yearsago
• Siberian Ice Maiden: 5th century BC
• Traditional Indian medicine
http://siberiantimes.com
• Analgesic, sedative, anxiolytic, appetite-
Introduced into UKby O’Shaughnessyin 1842
• British physician working inIndia
• Analgesic,anti-convulsant
• Fell out of favour in1930s
• Plant material too variable
• Shelf-life short andunpredictable
• Replacedby pure opiates and morereliable
synthetic drugs
• Removedfrom UK/USPharmacopeia1932 & ’41
• Prohibition 1930s related to bad publicity and
“Reefer Madness”
• Until recently-illegal in Canada since the 1970’s 6
8. Some Terminology
• Cannabis-is the botanical term for the plants
Cannabis sativa or Cannabis indica
• Marijuana -is a cultural term for the cannabis
plant - refers to the dried leaves, flowers, stems,
and seeds
• Medical marijuana/cannabis-marijuana that is
recommended/ endorsed by a medical
professional for the treatment of a variety of
medical conditions
8
10. Cannabismaybeendogenous, synthetic or derived fromplants
• Phytocannabinoids
• derived from plants: Cannabissativa
• dried leaves and flowering heads(marijuana)
• also resin of upper leaves & flowering beds
(hashish)
• Synthetic cannabinoids
• synthetic THC:dronabinol,nabilone
• many other forms (someillicit)
• Endogenous:Endocannabinoids - anandamide
• alter intracellular signaling
• ?function is to modulate painresponse and
a variety of other physiological functions
10
11. Cannabissativa
Marijuana (dried leaves/ flowering heads)
Isolated purecompounds
Non-cannabinoids Cannabinoids
Psychoactive
Δ9-
THC
Δ8-THC
cannabinol (CBN)(weak)
Active, not
psychoactive
Cannabidiol (CBD)
Inactive
>60
compounds
>400 chemical
compounds
>70 types of
cannabinoids
Most potent
psychoactive
ingredient
Phytocannabinoids
Kalant H. PainResManage2001;6:80-91
Dr Marc KerbaTBCCJune12th 2019
11
12. Forms of phytocannabanoids
(plant-derived cannabis)
• Inhaled leaf (smoked or vaporized)
• rapid onsetbut short duration(2-4 hrs)
• Buccalspray: Nabiximols (Sativex)
• 1:1 THC:CBD,TGAregistered forMS
• Ingested forms
• cannabisoil
• oral drops
• oral capsule(liposomalformulation)
• onset30-90 mins, duration 4-12hrs
• Concentration of THC,CBD,other constituents
vary widely but customizable with commercial
preparations ie THC/CBD ratio
12
15. Marijuana/Cannabinoids are commonly used
In North America, marijuana/cannabinoids are the 3rd most
commonly used substances after alcohol and tobacco:
Probably 22 Million Users in the last 30 days
(8% of people 12 years and older)
2014 National Survey of
Drug Use and Health
15
16. Some homegrown Canadian statistics- pun intentional
• More than 200 types of medical cannabis are available from Canadian licensed
producers
• The highest % of THC studied is 9.4%, but many current products around 15%.
• 43 % of adults reported prior lifetime usage- 12% within the past year.
• Average user consumed cannabis 2 -3 x week - 40% actually consuming >14
grams / week.
16
17. Why Do North Americans Use Marijuana/Cannabinoids?
Among North Americans who used marijuana in the past year:
17
SOURCE: Pew Charitable Trust, 2013 (reference list).
47%
30%
23%
For Fun For Medical Reasons For Fun and for Medical Reasons
18. Why do North Americans Use Medical Marijuana/Cannabinoids?
DISORDER THAT REQUIRES
TREATMENT
% CITING AS REASON FOR MJ
USE
Chronic Pain 58.2%
Mental Health Disorders 22.9%
Sleep Disorders 21.3%
Neurological Disorders 16.6%
HIV 1.6%
Cancer 1.5%
Glaucoma 1.3%
18
SOURCE: Reinarman et al., 2011 (reference list).
19. Who Uses Marijuana/Cannabinoids-1 ?
• Joe (23 years old)
• First used at a party age 15,
continued using through
college
• Now uses when he goes out
or is playing video games with
friends
• Also uses when stressed out
• On average, uses about 4-5
times/week
19
20. Who Uses Marijuana/Cannabinoids-2 ?
• Maria & Terry
(46 & 48 years old)
• Used in college; stopped
when she got pregnant
• Now smoke socially and
when they go to concerts
• Maria uses when work
stresses her out
• Terry uses for pain stemming
from chronic neuropathy
20
21. Who Uses Marijuana/Cannabinoids-3 ?
• Elise (78 years old)
• Never used marijuana until she
turned 63
• First used to improve appetite
during chemotherapy for
breast cancer
• Cancer has now metastasized
to her spine.
• Conventional painkillers don’t
work well; now uses several
times a day for pain relief
21
23. Colorado – The impact- of some early aspects
of legalization was actually studied
23
24. Colorado – Some Initial Impacts (2014)
• Traffic fatalities involving operators testing positive for marijuana increased 100%
from 2007 to 2012
• Increase in youth current marijuana users in 2012, to 10.47% of youth from
7.55% -nationally. Colorado, now ranked 4th in the nation, 39% higher than the
national average
• School drug related suspensions/expulsions increased 32% from school years
2008/2009 through 2012/2013
• A 57% increase in marijuana-related emergency room visits from 2011 through
2013
• Hospitalizations related to marijuana increased 82% from 2008 to 2013
24
25. Did US legalization produce increased compassionate
care danda
use of cannabinoids/marijuana?
<5%
■ Less than 5% of users
had
cancer, HIV/AIDS,
or life-threatening diseases
■ 90% are registered
for ailments such
as general pain or headaches
25
26. US legalization-Increased compassionate care use
versussimply increased access to marijuana?
>80%
■ Most card holders in
CA and CO are white
men between the
ages of 17 -35
■ No true history of chronic
illness
■Often history of Alcohol
and Drug Use
26
27. • Wearenow in alegalizedenvironment
• Bill C45the “CannabisAct” receivedRoyalAssent June21st2018
(Thank-you Wilson-Raybould...)
• Legalto purchase cannabis from retailors authorizedby provinces
– Oils
– Dry or freshleaves
– Seeds
– Plants
– Edibles -pending
• Legal to purchase from any federally licensed producer
And What about Canada-1? Regulation-BillC-45
Dr Marc Kerba TBCCJune 12th 2019 27
31. Phylogenetically the endocannabinoids system
evolved long before the actual plants appeared
• The endocannabinoid system appears to help regulate numerous
aspects of normal physiologic function, including cognition,
coordination, memory, appetite, pain perception, heart rate,
gastrointestinal mobility, intraocular pressure and immune function
31
32. CB1 and CB2 receptors
• CB1 receptors are the most widely expressed, located mainly in the
central and peripheral nervous systems, plus a few other locations
including cardiovascular, visual and gastrointestinal systems.
• CB2 receptors have a more limited distribution, being located
primarily in the immune system, including lymphatic tissue, spleen,
macrophages and the immune cells of the CNS
• Psychotropic effects are largely due to activation of the CB1 receptors,
while the CB2 receptors in the periphery affect immune cells and play
a role in inflammation and the immune response
32
35. WARNING if you are under age 25: Possible mis-wiring
of the early brain: THC disrupts cortex development in
fetus (Tortoriello et al., The EMBO J 2014)
• THC reorganizes wires in the developing and adult nervous
systems (Kano et al, 2009, Keimpema et al, 2010)
• THC disrupts development and maintenance of connections
critical for highly ordered executive and cognitive functions
(Kittler et al, 2000).
35
36. ? Explains the documented effects of cannabinoids on the
brain of adolescents
• The cerebellum plays a role in balance, psychomotor
speed, language generation, rhythm production,
inhibition, attention, and memory
36
37. Adolescent Marijuana Users Have Enlarged Brain
Cerebellum: Association with Poor Executive Function
Source: Medina KL, Nagel BJ, Taper SF. Abnormal cerebellar morphometry in abstinent adolescent marijuana users.
Psychiatry Research: Neuroimaging 182: 152-159, 2010.
Following one month of abstinence, adolescent MJ users had significantly larger posterior
cerebellar vermis volumes than non-using controls. These greater volumes are associated
with poorer executive and cognitive functioning. . Chronic adolescent MJ users have
shown significantly poorer sustained attention, cognitive inhibition, and abstract
reasoning
37
40. Some cannabinoid pharmacology
•THC identified in 1964
•Smoking:
o1 cigarette contains 0.5 to 1g
of cannabis
o20% absorbed by lungs
oOnset 15 minutes, duration 3
to 4 hours
Oral consumption:
oProlonged but poor
absorption-average 10-15%
oOnset 3-4 hours, duration 6
to 8 hours
•Converted to
metabolites
o11-hydroxy-THC
o11-nor-carboxy-THC
• Accumulates in fat
stores
oT1/2 = 20-30 hours
• Removal from body:
o1/3 excreted as urine
o2/3 eliminated in feces
40
41. Vaporization of medical cannabis
• Cannabinoids
vaporize at a temp
lower than combustion
• Increasingly popular
• Lower % of noxious
chemicals
• Volcano unit costs
around $450
http://www.volcanovaporizer.com/products-page/complete-sets/ Accessed 08/31/2012
41
42. A reversal of potency problems- “It’s not your dad’s ‘pot’ anymore”
• Marijuana growers have worked hard to make the drug as potent
as possible.
• In 1960s-70s average THC concentrations were 1-2%. Today, they
are as high as 20%
42
45. However adverse events in cancer patients appear
tolerable and possibly transient for most patients
45
Practical Considerations in Medical Cannabis Administration And Dosing
MacCalluma et al, European Journal of Internal Medicine 49 (2018) 12–19
46. Cannabis and psychosis
• There is reasonable evidence that heavy cannabis use, and perhaps
acute use in sensitive individuals, can induce an acute psychosis
(Paranoia)
• Scientific literature documents that heavy marijuana use can
precipitate schizophrenic episodes but it is unknown if usge can cause
the underlying psychotic disorder
• At a population level, assuming a causal relationship, elimination of
cannabis might reduce the incidence of schizophrenia by
approximately 8%,
46
47. Marijuana and abuse/dependence
• SUD falls on a continuum of alcohol and drug use
47
PROBLEMATIC SUBSTANCE USE
Risky Substance
Use
Substance Abuse
Substance
Dependence
SUBSTANCE USE DISORDERS (SUD)
48. Marijuana abuse/dependence
• Most individuals use marijuana without developing
SUD.
• However, because usage is so widespread, more people
end up using marijuana problematically than other
drugs.
• In LA County, marijuana use accounted for more
substance use disorders treatment admissions (23.3%)
than any other drug, including alcohol (22%).
SOURCES: Los Angeles County DPH, 2011; NIDA, 2012a (reference list).
48
49. Cannabis use disorder-How might the addictive risk
compare?
DRUG
LIFETIME RISK OF
DEPENDENCE
Nicotine 32%
Heroin 23%
Cocaine 17%
Alcohol 15%
Marijuana 9%
49
SOURCE: Bostwick, 2012 (reference list).
50. Cannabis withdrawal syndrome
• A true clinical entity noted in heavy users
• 3 (or more) of the following signs and symptoms
develop within approximately 1 week:
• Irritability, anger, or aggression.
• Nervousness or anxiety.
• Sleep difficulty (e.g., insomnia, disturbing dreams).
• Decreased appetite or weight loss.
• Restlessness.
• Depressed mood.
• At least 1 of the following physical symptoms causing
significant discomfort: abdominal pain,
shakiness/tremors, sweating, fever, chills, or
headache.
50
51. Cannabinoid hyperemesis syndrome
Impressyourcolleagueswithyourdiagnosticacumen
• First described in 2004
• Associated with chronic, heavy use of cannabis -presumably
recreational or medical
• Patient presents to emerg →complaint-recurrent episodes of
severe nausea, retching and cyclical vomiting in the absence of
other pathology
• Pathgnomic history→temporary relief from hot
showers/baths triggers compulsive showering!
• Symptoms stop after cannabinoid cessation but may recur
within weeks of resuming
Schreck B., et al. Cannabinoid hyperemesis syndrome: review of the literature
DrugAlcohol Depend. (2017) 182 27–32.
53. Resurgencein interest in cannabisas treatmentforcancerover last 20 years
• Non-legal use in community: anecdotes
• Researchsince 1980s (esp. Israel)
• Identified endogenous cannabinoids with influenceon
neurologic, immune, gastro-intestinal systems
• Synthetic THCdeveloped
• FDAapproved: nauseaand vomiting due to chemotherapy
• Dronabinol 1986 ,Nabilone2010)
• Subsequently approved in various jurisdictions
• Clinical trials launched in a variety of countries
• Medical prescribing permitted in a number of countries
including Europe, Canada, Australia, Israel etc
53
56. Dr Marc Kerba TBCCJune12th2019
Malignancy
All respondents
(n=1987)
Anylifetime use
(n=834)
Usein last 6
months(n=356)
Breast 428 166 (39%) 65 (15%)
Lung 171 78 (46%) 43 (25%)
Genitourinary 286 107 (37%) 43 (15%)
Brain/H&N 240 105 (44%) 42 (18%)
Gastrointestinal 345 152 (44%) 70 (20%)
Hematologic 290 135 (47%) 55 (19%)
Skin 28 13 (46%) 3 (11%)
Gynecologic 129 52 (40%) 24 (19%)
Other 70 26 (37%) 11(16%)
Cannabis/Cannabinoidsusebycancerpatientsbytumorsite
56
57. No. of activeusers
n=356(%)
Reasonfor Use
Anycancersymptom (combined) 70
Cancerrelated pain 46
Cancerrelated nausea 34
Other cancersymptoms 31
Anynon-cancerreason (combined) 56
ReasonsforCannabis/Cannabinoidsusebycancerpatientswithinthelast6months
Dr Marc Kerba TBCCJune12th2019
57
58. So what might we really know about
usefulness in cancer patients?-Two large well
conducted trials –Netherlands-Israel
58
59. Important aspects of this comprehensive study involving> 1700 cancer patients
• >60% achieved satisfactory pain reduction with cannabinoid therapy
• In relation to opioids
• 50% continued to take same dose
• 10% decreased dosing
• 36% ceased taking completely
• Other Improvements in: insomnia, restlessness, anxiety, depression, pruritus and headache.
• 30% of patients experienced one side effect,
• Commonest side effects were, dizziness, dry mouth, hyperphagia, sleepiness,psychoactive effect.
Conclusion: cannabis represents a safe well-tolerated palliation for the majority of cancer patients
59
61. Somepossibleclinicalrecommendations/concernsinCancerPatients
EVIDENCE FOR EFFCTS in CANCER PATIENTS
Cannabis can be a useful adjunct in treating cancer pain.
Cannabis is effective for nausea and vomiting.
Cannabis may be useful in some patients for stimulating appetite.
Cannabis may help treat anxiety, depression and insomnia.
There is moderate evidence that cannabinoids are effective for
seizures/spasticity.
There is no concrete evidence that cannabis cures cancer or
significantly alters tumor growth
There are a number of theoretical concerns regarding potential
interactions between cannabis/cannabinoids and various
cancer therapies or individual oncology drugs
61
63. A systematic review identified 28 studies (27 placebo-controlled, 1 treatment-
controlled) of cannabis in a total of 2454 participants with chronic pain.
12 studies of neuropathic pain
6 trials of other types of pain
3 for cancer pain
Chronic Pain
3 for diabetic neuropathy
2 for fibromyalgia
2 for HIV-associated sensory neuropathy
Preparations tested included nabiximols, nabilone, inhaled cannabis, THC (oral or
oromucosal), and dronabinol.
Studies generally showed improvements in
pain measures with cannabis and cannabinoids.
63
64. Cannabis-Opioid Interactions
A study of 21patients with chronic pain treated with
sustained-release morphine or oxycodone found that
adding inhaled cannabis for 5 days
Significantly decreased pain by 27% (95% CI 9-46)
Had no significant effect on plasma opioid levels.
OPIOID
Co-administration of cannabis or cannabinoids withopioids
is safe and may allow for use of lower doses of opioids.
CANNABIS
65. A systematic review identified 28 RCTs (8 placebo-controlled,
20 treatment-controlled) with 1772 participants that examined
the effects of cannabinoids on CINV.
14studies tested nabilone (which mimics THC)
9 studies tested dronabinol (THC)
4 studies tested levonantradol (no longer used inmedicine)
1study tested nabiximols (THC and CBD)
Studies generally showed a benefit
of cannabinoids for CINV.
Chemotherapy-Induced
Nausea and Vomiting (CINV)
65
67. An RCT of 243 patients with CACS found no superiority of
cannabis extract or THC over placebo for affecting
appetite or quality of life.
A double-blind, RCT of 469 patients with CACS found that
megestrol acetate was more effective than dronabinol for
stimulating appetite and increasing weight gain.
Combined treatment was no more effective than
megestrol acetate alone.
The effect of dronabinol on appetite and weight
gain are small; megestrol acetate is superior.
Summary:Appetite/Weight
Cancer-related Anorexia Cachexia Syndrome (CACS)
68. A randomized treatment-controlled crossover trial in 29
fibromyalgia patients with chronic insomnia found that
nabilone 0.5-1 mg/kg before bedtime was superior to
amitriptyline for improving sleep.
19 other studies that assessed sleep as a secondary outcome
measure found that cannabinoids (primarily nabiximols)
improved sleep quality.
A randomized controlled trial of 10 patients with
generalized Social Anxiety Disorder found that 4 0 0 mg
CBD significantly decreased anxiety.
Cannabinoids may help with some
measures of sleep quality/anxiety.
Sleep Disorders/Anxiety
71. Current evidence – anti-tumour effects
NIH summary of laboratory/animal/preclinical studies
• Theoretically Cannabinoids mightcauseanti-tumour effects by variousmechanisms
• induction of cell death and inhibition of cell growth
• inhibition of tumour angiogenesis, invasion and metastasis
• Someevidenceof potential anti-tumour effects in cellcultures/xenografts
• glioma, hepatocellular carcinoma,non-small cell lung cancer and breast cancer
• CBDmayalso enhance uptake of cytotoxic drugs into certain malignantcells
• Thus far, shown in mouse models ofglioma
• Only 1 human study (Spanish,n=9)
• patients with glioblastoma multiforme(GBM)-non randomiseddesign
• THCdirectly infused into tumour daily by subcutaneouscatheter
• established safety but no conclusions reefficacy
• Guzmán et al, Br JCancer2006
71
72. Cannabis and Immunosuppression
• Possibly Good news: THC was found to induce cell death in different
types of cancer cells that have cannabinoid receptors.
• Possibly Bad news: it can lead to enhanced growth of tumors that
express low to undetectable levels of cannabinoid receptors by
specifically suppressing the antitumor immune response.
All these studies have been done in vitro and therefore little is known
about the immune effects of chronic low- dose exposure to cannabis.
72
75. What potential interactions need we be mindful of?
Cannabis Pharmacokinetics
• Most of the potential cannabinoid cytochrome interactions concern
inhibition, rather than stimulation of transport or metabolism
• THC is metabolized by CYP3A4 and CYP2C9
• CBD is metabolized by CYP3A4 and 2CY2C19
• Both THC and CBD competitively inhibit CYP3A4, with CBD being far more
potent in this regard
• A number of anticancer medications are also metabolized by cytochromes
CYP3A4 and CYP2D6
Brigden and England Oncology Exchange 17, 3, 2018
75
76. Pharmacokinetic Interactions AndCannabis
Drugsthat maytheoretically increase/decrease cannabis/cannabinoidblood levels
1.CYP2C9 inhibitors may increase serum concentration of THC
Strong inhibitors: capecitabine, 5-fluorouracil
Moderate inhibitors: abiraone, sorafenib, omeprazole, Septra
2.CYP3A4 inhibitors may increase serum concentration of THC & CBD
Strong inhibitors: ketoconazole, clarithromycin, antiretrovirals,
idelalasib moderate: aprepitant, diltiazem, imatinib, nilotinib,
fluconazole, grapefruit
3.CYP3A4 inducers may reduce serum levels of THC and CBD
Strong inducers: carbamazepine, phenytoin, enzalutamide
76
Brigden and England Oncology Exchange 17, 3, 2018
77. Purity concerns-few Canadian studies
Despite legalization, quality control problems persist
• American study-After analyzing > 600 samples from certified growers /sellers,
a state licensed lab detected little THC/CBD and lots of contamination.
• The average CBD amount: just 0.1 %
• Several marijuana flowers were "crawling" with up to 1 million fungal spores.
• Some grower spray crops with dangerous pesticides-residues may pass into
cannabis smoke
• Any extraction process may leave behind residual solvents
• Standards for quality control and analytical testing need to be rigorously
enforced
77
79. • Listing
conditions for
which marijuana
can be obtained,
including other
conditions as
determined in
writing...”
Why Canadian regulatorybodies wereappropriately leery of
US style "Marijuana Pill Mills”
79
80. CMA, Canadian Family Physician, CMPA, Individual Provincial College’s Positions
• The Canadian Medical Association has consistently opposed Health
Canada’s approach which places physicians in the role of gatekeeper
in authorizing access to marijuana.
• Current Canadian Family Physician guidelines do not enthusiastically
endorse cannabinoids
• CMPA publications detailed individual physician’s responsibility and
informed decision-making- also emphasize no obligation on the part
of reluctant physicians to participate in prescribing
• All of the above-? Relevance after legalization
80
85. Next: Be sure to satisfy any legal and documentation concerns
• Few absolute contraindications but if recommending should assess/council for
psychosis, bipolar disorder, significant cardiac disorder, lactation and pregnancy, prior
history of significant substance abuse, and documented cannabis allergies.
• Should document education:driving not recommended for 4 hours after inhaled, 6
hours after oral, or 8 hours if any “high” or euphoria experienced , as well as other risks
• Fortunately no longer necessary to arrange and document regular follow-ups as per
earlier pre-legalization individual provincial requirements
85
86. Some final considerations if one decides to recommend
POTENTIAL AREAS OF CAUTION
Cannabis is contraindicated with any history of psychosis; current or past
substance use disorder, cardiovascular or respiratory disease; pregnancy.
• Use caution in patients with active mood disorders, risk factors for
cardiovascular disease, users of high doses of alcohol or benzodiazepines
• Use caution in patients younger than 25.
• Do not suggest smoking dried product- suggest oral intake or
vaporization, which is likely safer in the long run.
• Recommend products with a balanced THC/CBD ratio (for example,
5%: 6% or 9%:9%).
• Once started and effects accessed , THC/CBD ratio can be further adjusted to
meet symptom needs
.
“Start low, go slow” 86
88. Some final conclusions-my take1
• "Love it or leave it"-medical marijuana/cannaboid use is now commonly
encountered in clinical practice in Canada, so it is critical for all health
care providers to understand both the scientific rationale and practical
implications of possible usage.
• Medical marijuana/cannabinoids are not a panacea- may have significant
health risks as well as many potential medical benefits.
• IF physicians decide to make recommendations/endorsement for medical
cannabis based on an individual's medical history/situation, appropriate
documentation and counselling are recommended
88
89. Some final conclusions-my take 2
Specific to oncology
• Marijuana/cannabinoids are particularly appealing for oncology
patients offering the possibility of a single medication to encompass a
variety of problems, such as pain, nausea, anorexia, sleep disorders ,
and anxiety
• More research is clearly needed in relations to indications, efficacy,
potential interactions with other oncology therapies, plus who is most
likely to benefit
89
91. Some potential resources
University of California's Center
for Medicinal Cannabis Research
www.cmcr.ucsd.edu
The CanadianConsortium
for the Investigation of Cannabinoids
www.ccic.net
Patients Out of Time
9 1
www.medicalcannabis.com