Lessons Learned, and Not Learned

What lessons could we learn from nicotine chewing gum?

You might be surprised.

Read on.

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Having never been addicted to anything (or, anyone), the craving for a substance, other than food & water for sustenance, it interests me to understand the strong cravings that some have for non-food substances, including, for example, tobacco, spiritous beverage, or narcotics abused, or other illicit substances, including cocaine, methamphetamine, etc.

For years, I have, on a personal level, maintained that addiction was not what many were saying that it was, some years ago. And in the interim, from then until now, indeed, the definition, and our understanding of addiction has substantially changed, precisely because of our increased understanding of physiology, in conjunction with improved recognition of cause-and-effect patterns of human behavior.

For example, with smokers, they almost always fall into habituation through association with routine. Wake up, toilet, smoke, bathe, smoke. Drink coffee, smoke. Drive to work, smoke. Work a couple hours, smoke break. Work a few more, lunch break, smoke. Work a bit, smoke break. Off work, drive home, smoke. Get cleaned up, smoke. Watch teevee, smoke. Eat supper, smoke. Have cocktails/nightcap, smoke. And it all repeats itself the next day. That’s significantly serious behavioral reinforcement.

Those who make effort to quit, frequently forget the association of routine with smoking, and when determined to quit, they sometimes

Dog Came to Me in a Dream and Said…

…and Dog said, “Don’t get the vaccine.”

I was going to vaccinate Dog against rabies.

So, I asked Dog, “Dog, do you want to get the vaccine?”

Dog said, “I’m worried that it’ll make me sterile.”

I reminded Dog that she’d been spayed since shortly after she adopted me, about 5ive years.

Dog then said, “I need to be free to make my own decision.”

I reminded Dog that

A Common Sense Approach To Lowering Medical Bills

Common sense approaches work well.

Unfortunately, common sense isn’t so common, anymore.

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Why Medical Bills Can Be Lower in Maryland

Dr. Elisabeth Rosenthal, MD

October 24, 2021

Guest Essay

Dr. Rosenthal is the Editor in Chief of Kaiser Health News. She was an Emergency Room physician before becoming a journalist.

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A $1,775 Doctor’s Visit Cost About $350 in Maryland. Here’s Why.

Illustration by Alvaro Dominguez

For the past 18 months, while I was undergoing intensive physical therapy and many neurological tests after a complicated head injury, my friends would point to a silver lining: “Now you’ll be able to write about your own bills.” After all, I’d spent the past decade as a journalist covering the often-bankrupting cost of U.S. medical care.

But my bills were, in fact, mostly totally reasonable.

That’s largely because I live in Washington, D.C., and received the majority of my care in next-door Maryland, the one state in the nation that controls what hospitals can charge for services and has a cap on spending growth.

Players in the health care world — from hospitals to pharmaceutical manufacturers to doctors’ groups — act as if the sky would fall if health care prices were regulated or spending capped. Instead, health care prices are determined by a dysfunctional market in which providers charge whatever they want and insurers or middlemen like pharmacy benefit managers negotiate them down to slightly less stratospheric levels.

But for decades, an independent state commission of health care experts in Maryland, appointed by the governor, has effectively told hospitals what each of them may charge, with a bit of leeway, requiring every insurer to reimburse a hospital at the same rate for a medical intervention in a system called “all-payer rate setting.” In 2014, Maryland also instituted a global cap and budget for each hospital in the state. Rather than being paid per test and procedure, hospitals would get a set amount of money for the entire year for patient care. The per capita hospital cost could rise only a small amount annually, forcing price increases to be circumspect.

If the care in the Baltimore-based Johns Hopkins Medicine system ensured my recovery, Maryland’s financial guardrails for hospitals effectively protected my wallet.

During my months of treatment, I got a second opinion at a similarly prestigious hospital in New York, giving me the opportunity to see how medical centers without such financial constraints bill for similar kinds of services.

Visits at Johns Hopkins with a top neurologist were billed at $350 to $400, which was reasonable, and arguably a bargain. In New York, the same type of appointment was $1,775. My first spinal tap, at Johns Hopkins, was done in an exam room by a neurology fellow and billed as an office visit. The second hospital had spinal taps done in a procedure suite under ultrasound guidance by neuroradiologists. It was billed as “surgery,” for a price of $6,244.38. The physician charge was $3,782.

I got terrific care at both hospitals, and the doctors who provided my care did not set these prices. All of the charges were reduced after insurance negotiations, and I generally owed very little. But since the price charged is often the starting point, hospitals that charge a lot get a lot, adding to America’s sky-high health care costs and our rising insurance premiums to cover them.

It wasn’t easy for Maryland to enact its unique health care system. The state imposed rate setting in the mid-1970s because hospital charges per patient were rising fast, and the system was in financial trouble. Hospitals supported the deal — which required a federal waiver to experiment with the new system — because even though the hospitals could no longer bill high rates for patients with commercial insurance, the state guaranteed they would get a reasonable, consistent rate for all their services, regardless of insurer.

The rate was more generous than Medicare’s usual payment, which (in theory at least) is calculated to allow hospitals to deliver high-quality care. The hospitals also got funds for teaching doctors in training and taking care of the uninsured — services that could previously go uncompensated.

In subsequent decades,

Research: Psilocybin Improves Depression

Better living through chemistry.

Because corrupt Republican President Richard Nixon’s 50-year lost cause, failed social experiment of the “War on Drugs” and Nancy Reagan’s “just say no” have never, and will never, work, nor ever benefited anyone who needed help — only those who perpetuated the war.

And, because no one — NO ONE — has ever said “when I grow up, I want to become an addict,” nor waked up one day and said, “gee… I think I want to become an addict.”

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In September 2018, Johns Hopkins researchers suggested that psilocybin should be re-categorized from a schedule I drug — one with no known medical potential — to a schedule IV drug (the lowest classification) such as with prescription sleep aids, but with somewhat tighter control, and summarized their analysis in the October print issue of Neuropharmacology, a peer-review professional journal.

Dr. Matthew W. Johnson, Ph.D., Professor of Psychiatry and Behavioral Sciences at Johns Hopkins is one of the world’s leading researchers, and most published scientists on the effects of psychedelics on humans, and has conducted original and innovative research in the behavioral economics of drug use, addiction, and risk behavior. Dr. Johnson earned his Ph.D. in experimental psychology at the University of Vermont in 2004.

Dr. Johson spoke with JHU reporters about the research, and said, “We want to initiate the conversation now as to how to classify psilocybin to facilitate its path to the clinic and minimize logistical hurdles in the future. We expect these final clearance trials to take place in the next five years or so. We should be clear that psilocybin is not without risks of harm, which are greater in recreational than medical settings, but relatively speaking, looking at other drugs both legal and illegal, it comes off as being the least harmful in different surveys and across different countries. We believe that the conditions should be tightly controlled and that when taken for a clinical reason, it should be administered in a health care setting, monitored by a person trained for that situation.”

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One Dose Of Psilocybin Improved Neural Connections Lost In Depression, Study Says

By Joseph Guzman, July 6, 2021

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The psychedelic psilocybin mushroom has shown promise in treating depression, and a number of clinical trials into the fungus’s therapeutic effects have been conducted in recent years.

But now, a Yale University study published in the peer reviewed professional journal Neuron July 5, 2021, has shed light on how the compound psilocybin —the active ingredient found in so-called “magic mushrooms” — may produce antidepressant effects.

Researchers administered a single dose of psilocybin to mice and used a laser-scanning microscope to visualize dendritic spines in the rodents’ brains in high resolution. Dendritic spines are small protrusions found on nerve cells that play a key role in transmitting information between neurons. Previous laboratory experiments demonstrated promise that psilocybin, and the anesthetic ketamine, could decrease depression.

Stress and depression degrade and reduce the number of neuronal connections.

Within 24 hours of the single psychedelic dose, researchers observed an immediate and lasting increase in

“Just say ‘NO’” has never worked. Here’s what does.

Freedom.

What a concept, eh?

The very idea that you have a brain, and therefore, can think independently to decide FOR YOURSELF what you want, or ought, to do, continues to frustrate others who think that they know better than you do what personal decisions you should make for yourself!

It’s an adult decision.

Why, it’s nothing short of… LIBERTY!

ENOUGH! of the “Nanny State”!

Take your religion home, and GET IT OUT OF GOVERNMENT!!

Practice it PRIVATELY, with your family, friends, and other like-minded individuals. STOP forcing your PRIVATE religious ethics and morals upon others by writing public laws that mirror your private interpretation of your religion.

Thomas Jefferson wrote a letter to the Danbury Baptists that cited the establishment clause of our nation’s Constitution, which as he wrote, erected a “a wall of separation between Church & State,” or as we now say, between government, and religion.

Religious nuts have been trying to tear it down, ever since.

And they’re STILL TRYING TODAY!

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‘Drug Use For Grown-Ups’ Serves As An Argument For Personal Choice

If you grew up scared of what illicit drugs could do to you — hearing about all the horrors that could befall you from everyone from Nancy Reagan to your parents — the threat may have felt very real: If you actually took a puff off that joint that the kid who slept through math class offered you, it could lead to failed relationships, chronic unemployment, self-destruction.

The shame would outlive you.

But drugs are a more complicated matter than they’ve been made out to be, according to Dr. Carl L. Hart. In his new book Drug Use for Grown-Ups, the Columbia University professor of psychology and psychiatry zealously argues that drug use should be a matter of personal choice — and that, in more cases than not, personal choice can lead to positive outcomes. His positions may seem quite extreme to some but they also, by and large, make a lot of sense — and are backed up by ample research.

A major reason drugs have such a negative public image, Hart asserts, is racism. He notes that after the Civil War, some Chinese railroad construction workers smoked opium and, sometimes, established “opium dens” to do so. Over time, more and more white Americans visited these dens to smoke opium too. That in turn led to broader, bigoted social fear among whites, like, for example, the sentiments captured in H.H. Kane’s 1882 report:

“The practice spread widely…Many women and young girls, as also young men of respectable family, were being induced to visit the dens, where they were ruined morally and otherwise.”

Then there was the post-Civil War use of cocaine among some Black day laborers, something Hart writes was at first encouraged by white employers because of the productivity it could promote. Soon enough, however, articles appeared widely that tried to make a connection between African American cocaine use and criminality. One particularly egregious article in The New York Times in 1914, cited by Hart, even reported that some police in the South “who appreciate the vitality of the cocaine-crazed” were switching to higher-caliber weaponry capable of “greater shocking power for the express purpose of combating ‘the fiend’.”

But horrifying history aside, one of the book’s most eye-opening aspects is its challenge of the long-running association between drugs and addiction. First the basics: Addiction, according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM – 5), must be a source of distress for a drug user. It must also interfere with a person’s job, parenting or personal relationships. Other indications of addiction may be

Remember: TAKE OUT THE TRASH IN NOVEMBER!

You KNOW things are serious when a majority of physicians, scientists, researchers and others come out against a political leader, especially and particularly the President… when they’ve NEVER DONE IT BEFORE.

America has NOT been made “great again” by our feckless misleader, the Liar in Chief, Donald John Trump.

It’s time to TAKE OUT THE TRASH IN NOVEMBER!

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In an uncharacteristic move, The New England Journal of Medicine recently took a step which they have not since their 1812 founding.

 

A scathing editorial signed by all 34 editors of the publication – physicians, scientists, health researchers, and medical experts – acknowledged that in response to the COVID-19 pandemic, the President and his administration have “taken a crisis and turned it into a tragedy.”

The group minced no words in their scorching criticism of the President and his administration for their abysmal, still-ongoing failures which have claimed at least 212,466 lives, and counting, by writing that “Instead of relying on expertise, the administration has turned to uninformed ‘opinion leaders’ and charlatans who obscure the truth and facilitate the promulgation of outright lies.”

Solution being carefully poured into a petri dish that sits under a micro scope. A medical scientist wearing glasses can be seen concentrating as he pours from the glass flask. Selective focus.

Noting that physicians and other healthcare professionals face the possibility of lawsuits, and loss of license for such malpractice, they acknowledged that the nation’s solitary recourse for political malfeasance is to vote him out of office, and wrote that, “Anyone else who recklessly squandered lives and money in this way would be suffering legal consequences. Our leaders have largely claimed immunity for their actions. But this election gives us the power to render judgment.”

They cited America’s Trump-led failures and wrote that in comparison to other nations, “We have failed at almost every step. We had ample warning, but when the disease first arrived, we were incapable of testing effectively and

How Can I Keep From Getting COVID-19 ?

Preventing COVID-19 Infection

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Of necessity, the introduction is somewhat wordy, simply because it’s necessary for the purposes of clarification, and understanding the topic, which can be complex to the average layperson. While it is outside the scope of this blog to treat patients, per se, the purpose in sharing this and other information, is to inform of the latest valid scientific findings. Those who read are free to treat themselves as they see fit, as is everyone. Again, the purpose in sharing these findings is to inform. –Ed.

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Among professional scientific, medical, and research cadre the novel coronavirus is properly known as, and is called SARS-CoV-2. Colloquially, it’s known as COVID-19. SARS is the abbreviation for Severe Acute Respiratory Syndrome, while CoV is the abbreviation for coronavirus, thus COVID is shorthand for COronaVIrus Disease, while the number 19 refers to the year in which is was first discovered. If you’re froggy enough, here’s a great read on the nomenclature.

But the point of this entry is not about the name, but about the disease, and more specifically, about preventing the disease.

And suffice it to say, that while there are naysayers who (in some cases) loudly proclaim that COVID-19 is no worse than the flu or (insert your choice of disease here _X_), or that it doesn’t affect (_X_ – insert your choice of category people group(s), young, old, middle-aged, people who live in the tropics, in Scandinavia, etc.), none of the bizarre comments or nonsensical off-the-wall “justifications” such naysayers use, none of it’s true.

Remember: Despite the unambiguously incontrovertible and overwhelming evidence that the Earth is shaped like a ball, there are some who insist that the Earth is flat.

Point being, is that there will likely always be nut cases in the world, and practically nothing that anyone says or does will change their warped, demented minds… which are like concrete – thoroughly mixed, and permanently set.

When used in the scientific medical sense, the word “novel” means new. So this coronavirus is a new type of coronavirus, meaning one which has never been seen before.

Again, not to go off the deep end (for there are plenty of people who do), but simply because a virus is new, doesn’t mean that it was “man-made” or that it was an existing virus which became “weaponized.” To make such preposterously absurd claims is not only ignorantly stupid, it is false, simply because humanity does not know everything about anything, much less everything about everything. There are plenty of things in the world that we do not know about, and there are principles in the world about which we do not now know. And in fact, there are more things about which we know little, or nothing, than there are things about which we do know.

Again, point being, is that humans aren’t “know-it-alls,” and to claim that we know practically anything the novel coronavirus is false, because we do not. Hell… we don’t even know how to treat it! The only thing we’re doing now is treating symptoms. We do the exact same thing with the common cold, for which we also have no cure, and no vaccine to prevent it.

And as regarding prevention – an ounce of which is worth a pound of cure (as the saying goes) – the only thing we can do now with the coronavirus is to MECHANICALLY prevent its spread, simply because (that we now know of) we have no ability to prevent it with a vaccine. And to be certain, when we say “mechanically” prevent its spread, we mean by physical means, by actions, not by medicine.

And that is precisely why the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and other public health groups have recommended maintaining a distance of 6 feet from others while in public (aka “social distancing”), wearing a face & nose covering (mask), disposable gloves, avoiding groups of people, minimizing public outings to as great an extent as possible, along with increased hand-washing, surface cleanings (disinfecting), etc.

Because we have learned that people infected with the novel coronavirus are at least 30-50% asymptomatic (meaning that they show NO signs or symptoms of infection, not even one – which also means temperature checks at certain public places are therefore effectively USELESS at preventing spread), it is critically important to maintain the physical (mechanical) precautions (preventions) at all times when out in public.

And, because 30-50% of all persons infected with COVID-19 are asymptomatic (they do NOT show even one sign or symptom of infection), that is why 100% testing of ALL people (aka “universal testing”) is critically important.

Again, EVERYONE is on a “learning curve” with the novel coronavirus, and that means EVERYONE – all scientists, all physicians, all nurses, all researchers… EVERYONE. So no one knows it all.

Now, let’s move along toward treatment.

We’re working our way toward the topic – unlike some, or even many articles, which say nothing of any value about anything. Such articles are like saying “how to lower the death rate – prevent drowning in bath tubs,” and then talking about building and installing tubs, why you should take a shower, and how expensive it is to operate swimming pools. Utter nonsense.

So, as we know, the only thing that we can do now is treat the symptoms of COVID-19 infection. And when it comes to treating the symptoms, if the symptoms are severe enough, someone will likely be in hospital, rather than at home. Thus, they’re pretty sick. And if they’re in an ICU (Intensive Care Unit), they’re really sick. And if they’re on a ventilator, they’re seriously critically sick. So there are levels of sickness with this, and other diseases, and the severity of sickness is determined by several factors, including how many signs and symptoms are being experienced (exhibited), and how much those symptoms are interfering with their ability to maintain homeostasis – our bodies’ innate ability to maintain proper function (circulate oxygenated blood, maintain proper operating temperature, utilize nutrients in food, and excrete waste by-products from digestion).

The human body is a series of complex mechanisms, all of which work together in harmony with other body systems to continue and maintain life (homeostasis).

What we do know about the more severe cases of COVID-19, is that it affects the lungs. We’re learning also that it quite likely affects other body systems, and may also have long-term implications, but the most notable, and most immediately life-threatening, is the damage done to the lungs.

We know also that COVID-19 is characterized by inflammation of the lungs, which is, in effect, a proper response mechanism of the body gone haywire. Imagine, if you will, a huge firetruck – even the whole Fire Department – responding to a small backyard barbecue fire which is nothing more than a flare-up, and easily (and most often) extinguished by you, the cook, or someone else. No drastic measures are required.

But, imagine if, in response to

Questions & Answers About Cannabis

NOTE: The more frequently, regularly updated version of this entry is found on the front page of this blog, which is linked here:
https://warmsouthernbreeze.wordpress.com/questions-answers-about-cannabis/

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Updated Tuesday, 26 October 2021

Effort is made to update this page regularly.

While the intended audience for these Q’s & A’s is meant primarily for medical, and healthcare science professionals, they may still be of some interest, or use, by others –– particularly for those who do not know that there is legitimate science behind the use, and recommendation of cannabis in various therapies.

From Franz Eugen Köhler’s Medizinal-Pflantzen. Published and copyrighted by Gera-Untermhaus, FE Köhler in 1887 (1883–1914). Hemp plant. A–flowering male and B–seed-bearing female plant, actual size; 1-male flower, enlarged detail; 2&3-pollen sac of same from various angles; 4-pollen grain of same; 5-female flower with cover petal; 6-female flower, cover petal removed; 7-female fruit cluster, longitudinal section; 8-fruit with cover petal; 9-same without cover petal; 10-same; 11-same in cross-section; 12-same in longitudinal section; 13-seed without hull.

So in that sense, enjoy!

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QUESTION: How should a clinician monitor the outcome of cannabinoid-based therapy?

ANSWER: As suggested by the Australian Centre for Cannabinoid Clinical and Research Excellence, monitoring should initially involve reviewing the patient weekly in person, and via phone if required in the interim between clinical reviews.
“There are three areas of outcomes that should be considered:
1.) Symptom control
“A pre-defined measure of success should be negotiated with the patient prior to commencement of therapy. This can be measured by using a validated tool, for example by the Palliative Care Symptom Assessment Scale.”
2.) Drug adverse events
“Careful monitoring of patients for adverse events and the need for a change in dosage is important. Adverse events may become apparent after commencement or after change in dose… Adverse events may be related to other concurrent medications. Doses of these medicines should be adjusted as appropriate.”
3.) Pathology monitoring
“Drug concentrations of drugs where there is a potential or actual drug-drug interaction may be important. Cannabidiol may cause hepatocellular injury. Patient’s liver function biochemistry should be monitored prior to initiation and periodically as clinically indicated.“

reference: Prescribing Cannabis Medicines for Chronic Non-cancer Pain v2 September 2019 c10. – by the Australian Centre for Cannabinoid Clinical and research Excellence https://www.ces.edu.co/wp-content/uploads/2020/09/acre-prescribing-guidance-chronic-non-cancer-pain.pdf

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QUESTION: Some patients use cannabinoid-based medicines to treat nausea and vomiting. Is one of the side effects of cannabinoid-based medicines nausea/ vomiting?

ANSWER: Yes. The adverse event profile of cannabinoid-based formulations is dependent upon the ratio of CBD:THC, the presence of other cannabinoids and terpenes, and the dose consumed. The known common adverse effects of cannabinoid-based medicines include sedation/somnolence, dizziness, anxiety, cognitive dysfunction, nausea, vomiting, diarrhea, vertigo, increased or decreased appetite and dry mouth.

reference: “Brenneisen R, Egli A, ElSohly MA, Henn V, Spiess Y. The effect of orally and rectally administered delta9-tetrahydrocannabinol on spasticity: a pilot study with 2 patients. Int. J. Clin. Pharmacol. Ther. 1996 Oct;34(10)446-52. https://pubmed.ncbi.nlm.nih.gov/8897084/

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QUESTION: Even if an individual employs the same mode of administration over time, the effects of cannabinoids may change for that individual. Provide some reasons why this may be so.

ANSWER: The effects of cannabinoids may change over time due to multiple factors, including:
• Tolerance to the cannabinoids may develop
• A change in the patient’s health status/ medical condition may change over time and lead to physiological changes in the endocannabinoid system (For example, inflammation impacts the ECS. Also, impaired G.I./liver function affects the absorption and metabolism of cannabinoids.)
• The patient may start or stop taking a medication that interacts with cannabinoids or affects the metabolism of the cannabinoid-based product.
• Physiologic changes in the endocannabinoid system take place as patients age.

reference: Grotenhermen F. Clinical pharmacokinetics of cannabinoids. J Cannabis Ther, 2003; 3(1): 3-51. https://www.tandfonline.com/doi/abs/10.1300/J175v03n01_02 Huestis MA. Human cannabinoid pharmacokinetics. Chem Biodivers. 2007;4(8):1770-804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689518/

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QUESTION: The effects of cannabinoids are dependent upon the route of administration, the health of the consumer and other factors. There is also interindividual variation. Provide some reasons why the effects of cannabinoids vary among individuals.

ANSWER: There are many reasons why the effects of cannabinoids vary among individuals. SOME of the reasons are: diet, age, health of the patient, and co-administered medications may impact metabolism and efficacy of cannabinoid-based products. Also, some patients have a genetic profile such that they are predisposed to experience side effects (for ex., exacerbation of a psychotic disorder/schizophrenia) after exposure to THC. In addition, patients that have been consuming cannabinoid-based products long-term react differently than patients who have never consumed cannabinoid-based products.

reference: Grotenhermen F. Clinical pharmacokinetics of cannabinoids. J Cannabis Ther, 2003; 3(1): 3-51. https://www.tandfonline.com/doi/abs/10.1300/J175v03n01_02 Huestis MA. Human cannabinoid pharmacokinetics. Chem Biodivers. 2007;4(8):1770-804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689518/

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QUESTION: How should the cannabinoid-based therapy be withdrawn?

ANSWER: According to the Health Canada document entitled “Information for Health Care Professionals – Cannabis (marihuana, marijuana) and the Cannabinoids,” “If intolerable adverse effects appear without significant benefit, dosing should be tapered and stopped. Tapering guidelines have not been published, but the existence of a withdrawal syndrome suggests that tapering should be done slowly (i.e. over several days or weeks).” Note: When discontinuing cannabidiol therapies used for the treatment of seizure disorders, the dose should be decreased gradually. As with all antiepileptic drugs, abrupt discontinuation should be avoided when possible, to minimize the potential risk of increased seizure frequency and status epilepticus.

reference: Grotenhermen F. Clinical pharmacokinetics of cannabinoids. J Cannabis Ther, 2003; 3(1): 3-51. https://www.tandfonline.com/doi/abs/10.1300/J175v03n01_02. Huestis MA. Human cannabinoid pharmacokinetics. Chem Biodivers. 2007;4(8):1770-804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689518/

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QUESTION: What is the half life of CBD? How does it compare to the half life of THC?

ANSWER: The half life of CBD is 18-32 hours, which is similar to the half life of THC of 20-30 hours. Both CBD and THC are distributed to fatty tissues and highly perfused organs such as brain, heart, lung, and liver.

reference: Medical Marijuana, Recreational Cannabis, and Cardiovascular Health: A Scientific Statement From the American Heart Association. Robert L. Page II , Larry A. Allen , Robert A. Kloner , Colin R. Carriker, Catherine Martel , Alanna A. Morris , Mariann R. Piano , Jamal S. Rana , Jorge F. Saucedo , … See all authors. Originally published 5 Aug 2020. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000883

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QUESTION: What are some of the more common reasons dermatologists recommend cannabinoid-based medicines?

ANSWER: According to the results of a survey of 145 dermatologists, 91 % of dermatologists were in support of medical cannabis use and 13.8 % have recommended it for a dermatologic condition. Atopic dermatitis (45 %) and psoriasis (40 %) were the most common. The most common form of administration was topical (75 %). The main reasons for not recommending medical cannabis were limited knowledge (56 %) and lack of experience (48 %).

reference: Perceptions and recommendation behaviors of dermatologists for medical cannabis: A pilot survey. Samuel Yeroushalmi, Kamaria Nelson, AndrewSparks, AdamFriedman. https://pubmed.ncbi.nlm.nih.gov/33220620/

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QUESTION: Has the use of a transdermal gel for regional and systemic delivery of CBD been evaluated for the treatment of epilepsy?

ANSWER: Yes. A transdermal gel for regional and systemic delivery of CBD (Zynerba Pharmaceuticals) is in clinical development for treatment of epilepsy, developmental and epileptic encephalopathy, fragile-X syndrome, and osteoarthritis. NOTE: As of September 2021, the company’s website indicates that the product is not yet approved by government regulatory bodies, including the United States Food and Drug Administration (FDA) and other agencies, and must be tested to see if it is an effective and safe treatment.

reference: A Review of the Safety and Effectiveness of Select Ingredients in Compounded Topical Pain Creams.” National Academies of Sciences, Engineering, and Medicine. 2020. Compounded Topical Pain Creams: Review of Select Ingredients for Safety, Effectiveness, and Use. Washington, DC: The National Academies Press. https://www.nap.edu/catalog/25689/compounded-topical-pain-creams-review-of-select-ingredients-for-safety

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QUESTION: Have human studies evaluated the effects of cannabinoid consumption on cortisol levels?

ANSWER: Yes – Human studies have demonstrated that the consumption of cannabinoids modulate cortisol release. Acutely, the consumption of cannabis (or THC) by naive or infrequent cannabis users may increase the secretion of cortisol. In chronic cannabis users, the stimulatory effect of THC on cortisol levels is blunted. This blunted response suggests that a tolerance develops. Some studies have reported that chronic cannabis users exhibit elevated basal cortisol levels, but that stress- induced activation of the axis is blunted in chronic adult and adolescent cannabis users.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021. https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: Do endocannabinoids impact insulin release?

ANSWER: Yes. Endocannabinoids act in an autocrine and paracrine fashion to mediate the activity of the pancreas and mediate insulin secretion. – It has been shown that endocannabinoids influence basal as well as glucose-induced insulin release. Also, endocannabinoids have been shown to have an effect on β cell proliferation and survival. (Pancreatic β cells are the cells that synthesize and secrete insulin.)

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021. https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: Can children with developmental and epileptic encephalopathies tolerate adjunctive cannabidiol (CBD) transdermal gel, and is CBD gel associated with reduced seizure frequency?

ANSWER: Yes, CBD is well tolerated, and is associated with a reduction in seizure activity – frequency and intensity – in children, including improvements in alertness, energy, improved sleep, and in cognition or concentration. According to a JAMA Open Network article published in September 2021, in a “nonrandomized controlled trial, CBD transdermal gel was well tolerated over 6.5 months of treatment, with 60% of patients experiencing a treatment-related adverse event, 96% of which were mild or moderate. A 43.5% reduction in seizure frequency was observed in focal impaired awareness seizures and tonic-clonic seizures.” Also, the researchers stated that “Parents and caregivers noted improvements in social or interpersonal engagement and irritability (33 of 43 [77%] participants); alertness, energy, and sleep (23 of 43 [53%]); and cognition or concentration (20 of 43 [47%]).”

reference: Scheffer IE, Hulihan J, Messenheimer J, et al. Safety and Tolerability of Transdermal Cannabidiol Gel in Children With Developmental and Epileptic Encephalopathies: A Nonrandomized Controlled Trial. JAMA Netw Open. 2021;4(9):e2123930. doi:10.1001/jamanetworkopen.2021.23930 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2783716

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QUESTION: What influences chronic pain patients’ use of medical cannabinoids?

ANSWER: The British Medical Journal recently published results of a systematic review that explored values and preferences towards medical cannabis (MC) among people living with chronic pain. The results were as follows: “High to moderate certainty evidence showed that patient’s use of MC for chronic pain was influenced by both positive (eg, support from friends and family) and negative social factors (eg, stigma surrounding cannabis use). Most patients using MC favoured products with balanced ratios of THC and CBD, or high levels of CBD, but not high THC preparations. Many valued the effectiveness of MC for symptom management even when experiencing adverse events related to concentration, memory or fatigue. Reducing use of prescription medication was a motivating factor for use of MC, and concerns regarding addiction, losing control or acting strangely were disincentives. Out-of-pocket costs were a barrier, whereas legalisation of MC improved access and incentivised use.”

reference: Zeng L, Lytvyn L, Wang X, et al Values and preferences towards medical cannabis among people living with chronic pain: a mixed-methods systematic review BMJ Open 2021;11:e050831. doi: 10.1136/bmjopen-2021-050831. https://bmjopen.bmj.com/content/11/9/e050831#ref-10

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QUESTION: Do cannabinoids affect the male reproduction system?

ANSWER: Yes. Cannabinoid receptors are located in multiple parts of the male reproductive system, including the hypothalamus, pituitary, Leydig cells, and sperm. The binding of cannabinoids to cannabinoid 1 receptors may lead to a reduction in plasma testosterone, LH and FSH.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021 https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: How does anandamide’s activation of CB1 receptors on sperm cells impact sperm cells?

ANSWER: Activation of CB1 receptors on sperm by anandamide – a fatty acid neurotransmiter endocannabinoid, or THC, leads to reduction of sperm survival and motility, and inhibition of fertilization capacity by hindering the capacitation-induced acrosome reaction needed to penetrate the zona pellucida.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021 https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: Marijuana use has been associated with an impairment of spermatogenesis and testicular function. How long will those effects last?

ANSWER: It has been reported that recovery of spermatogenesis and testicular cell function status post exposure to marijuana is approximately about 45 days.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021 https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: How do endocannabinoids differ from many other neurotransmitters?

ANSWER: Endocannabinoids are very lipophilic and therefore cannot be stored in vesicles like many other neurotransmitters. The precursors of endocannabinoids are present in lipid membranes and, upon activation of some G-protein coupled receptors, these precursors are released into the extracellular space. Endocannabinoids are synthesized on demand in post-synaptic structures and travel retrograde through the synaptic cleft to cannabinoid type 1 receptors located presynaptically. Activation of cannabinoid type 1 receptors leads to inhibition of neurotransmitter release.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021 https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: Polycystic ovarian syndrome (PCOS) is a syndrome associated with hyperandrogenism, menstrual irregularities, and polycystic ovaries. Is there any evidence that the endocannabinoid system is involved in the development of PCOS?

ANSWER: Yes. In a human study that evaluated the possibility of a link between the endocannabinoid system and PCOS, the researchers found that the endometrium of PCOS patients exhibited reduced levels of fatty acid amide hydrolase, (the catabolic enzyme for anandamide), compared to women without PCOS. This finding correlated with increased levels of anandamide in patients with PCOS. Also the activation of the ECS and overexpression of CB1 receptors may be associated with insulin resistance in women in PCOS.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021. https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: Does marijuana impact platelet function?

ANSWER: Yes. Some cannabinoids have antiplatelet and antithrombogenic effects. However, in some instances marijuana use has been reported to have the opposite effect and promote platelet aggregation.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021. https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: Are endocannabinoids hydrophilic or lipophilic?

ANSWER: Endocannabinoids are lipophilic neurotransmitters. They mediate agonist as well as antagonist effects via cannabinoid receptors found in the brain and peripheral nervous system.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021 https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: When the endocannabinoid system was originally discovered in the 1990’s, it was described as a neural communication system. Does the endocannabinoid system have functions other than neural communication?

ANSWER: Yes. The endocannabinoid system can be found in almost every cell/ tissue and this system plays an important role in the normal functioning of many organ systems.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021 https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: How do exogenous cannabinoids (phytocannabinoids or synthetic cannabinoids) affect physiologic systems like the endocrine system?

ANSWER: Exogenous cannabinoids bind to endogenous cannabinoid receptors in various organs, and may also modulate cannabinoid receptor expression. As a result, exogenous cannabinoids may alter endocannabinoid target effects and organ function.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021 https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: True or false? Cannabinoid type 1 receptors are G-protein coupled receptors found in multiple organ systems, including the nervous system, skeletal system, lungs, cardiovascular system, musculoskeletal system, gi tract, and the lymph system, as well as in many endocrine organs, including the hypothalamus, pituitary, thyroid, adrenals, uterus, ovaries, testes, and placenta.

ANSWER: The statement is true, but the density and level of expression of cannabinoid receptors varies in the different organ systems.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021 https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: On what cell surfaces are cannabinoid type 2 receptors typically found?

ANSWER: Cannabinoid type 2 receptors, like type 1 receptors, are G-protein coupled receptors; the type 2 receptors are primarily on the surface of the immune system cells, tonsils, the gi tract, bone, and peripheral nerve endings. Expression is highly inducible and is most often expressed when there is active inflammation or injury.

reference: Meah, F., Lundholm, M., Emanuele, N. et al. The effects of cannabis and cannabinoids on the endocrine system. Rev Endocr Metab Disord (2021). Aug 30, 2021 https://doi.org/10.1007/s11154-021-09682-w

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QUESTION: In some legal states, edibles, such as candies, baked goods, beverages and condiments (butter and oils) containing THC may be sold. Is 2.5mg of THC in an edible a low dose or high dose of THC to be consumed orally?

ANSWER: The dosing of THC always needs to be adjusted on an individual basis. For reference, 2.5 mg is the lowest dose of dronabinol, a synthetic THC that is FDA-approved.

reference: Meehan-Atrash, J., Luo, W., & Strongin, R. M. (2017). Toxicant Formation in Dabbing: The Terpene Story. ACS Omega, 2(9), 6112–6117. https://doi.org/10.1021/acsomega.7b01130

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QUESTION: Does short term treatment with THC rich cannabis induce clinical remission and improve quality of life in patients with mild to moderately active ulcerative colitis?

ANSWER: Yes, according to a recent study. However, these beneficial clinical effects were NOT associated with significant anti-inflammatory improvement in the Mayo endoscopic score or laboratory markers for inflammation. These results were derived from a double-blind, randomized, placebo-controlled trial, – 32 patients received either cigarettes containing 0.5 g of dried cannabis flowers with 80mg THC or placebo cigarettes for 8 weeks. Parameters of disease including Lichtiger disease activity index, C reactive protein (CRP), calprotectin, Mayo endoscopic score and quality of life (QOL) were assessed before, during and after treatment.

reference: Cannabis is associated with clinical but not endoscopic remission in ulcerative colitis: A randomized controlled trial Timna Naftali , Lihi Bar-Lev Schleider, Fabiana Scklerovsky Benjaminov, Fred Meir Konikoff, Shelly Tartakover Matalon, Yehuda Ringel Published: February 11, 2021 https://doi.org/10.1371/journal.pone.0246871

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QUESTION: What are the effects of cannabis-based therapies on oxaliplatin-induced peripheral neuropathy among oncology patients?

ANSWER: The results of a retrospective study indicated that the rate of neuropathy was reduced among patients treated with cannabis-based therapies and oxaliplatin. This reduction was more significant in patients who received cannabis-based products prior to treatment with oxaliplatin, suggesting a protective effect. (A large prospective trial examining the effects of cannabis-based products on oxaliplatin-induced neuropathy is planned.)

reference: Waissengrin B, Mirelman D, Pelles S, et al. Effect of cannabis on oxaliplatin-induced peripheral neuropathy among oncology patients: a retrospective analysis. Theranpeutic Advances in Medical Oncology. January 2021. doi: 10.1177/1758835921990203. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876573/

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QUESTION: The Veterans Health Administration (VHA) abides by the classification of cannabis as a Schedule I substance. Does the VHA prohibit their clinicians from speaking with their patients about cannabis?

ANSWER: No, the VHA recently recommended that clinicians discuss cannabis with their patients. However, according to a study published in February 2021, VHA clinicians identified several factors that inhibit conversations about cannabis use with their patients including the unfamiliarity with pharmacology, formulations, and dosing of cannabis; and uncertainty regarding VHA policy.

reference: Vivian A Christensen, Shannon M Nugent, Chelsea K Ayers, Benjamin J Morasco, Devan Kansagara; A qualitative study of VHA clinicians’ knowledge and perspectives on cannabis for medical purposes; Family Practice, 2021; cmaa151, https://doi.org/10.1093/fampra/cmaa151

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QUESTION: True or false? CBD interacts with transient receptor potential cation channel subfamily V member 1 (TRPV1) receptors.

ANSWER: True. It has been found in rat models of acute inflammation that the vanilloid TRPV1 receptor mediates the antihyperalgesic effect of cannabidiol.

reference: Maguire R.F, Wilkinson D.J., England T.J., O’Sullivan S.E.; The Pharmacological Effects of Plant-Derived versus Synthetic Cannabidiol in Human Cell Lines. Medical Cannabis and Cannabinoids. July 29 2021. https://www.karger.com/Article/Pdf/517120

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QUESTION: True or false? CBD interacts with serotonin 1 A receptors (5HT1A) and impacts cellular activity of some cell lines.

ANSWER: True. In in vitro models, COX-2 and PPAR-γ confer cannabidiol-induced apoptosis of human lung cancer cells.

reference: Ramer R, Heinemann K, Merkord J, Rohde H, Salamon A, Linnebacher M, et al.; COX-2 and PPAR-γ confer cannabidiol-induced apoptosis of human lung cancer cells. Mol Cancer Ther. 2013 Jan 1;12(1):69–82. https://mct.aacrjournals.org/content/12/1/69

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QUESTION: Did the “Stay at Home” orders during COVID lead to a significant decrease in sales of cannabinoid-based products in Alaska, Colorado, Oregon and Washington?

ANSWER: No. Actually, cannabis sales increased in all four states coinciding with state stay-at-home orders, and sales reached a three-year peak in all four states between May and July 2020.

reference: Schauer GL et al. Cannabis sales increases during COVID-19: Findings from Alaska, Colorado, Oregon, and Washington, International J of Drug Pol Vol 98, 2021. https://www.sciencedirect.com/science/article/abs/pii/S0955395921002899

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QUESTION: Are cannabinoid receptors present on skin cells?

ANSWER: Yes. Cannabinoid receptors are present on many types of skin cells, including keratinocytes and fibroblasts. The results of preliminary studies evaluating the effects of cannabis extracts on skin cells indicate that hemp extracts may reduce oxidative stress, inhibit skin aging processes and positively affect the viability of skin cells. Analyses also showed that hydrogels based on cannabis extracts have a positive effect on skin hydration.

reference: Zagórska-Dziok,M.; Bujak, T.; Ziemlewska, A.; Nizioł-Łukaszewska, Z. Positive Effect of Cannabis sativa L. Herb Extracts on Skin Cells and Assessment of Cannabinoid-Based Hydrogels Properties. Molecules 2021, 26, 802. https://www.mdpi.com/1420-3049/26/4/802

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QUESTION: The labels of some probiotic supplements indicate that probiotics support a healthy immune system, strengthen digestive balance, help maintain a balance of healthy intestinal bacteria, help breakdown undigested carbohydrates and sugars, and facilitate the absorption of nutrients. Do cannabis-based edibles exhibit pre-biotic/probiotic properties?

ANSWER: In addition to cannabinoids, flavonoids, terpenoids, and polysaccharides may be present in cannabis-based edibles, and these cannabis constituents may exhibit prebiotic/probiotic properties and improve the composition of the gut microbiome.

reference: Cannabis and Cannabis Edibles: A Review; Han Peng and Fereidoon Shahidi* J. Agric. Food Chem. 2021, XXXX, XXX, XXX-XXX. © 2021 American Chemical Society Publication Date: February 8, 2021 https://doi.org/10.1021/acs.jafc.0c07472

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QUESTION: What is the most common mode of administration of CBD?

ANSWER: According to an online survey conducted in 2017-2018, the most common method of CBD administration was sublingual, followed by vaping, oral ingestion of capsules and liquids, smoking, edibles, and topical administration.

reference: Corroon J, Phillips JA. A cross-sectional study of cannabidiol users. Cannabis Cannabinoid Res 2018; 3(1):152–61. https://pubmed.ncbi.nlm.nih.gov/30014038/

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QUESTION: Does THC have a dose-dependent effect on sleep?

ANSWER: Yes – Human experimental data suggests “THC has a dose-dependent effect on sleep—low doses appear to decrease sleep onset latency and increase slow-wave sleep and total sleep time, while high doses appear to cause sleep disturbances.” Also, “limited evidence from clinical studies also suggest that certain cannabinoids (cannabis, nabilone, dronabinol, nabiximols) may improve sleep in patients with disturbances in sleep associated with certain chronic disease states.”

reference: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf

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QUESTION: Is there ANY evidence that CBD attenuates the THC-induced psychosis?

ANSWER: Yes – “Emerging evidence from pre-clinical, clinical and epidemiological studies suggests CBD may attenuate THC-induced psychosis.”

reference: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf

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QUESTION: Efficacy and safety of add-on cannabidiol (CBD) to treat seizures associated with Lennox Gastaut Syndrome (LGS) was demonstrated in two randomized controlled trials (RCTs). Have the long-term effects of CBD use to treat the drug resistant seizures of LGS been evaluated?

ANSWER: Yes. 366 patients enrolled in a long-term open-label extension trial. The results are as follows: “Adverse events (AEs) occurred in 96% of patients, serious AEs in 42%, and AE-related discontinuations in 12%. Common AEs were convulsion (39%), diarrhea (38%), pyrexia (34%), and somnolence (29%). Fifty-five (15%) patients experienced liver transaminase elevations more than three times the upper limit of normal; 40 (73%) were taking concomitant valproic acid. Median percent reductions from baseline ranged 48%–71% for drop seizures and 48%–68% for total seizures through 156 weeks. Across all 12-week visit windows, 87% or more of patients/caregivers reported improvement in the patient’s overall condition on the Subject/Caregiver Global Impression of Change scale.”

reference: Patel, AD, Mazurkiewicz-Bełdzińska, M, Chin, RF, Gil-Nagel, A, Gunning, B, Halford, JJ, et al. Long-term safety and efficacy of add-on cannabidiol in patients with Lennox–Gastaut syndrome: Results of a long-term open-label extension trial. Epilepsia. 2021; 00: 1– 12. https://onlinelibrary.wiley.com/doi/abs/10.1111/epi.17000

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QUESTION: CBD interacts with warfarin. Does this drug:drug interaction lead to an increased risk of bleeding or a decrease in warfarin’s anticoagulation effect?

ANSWER: The inhibition of CYP2C19 by CBD can increase levels of warfarin, and multiple reports have indicated that the interaction between warfarin and CBD results in an increased risk of bleeding.

reference: 1.) Treese NM, Flowers M. Pharmacist’s guide to CBD oil. US Pharm. 2020; 45(3):20-23. https://www.uspharmacist.com/article/pharmacists-guide-to-cbd-oil 2.) Welty TE, Chapman KE, Faught RE, Kotloski RJ. American Epilepsy Society (AES): Written Comments to Norman E. “Ned” Sharpless, MD, Acting Commissioner of Food and Drugs, U.S. Food and Drug Administration (FDA), Department of Health and Human Services (HHS): on Docket ID# FDA-2019-N-1482, Scientific Data and Information about Products Containing Cannabis or Cannabis-Derived Compounds; Public Hearing; Request for Comments: Submitted on: July 16, 2019. Epilepsy Currents 2019; 19(6):361-368. doi:10.1177/1535759719878716. https://journals.sagepub.com/doi/10.1177/1535759719878716

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QUESTION: Have CBD’s effects in monkeys been evaluated?

ANSWER: Yes, according to a World Health Organization Cannabidiol (CBD) report in November 2017, in studies involving the use of CBD in monkeys, no effect on a wide range of physiological and biochemical parameters or significant effects on animal behavior were noted unless extremely high doses of CBD (e.g., in excess of 150 mg/kg iv as an acute dose or in excess of 30 mg/kg orally daily for 90 days) were administered.

reference: World Health Organization (WHO) – Expert Committee on Drug Dependence Thirty-ninth Meeting Cannabidiol (CBD) Pre-Review Report Agenda Item 5.2 Geneva, 6-10 November 2017 See: https://www.who.int/medicines/access/controlled-substances/5.2_CBD.pdf

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QUESTION: PRE-CLINICAL studies show that certain cannabinoids (THC, CBD, THCV, CBDV) and cannabinoid acids (THCA and CBDA) suppress acute nausea and vomiting. Do PRE-CLINICAL studies also show that those same cannabinoids and cannabinoid acids suppress anticipatory nausea?

ANSWER: Yes. In addition, there is limited evidence from CLINICAL studies that suggests that the use of certain cannabinoids and cannabis may provide relief from chemotherapy-induced nausea and vomiting (CINV).

reference: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf

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QUESTION: Evidence from observational studies and clinical studies suggests that marijuana (limited evidence) and prescription cannabinoids (e.g. dronabinol, nabilone, or nabiximols) may be useful in alleviating one or several co-occurring symptoms often experienced by patients in the palliative care setting. What are some of these palliative care setting symptoms?

ANSWER: These symptoms may include, but are not limited to, intractable nausea and vomiting associated with chemotherapy or radiotherapy, anorexia/cachexia, severe intractable pain, severe depressed mood and anxiety, and insomnia. Also, a limited number of observational studies suggest that the use of cannabinoids in the palliative care setting may be associated with a decrease in the number of some medications used by palliative care patients.

reference: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf

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QUESTION: Available evidence from human clinical studies suggests that marijuana (limited evidence) and prescription cannabinoid-based medicines (dronabinol) may increase appetite and caloric intake, and promote weight gain in patients with HIV/AIDS. Has the use of cannabinoid-based medicines in cancer or anorexia nervosa been evaluated, too?

ANSWER: Yes. The evidence for dronabinol is mixed and effects modest for patients with cancer and weak for patients with anorexia nervosa.

reference: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf

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QUESTION: Evidence from PRE-CLINICAL studies suggests THC, CBD and nabiximols improve multiple sclerosis (MS) associated symptoms of tremor, spasticity and inflammation. Has the utility of cannabinoids for MS symptoms been evaluated in CLINICAL STUDIES?

ANSWER: Yes. -the available evidence from CLINICAL studies suggest marijuana (limited evidence) and certain cannabinoids (dronabinol, nabiximols (Sativex), THC/CBD) are associated with some measure of improvement in some MS symptoms and spinal cord injury (SCI), including spasticity, spasms, pain, sleep and symptoms of bladder dysfunction.

reference: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf

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QUESTION: An oral CBD product (Epidiolex®) has been approved by the FDA for the treatment of certain drug-resistant seizures, including Dravet syndrome and Lennox-Gastaut syndrome. Does THC also have anti-seizure properites?

ANSWER: The available evidence from pre-clinical studies suggests that some CB1 receptor agonists (including THC) may have either pro- or anti-epileptic properties.

reference: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf

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QUESTION: What is the half life of CBD?

ANSWER: The half life of CBD is dependent upon the mode of administration. When administered intravenously, the half life of CBD is 18-30 hours, when administered via inhalation, the half life is 27-35 hours, and when administered orally, the half life is 2-5 days.

reference: SOUZA, A.A.F. de; SILVA, A.F.M. da .; ABREU, L.R. de; SILVA, T.F. da; GRECO, G.; SANTOS, S. da S.; GONZAGA, R.V.; Medicinal uses of Cannabis sp. Research, Society and Development, [S.l.], v.10, n.7, p.e58010716930, 2021. DOI: 10.3344

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QUESTION: N-arachidonoyl ethanolamine (AEA) aka anandamide, and 2- arachidonoyl glycerol (2-AG) are the two most well-studied endocannabinoids. Are there other endocannabinoids?

ANSWER: Other than Anandamide and 2-AG, there are other endocannabinoids: “virodhamine… acts as a full and selective CB1 agonist; N-arachidonyl- dopamine (NADA) is a CB1 agonist and potent activator of TrpV1; and palmitoylethanolamide (PEA) is involved with anti- inflammatory, analgesic and neuroprotective processes.”

reference: SOUZA, A. A. F. de; SILVA , A. F. M. da .; ABREU , L. R. de .; SILVA, T. F. da .; GRECO, G. .; SANTOS, S. da S. .; GONZAGA, R. V. Medicinal uses of Cannabis sp. . Research, Society and Development, [S. l.], v. 10, n. 7, p. e58010716930, 2021. DOI: 10.33448/rsd-v10i7.16930. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/16930. Acesso em: 2 jul. 2021. https://rsdjournal.org/index.php/rsd/article/view/16930

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QUESTION: What are THCA-A and CBDA?

ANSWER: THCA-A (tetrahydrocannabinolic acid-A) and CBDA (cannabidiolic acid ) are the acid forms (the carboxylated forms) of THC and CBD, and these acid forms are found in the cannabis plant. Decarboxylation of THCA-A and CBDA takes place when the plant products are heated, and results in the bioactive compounds THC and CBD, respectively.

reference: SOUZA, A. A. F. de; SILVA , A. F. M. da .; ABREU , L. R. de .; SILVA, T. F. da .; GRECO, G. .; SANTOS, S. da S. .; GONZAGA, R. V. Medicinal uses of Cannabis sp. . Research, Society and Development, [S. l.], v. 10, n. 7, p. e58010716930, 2021. DOI: 10.33448/rsd-v10i7.16930. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/16930. Acesso em: 2 jul. 2021. https://rsdjournal.org/index.php/rsd/article/view/16930

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QUESTION: Are cannabinoids lipophilic or hydrophylic?

ANSWER: Cannabinoids are actually highly lipophilic. In fact, oral and topical cannabinoid products are often administered with a carrier to facilitate their absorption. The high lipophilicity of cannabinoid-based products is associated with a THC and CBD oral absorption range of only 10 to 20%.

reference: SOUZA, A. A. F. de; SILVA , A. F. M. da .; ABREU , L. R. de .; SILVA, T. F. da .; GRECO, G. .; SANTOS, S. da S. .; GONZAGA, R. V. Medicinal uses of Cannabis sp. . Research, Society and Development, [S. l.], v. 10, n. 7, p. e58010716930, 2021. DOI: 10.33448/rsd-v10i7.16930. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/16930. Acesso em: 2 jul. 2021. https://rsdjournal.org/index.php/rsd/article/view/16930

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QUESTION: N-arachidonoyl ethanolamine (AEA) aka anandamide, and 2- arachidonoyl glycerol (2-AG) are the two most well-studied endocannabinoids. Are there other endocannabinoids?

ANSWER: Other than Anandamide and 2-AG, there are other endocannabinoids: “virodhamine… acts as a full and selective CB1 agonist; N-arachidonyl- dopamine (NADA) is a CB1 agonist and potent activator of TrpV1; and palmitoylethanolamide (PEA) is involved with anti- inflammatory, analgesic and neuroprotective processes.”

reference: SOUZA, A. A. F. de; SILVA , A. F. M. da .; ABREU , L. R. de .; SILVA, T. F. da .; GRECO, G. .; SANTOS, S. da S. .; GONZAGA, R. V. Medicinal uses of Cannabis sp. . Research, Society and Development, [S. l.], v. 10, n. 7, p. e58010716930, 2021. DOI: 10.33448/rsd-v10i7.16930. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/16930. Acesso em: 2 jul. 2021. https://rsdjournal.org/index.php/rsd/article/view/16930

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QUESTION: Cannabinoids may impact gastro-intestinal motility and gastro-intestinal secretory activity. Have these effects been noted in IBD patients who consume marijuana to treat their conditions?

ANSWER: Yes. In fact, according to population studies, diarrhea was one of the most common symptoms that improved with cannabis use.

reference: Storr M, Devlin S, Kaplan GG, Panaccione R, Andrews CN. Cannabis use provides symptom relief in patients with inflammatory bowel disease but is associated with worse disease prognosis in patients with Crohn’s disease. Inflamm Bowel Dis. 2014;20(3):472–80. https://doi.org/10.1097/01.MIB.0000440982.79036.d6.

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QUESTION: Are blunts and joints the same thing?

ANSWER: No. Blunts and joints are not the same. Blunts consist of marijuana wrapped in tobacco leaves, whereas joints consist of marijuana wrapped in cigarette paper.

reference: Cooper ZD, Haney M. Comparison of subjective, pharmacokinetic, and physiological effects of marijuana smoked as joints and blunts. Drug and Alcohol Dependence. Vol 103 Iss 3, 1 August 2009, Pages 107-113. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2776770/ https://rdcu.be/cnacn

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QUESTION: How does THC impact the gastro-intestinal system of a patient with IBD?

ANSWER: Cannabis might be a mediator within the gastrointestinal system, affecting inflammation, motility and the secretory response. Also, some cannabinoids increase appetite. A thorough 2021 review article summarized the current research evaluating the relationship between cannabinoid-based medicines and the treatment of IBD. A summary of their highlights include the following: “Patients with IBD often experience pain, nausea, and decreased appetite. As described here, in multiple studies, patients with IBD reported a significant improvement in symptoms and quality of life metrics with the use of cannabis. While initially promising, additional double-blind, placebo-controlled studies have found that even though CBD may improve perceived symptoms, it does not reduce inflammation or address underlying disease activity. These studies failed to demonstrate that when given cannabis, patients with IBD had an improvement in inflammatory markers [including CRP and calprotectin] or mucosal healing on endoscopy compared to patients with IBD in placebo conditions.”

reference: Buckley, M.C., Kumar, A. & Swaminath, A. Inflammatory Bowel Disease and Cannabis: A Practical Approach for Clinicians. Adv Ther (2021). https://doi.org/10.1007/s12325-021-01805-8. https://rdcu.be/cnacn

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QUESTION: Cannabis-based products may be some of the world’s oldest medicines. Documents dating back thousands of years BC describe the use of cannabis-based medicines in many Eastern cultures. What is the Chinese character for cannabis? Is that character used to represent other things?

ANSWER: The Chinese character for cannabis is 大麻 and the Chinese character for anesthesia is 麻木. The character 麻 means to “have pins and needles”

reference: Schlag, A.K., O’Sullivan, S.E, Zafar, R.R, Nutt, D.J, Current controversies in medical cannabis: recent developments in human clinical applications and potential therapeutics, Neuropharmacology; https://doi.org/10.1016/j.neuropharm.2021.108586 . And Google translation.

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QUESTION: Has the terpenoid caryophyllene, which is found in the cannabis plant, been found to significantly reduce craving to cigarettes?

ANSWER: Yes, according to one study with significant findings (P <0.01). Forty-eight cigarette smokers participated in a 3-h session conducted after deprivation from smoking overnight. The subjects were randomly assigned to one of three conditions: one group of smokers puffed on a device that delivered a vapor from essential oil of black pepper (black pepper contains caryophyllene); a second group puffed on the device with a mint/menthol cartridge, and a third group used a device containing an empty cartridge. Subjects puffed and inhaled ad libitum from the device throughout the session during which no smoking was allowed. Reported craving for cigarettes was significantly reduced in the pepper-containing device group relative to each of the two control conditions. Also, it was noted that negative affect and some somatic symptoms of anxiety were alleviated in the pepper-containing device group relative to the unflavored placebo. The authors suggested that one possible mechanism is via CB2 receptor agonism, with caryophyllene being a CB2R agonist.

reference: Rose JE, Behm FM. Inhalation of vapor from black pepper extract reduces smoking withdrawal symptoms. Drug Alcohol Depend. 1994 Feb;34(3):225-9. doi: 10.1016/0376-8716(94)90160-0. PMID: 8033760.

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QUESTION: The most common conditions for which cannabinoid-based medicines are used include chronic pain, anxiety, and depression. Of these 3 conditions, which , if any, is there a high strength of evidence for the efficacy of cannabinoid-based medicines.

ANSWER: Of the three conditions (chronic pain, anxiety and depression) there is only a high strength of evidence for chronic pain.

reference: Schlag, A.K., O’Sullivan, S.E, Zafar, R.R, Nutt, D.J, Current controversies in medical cannabis: recent developments in human clinical applications and potential therapeutics, Neuropharmacology; https://doi.org/10.1016/j.neuropharm.2021.108586.

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QUESTION: How does the endocannabinoid system impart analgesic effects?

ANSWER: The endocannabinoid system inhibits release of presynaptic neurotransmitters, modifies postsynaptic neuronal excitability, activates descending inhibitory pathways, and reduces neuroinflammation.

reference: Chung M, Kim H, Abdi S. Update on cannabis and cannabinoids for cancer pain. Current Opinion in Anesthesiology. 2020, 33:825 – 831. https://pubmed.ncbi.nlm.nih.gov/33110020/ DOI:10.1097/ACO.0000000000000934

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QUESTION: There is a high strength of evidence for the efficacy of cannabinoid-based medicines for the treatment of intractable epilepsy, multiple sclerosis and cancer-related nausea. Which of these 3 conditions has the greatest relative number of patients using cannabinoid -based medicines to treat the condition?

ANSWER: Among epilepsy, multiple sclerosis and cancer-related nausea, the least number of patients use cannabinoid-based medicines for intractable epilepsy and the greatest number of people use cannabinoid-based medicines for cancer-related nausea.

reference: Schlag, A.K., O’Sullivan, S.E, Zafar, R.R, Nutt, D.J, Current controversies in medical cannabis: recent developments in human clinical applications and potential therapeutics, Neuropharmacology; https://doi.org/10.1016/j.neuropharm.2021.108586.

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QUESTION: CB1 receptors are abundant in the CNS, including areas involved in pain transmission. CB2 receptors are mostly located on peripheral tissues and immune cells. Are CB2 receptors involved with pain transmission?

ANSWER: Yes. When activated, CB2 receptors may modulate peripheral afferent pain fiber activity and immune-mediated neuro-inflammatory processes. For example, CB2 activation may lead to the inhibition of prostaglandin synthesis and/or mast cell degranulation; both of these cellular activities can precipitate and maintain chronic pain states.

reference: Current Psychiatry. 2021 May;20(5):21-23, 28-33 | doi:10.12788/cp.0121, and MD Raphael J. Leo Raymond M. St. Marie. “Cannabinoid-Based Medications for Pain.” MDedge Psychiatry, 3 May 2021, https://www.mdedge.com/psychiatry/article/239193/pain/cannabinoid-based-medications-pain.

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QUESTION: Haloperidol is an antipsychotic medication and used to treat schizoaffective disorders and schizophrenia. Is the metabolism of haloperidol impacted by THC?

ANSWER: Yes, THC inhibits CYP3A4, the enzyme that metabolizes haloperidol, and therefore the co-administration of THC and haloperidol may result in an increased availability of haloperidol.

reference: Current Psychiatry. 2021 May;20(5):21-23, 28-33 | doi:10.12788/cp.0121, and MD Raphael J. Leo Raymond M. St. Marie. “Cannabinoid-Based Medications for Pain.” MDedge Psychiatry, 3 May 2021, https://www.mdedge.com/psychiatry/article/239193/pain/cannabinoid-based-medications-pain.

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QUESTION: What has been the most common mode of administration of cannabinoid-based medicines (CBMs) in RCTs examining the efficacy of CBMs to treat pain?

ANSWER: Most RCTs evaluated inhaled herbal CBMs and oromucosal spray (nabiximols (Sativex) – an oral spray with 50:50 mix of THC:CBD); there is a paucity of data derived from studies evaluating the effectiveness of other CBM formulations.

reference: Current Psychiatry. 2021 May;20(5):21-23, 28-33 | doi:10.12788/cp.0121, and MD Raphael J. Leo Raymond M. St. Marie. “Cannabinoid-Based Medications for Pain.” MDedge Psychiatry, 3 May 2021, https://www.mdedge.com/psychiatry/article/239193/pain/cannabinoid-based-medications-pain.

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QUESTION: Do oral mucosal spray cannabinoid-based medicines (CBMs) have the same bioavailability as ingested CBMs?

ANSWER: No. The administration of CBMs via oromucosal sprays (sublingual) avoids first-pass metabolism (although some of the product is swallowed) and therefore sublingual administration has a higher bioavailability than ingested formulations.

reference: Current Psychiatry. 2021 May;20(5):21-23, 28-33 | doi:10.12788/cp.0121, and MD Raphael J. Leo Raymond M. St. Marie. “Cannabinoid-Based Medications for Pain.” MDedge Psychiatry, 3 May 2021, https://www.mdedge.com/psychiatry/article/239193/pain/cannabinoid-based-medications-pain.

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QUESTION: Is the bioavailability of THC greater with inhaled cannabinoid-based medicines (CBMs) or ingested CBMs?

ANSWER: The bioavailability of inhaled CBMs is nearly 30% while the bioavailability of ingested CBMs is approximately 4%-20%. (It should be noted that the bioavailability is higher with vaporized cannabis as compared with combusted (smoked) cannabis products.

reference: Current Psychiatry. 2021 May;20(5):21-23, 28-33 | doi:10.12788/cp.0121, and MD Raphael J. Leo Raymond M. St. Marie. “Cannabinoid-Based Medications for Pain.” MDedge Psychiatry, 3 May 2021, https://www.mdedge.com/psychiatry/article/239193/pain/cannabinoid-based-medications-pain.

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QUESTION: The most well studied endocannabinoids are N-arachidonoyl- ethanolamine (AEA; anandamide) and 2-arachidonoylglycerol (2-AG). Are these two neurotransmitters stored in the presynaptic neurons?

ANSWER: No. Unlike most neurotransmitters, neither AEA or 2-AG is stored within vesicles in presynaptic neuron axons. They are actually produced on demand; they are synthesized from arachidonic acid of the membranes of post-synaptic neurons, and then they are released directly into the synapse and bind to receptors on the pre-synaptic neuron. In other words, they act in a retrograde fashion.

reference: Current Psychiatry. 2021 May;20(5):21-23, 28-33 | doi:10.12788/cp.0121, and MD Raphael J. Leo Raymond M. St. Marie. “Cannabinoid-Based Medications for Pain.” MDedge Psychiatry, 3 May 2021, https://www.mdedge.com/psychiatry/article/239193/pain/cannabinoid-based-medications-pain.

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QUESTION: Some NFL players strongly believe that it’s safer for them to use marijuana to treat pain than to take prescription medication. What has the NFL done in response to this claim?

ANSWER: For years, the NFL suspended a player if the player tested positive for marijuana multiple times. That changed due to an agreement approved in 2020. Now, the pain management committee of the NFL and the NFL Players Association will provide $1 million in funding for research into pain management and cannabinoids. Specifically, the research is evaluating marijuana as a potential alternative to opioids. Also, the NFL is investigating how using cannabis-based products and CBD to treat pain affects performance in elite athletes.

reference: https://www.nfl.com/news/nfl-nflpa-will-provide-funding-for-research-into-pain-treatment-including-medica

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QUESTION: The results of recent clinical trials indicate that Cannabidiol (CBD) reduces seizures among patients with refractory epilepsies of various etiologies. Most of these clinical studies report efficacy over short time periods (<1 year). Is CBD effective long term?

ANSWER: Yes. A May 2021 study demonstrated that CBD does not lose its efficacy in controlling seizures over a treatment period of up to 60 months. In addition, other results on the efficacy and tolerability of CBD in the treatment of refractory epilepsies, suggest that CBD is an effective, safe, and well-tolerated anti-epileptic drug for long-term use.

reference: The long-term efficacy of cannabidiol in the treatment of refractory epilepsy. Sandip Patel, Reid Grinspoon, Bradley Fleming, Lauren A. Skirvin, Christina Wade. 29 May 2021 https://doi.org/10.1111/epi.16936

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QUESTION: Some patients in the US may wish to travel with CBD to Canada, or vice versa. CBD is legally sold in the US and in Canada. So, is it legal to transport CBD across the US/Canadian border?

ANSWER: The transporting of cannabis (in any form, including oils containing THC or cannabidiol) into or out of Canada without special authorization from Health Canada is a serious criminal offense.

reference: Cannabis in Canada – What you need to know; https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/resources/cannabis-act-what-you-need-to-know.pdf

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QUESTION: For what health conditions is the therapeutic applicability of CBD being evaluated?

ANSWER: The range of conditions for which CBD has been (or is being) assessed is quite diverse. Currently, clinical trials are evaluating CBD’s analgesic, neuroprotective, antiepileptic, anxiolytic, antipsychotic, anti-inflammatory, antitumor and anti-hypoxia/ischemia properties. According to a March 2021 search of the National Library of Medicine’s database, clinicaltrials.gov, there were more than 300 registered clinical trials that involve the use of CBD as a therapeutic intervention.

reference: Clinicaltrials.gov

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QUESTION: Does pretreatment with CBD prevent the transient psychotic symptoms induced by THC?

ANSWER: According to a study in humans, pretreatment with CBD does diminish THC’s psychotic effects. This particular study involved 6 healthy volunteers who were given THC intravenously on two separate occasions – once with a placebo pretreatment and once with a CBD pretreatment.

reference: Atakan Z. Cannabis, a complex plant: Different compounds and different effects on individuals. Ther Adv Psychopharmacol 2012 Dec; 2(6):241-254. doi:10.1177/2045125312457586. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736954/

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QUESTION: Has any national drug administration approved a CBD-containing product for therapeutic use in conditions other than epilepsy?

ANSWER: Yes. The oromucosal spray Sativex (nabiximols) is a cannabis extract that contains the principal cannabinoids delta-9-tetrahydrocannibinol (THC) and cannabidiol (CBD) in a 50:50 ratio, as well as specific minor cannabinoids and other non-cannabinoid components. Regulatory approval has been obtained in numerous countries outside the United States for the treatment of multiple sclerosis symptoms (nerve pain, spasticity, overactive bladder, and other symptoms).

reference: GW Pharmaceuticals website. Sativex. https://www.gwpharm.com/healthcare-professionals/sativex

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QUESTION: Some patients consume CBD hoping that it will cure their cancer. Do the findings of clinical research studies indicate that CBD cures cancer?

ANSWER: No. There is no substantial clinical evidence to support that cannabinoids (natural or synthetic), including CBD, can effectively and safely treat cancer in humans.

reference: NO CLINICAL RESEARCH CITATION

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QUESTION: Epidiolex is an FDA-approved oral CBD solution indicated for the treatment of seizures associated with Lennox-Gastaut syndrome (LGS), Dravet syndrome (DS), or tuberous sclerosis complex (TSC) in one year of age and older. Can it be prescribed for indications other than these three seizure disorders (i.e. off label)?

ANSWER: Yes, Epidiolex may be prescribed off-label, but insurance coverage may be subject to pre-authorization.

reference: GW Pharmaceuticals press release: “GW Pharmaceuticals plc and Its U.S. Subsidiary Greenwich Biosciences, Inc. Announce That EPIDIOLEX® (cannabidiol) Oral Solution Has Been Descheduled And Is No Longer A Controlled Substance” April 6, 2020. https://ir.gwpharm.com/news-releases/news-release-details/gw-pharmaceuticals-plc-and-its-us-subsidiary-greenwich-1 Accessed April 30, 2020. GW Pharmaceuticals website. Sativex. https://www.gwpharm.com/healthcare-professionals/sativex accessed Mar 31, 2021.

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QUESTION: St. John’s wort is an over the counter medication used as a remedy for mild depression. Does St. John’s wort interact with CBD?

ANSWER: Yes. St. Johns wort inhibits some of the liver enzymes that metabolize CBD. As a result, there is an increase in bioavailability of CBD, and a possible increase of adverse effects associated with CBD consumption.

reference: Brown JD, Winterstein AG. Potential Adverse Drug Events and Drug-Drug Interactions with Medical and Consumer Cannabidiol (CBD) Use. J Clin Med. 2019;8(7):989. Published 2019 Jul 8. doi:10.3390/jcm8070989. https://pubmed.ncbi.nlm.nih.gov/31288397/

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QUESTION: A seizure disorder is a qualifying condition in many medical marijuana state programs. Does CBD interact with commonly prescribed anti-epileptic medications?

ANSWER: Yes. According to a presentation at the 2014 annual meeting of the American Epilepsy Society, an increasing dose of CBD was associated with significant increases in serum levels of topiramate, rufinamide, and N-desmethylclobazam. Also, there is a significant association between increasing CBD doses and increased zonisamide and eslicarbazepine serum levels.

reference: Friedman D, Cilio MR, Tilton N, et al. The effect of Epidiolex (cannabidiol) on serum levels of concomitant anti-epileptic drugs in children and young adults with treatment-resistant epilepsy in an expanded access program. Presented at the annual meeting of the American Epilepsy Society, Seattle, December 5–9, 2014; abstract.

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QUESTION: Is CBD addictive?

ANSWER: According to the drug package insert of an FDA-approved CBD product, CBD is not addictive.

reference: GW Pharmaceuticals website. Sativex. https://www.gwpharm.com/healthcare-professionals/sativex accessed Mar 31, 2021.

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QUESTION: Proton pump inhibitors (PPIs) are commonly used to relieve the symptoms of gastro-esophageal reflux disease (GERD). Do PPIs interact with CBD?

ANSWER: Yes. PPIs inhibit some of the liver enzymes that metabolize CBD. As a result, there is an increase in bioavailability of CBD, and a possible increase of adverse effects associated with CBD consumption.

reference: Brown JD, Winterstein AG. Potential Adverse Drug Events and Drug-Drug Interactions with Medical and Consumer Cannabidiol (CBD) Use. J Clin Med. 2019;8(7):989. Published 2019 Jul 8. doi:10.3390/jcm8070989. https://pubmed.ncbi.nlm.nih.gov/31288397/

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QUESTION: Other than pill form, in what forms is CBD sold?

ANSWER: There are multiple CBD product types, including CBD oils (for oral/sublingual administration or vaporization), gummy candies, joint balms, creams, lotions, and capsules. CBD is also being sold in food products, beverages and healthcare goods, including hair products and skincare products. CBD has even been marketed as an ingredient in sleeping masks and dog treats.

reference: “Ads Pitching CBD as a Cure-all Are Everywhere. Oversight Hasn’t Kept Up.” The New York Times, Aug 13, 2019 – https://www.nytimes.com/2019/08/13/business/media/cbd-marijuana-fda.html – accessed Aug 2019.

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QUESTION: Does CBD alter the metabolism of methadone?

ANSWER: Yes. Cannabidiol inhibits CYP3A4 and CYP2C19, both of which are involved in the metabolism of methadone. As a result, the co-administration of CBD and methadone may lead to increased sedation.

reference: Madden K, Tanco K, Bruera E. Clinically Significant Drug-Drug Interaction Between Methadone and Cannabidiol. Pediatrics May 2020; e20193256; DOI: https://doi.org/10.1542/peds.2019-3256.
https://pediatrics.aappublications.org/content/145/6/e20193256

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QUESTION: The FDA has approved a CBD product (Epidiolex) for the treatment of 3 rare forms of epilepsy. What is the mechanism of action of CBD in this anti-epileptic medication? How does CBD exert its anti-convulsant effects?

ANSWER: According to the prescribing information of this FDA-approved product, “The precise mechanisms by which Epidiolex exerts its anticonvulsant effect in humans are unknown. Cannabidiol does not appear to exert its anticonvulsant effects through interaction with cannabinoid receptors.”

reference: Highlights for prescribing information for Epidiolex https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/210365lbl.pdf

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QUESTION: Fluoxetine (sold under the name Prozac) is a commonly prescribed antidepressant of the SSRI – Selective Serotonin Reuptake Inhibitor – class. Does Fluoxetine impact the metabolism of CBD?

ANSWER: Yes. Fluoxetine inhibits some of the liver enzymes that metabolize CBD. As a result, there is an increase in bioavailability of CBD, and a possible increase of adverse effects associated with CBD consumption.

reference: Brown JD, Winterstein AG. Potential Adverse Drug Events and Drug-Drug Interactions with Medical and Consumer Cannabidiol (CBD) Use. J Clin Med. 2019;8(7):989. Published 2019 Jul 8. doi:10.3390/jcm8070989. https://pubmed.ncbi.nlm.nih.gov/31288397/

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QUESTION: Some patients apply CBD topically. Does CBD easily penetrate the skin?

ANSWER: Due to CBD’s large size and hydrophobic properties, CBD does not penetrate the skin efficiently, however, permeation-enhancing gels have been developed. Currently, CBD-containing gels are being evaluated for the treatment of several pediatric disorders, and a heterogeneous group of rare and ultra-rare epilepsies known as developmental and epileptic encephalopathies.

reference: https://zynerba.com/in-development/zygel/

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QUESTION: Have CBD’s effects on human embryonic development been fully evaluated?

ANSWER: No, but according to a World Health Organization Cannabidiol (CBD) report in November 2017, in studies involving the use of CBD in monkeys, no effect on a wide range of physiological and biochemical parameters or significant effects on animal behavior were noted unless extremely high doses of CBD (e.g., in excess of 150 mg/kg iv as an acute dose or in excess of 30 mg/kg orally daily for 90 days) were administered.

reference: World Health Organization (WHO) – Expert Committee on Drug Dependence Thirty-ninth Meeting Cannabidiol (CBD) Pre-Review Report Agenda Item 5.2 Geneva, 6-10 November 2017

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QUESTION: CBD interacts with warfarin. Does this drug:drug interaction lead to an increased risk of bleeding or a decrease in warfarin’s anticoagulation effect?

ANSWER: The inhibition of CYP2C19 by CBD can increase levels of warfarin, and multiple reports have indicated that the interaction between warfarin and CBD results in an increased risk of bleeding.

reference: Treese NM, Flowers M. Pharmacist’s guide to CBD oil. US Pharm. 2020; 45(3):20-23. https://www.uspharmacist.com/article/pharmacists-guide-to-cbd-oil

Welty TE, Chapman KE, Faught RE, Kotloski RJ. American Epilepsy Society (AES): Written Comments to Norman E. “Ned” Sharpless, MD, Acting Commissioner of Food and Drugs, U.S. Food and Drug Administration (FDA), Department of Health and Human Services (HHS): on Docket ID# FDA-2019-N-1482, Scientific Data and Information about Products Containing Cannabis or Cannabis-Derived Compounds; Public Hearing; Request for Comments: Submitted on: July 16, 2019. Epilepsy Currents 2019; 19(6):361-368. doi:10.1177/1535759719878716

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QUESTION: What is the most common mode of CBD administration?

ANSWER: According to a 2017–2018 online survey evaluating modes of CBD administration, the most common method of CBD administration was sublingual, followed by vaping, oral ingestion of capsules and liquids, smoking, edibles, and topical administration

reference: Corroon J, Phillips JA. A cross-sectional study of cannabidiol users. Cannabis Cannabinoid Res. 2018;3(1):152–61. https://pubmed.ncbi.nlm.nih.gov/30014038/

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QUESTION: A common adverse effect of chronic recreational marijuana use is cannabinoid hyperemesis syndrome. In fact, cannabinoid hyperemesis syndrome is a near daily diagnosis in many Canadian emergency departments. Anecdotal evidence supports the use of haloperidol to treat cannabinoid hyperemesis syndrome. Is haloperidol more effective than odansetron for the treatment of the nausea and vomiting associated with cannabinoid hyperemesis syndrome?

ANSWER: According to the results of a randomized controlled trial involving 33 patients with cannabinoid hyperemesis syndrome, haloperidol (0.05 mg/kg or 0.1 mg/kg) was superior to odansetron 8mg for average reduction from baseline in abdominal pain and nausea at 2 hours, and was associated with the need for fewer rescue antiemetics and shorter time to ED departure. In this study, there were 2 haloperidol and 6 ondansetron return ED visits for ongoing nausea/vomiting, as well as 2 return visits for acute dystonia, both in the higher dose haloperidol group.

reference: Ruberto, A., Sivilotti, M., Forrester, S., Hall, A., Crawford, F., & Day, A. (2020). LO69: Haloperidol versus ondansetron for hyperemesis due to cannabis (HaVOC): A randomized, controlled clinical trial. CJEM, 22(S1), S32-S33. doi:10.1017/cem.2020.124. https://www.researchgate.net/publication/341353323_LO69_Haloperidol_versus_ondansetron_for_hyperemesis_due_to_cannabis_HaVOC_a_randomized_controlled_clinical_trial

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QUESTION: Cannabinoid receptors have been located in the central nervous system and the peripheral nervous system, as well as on immune cells. Have cannabinoid receptors been isolated in reproductive tissues/cells?

ANSWER: In addition to cannabinoid receptors being identified in the hypothalamus and the pituitary gland, cannabinoid receptors have also been identified on ovary, endometrial tissue, testes, and spermatozoa. In fact, research suggests that marijuana may alter the release of FSH and LH, ovulation, sperm motility, fertilization, as well as placentation.

reference: Caitlin Dunne, MD, FRCSC. THE EFFECTS OF CANNABIS ON FEMALE AND MALE REPRODUCTION. BCMJ, vol. 61 , No. 7 , September 2019 , Pages 282-285. https://bcmj.org/articles/effects-cannabis-female-and-male-reproduction

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QUESTION: What is the most common route of administration for the synthetic cannabinoids K2 or Spice?

ANSWER: K2 and Spice are used for recreational purposes, and smoking is the most common route of administration. Spraying or mixing the synthetic cannabinoids on dried plant material allows one to smoke it (using a pipe, a water pipe, or rolling the drug-laced plant material in cigarette papers). Also, liquid synthetic cannabinoids have been designed to be vaporized via e-cigarettes.

reference: Drugs of Abuse – A DEA Resource Guide /2020 Edition. https://www.dea.gov/sites/default/files/2020-04/Drugs%20of%20Abuse%202020-Web%20Version-508%20compliant-4-24-20_0.pdf

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QUESTION: What are K2 and Spice?

ANSWER: K2 and Spice are synthetic cannabinoid “designer drugs” that are intended to mimic the effects of THC. These synthetic cannabinoids are sold as “herbal incense” at convenience stores/gas stations, smoke shops and via the internet. They are produced in powder form, and then often dissolved in solvents, so they can be applied to dry plant material to make the “herbal incense” products.

rreference: Drugs of Abuse – A DEA Resource Guide /2020 Edition. https://www.dea.gov/sites/default/files/2020-04/Drugs%20of%20Abuse%202020-Web%20Version-508%20compliant-4-24-20_0.pdf

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QUESTION: Respiratory depression is associated with the overdose of opioids or benzodiazepines. Is respiratory depression associated with an overdose of cannabinoids? Why or why not?

ANSWER: Respiratory depression is not associated with cannabinoid use because CB1 receptors are not located in the midbrain, the part of the brain responsible for respiratory drive.

reference: Levinsohn EA, Hill KP. Clinical uses of cannabis and cannabinoids in the United States. J Neurol Sci. 2020 Apr 15;411:116717. doi: 10.1016/j.jns.2020.116717. Epub 2020 Jan 30. PMID: 32044684. https://pubmed.ncbi.nlm.nih.gov/32044684/

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QUESTION: As of January 2020, how many Americans were using marijuana-based products for medicinal purposes?

ANSWER: It has been estimated that more than 2 million Americans use marijuana for medical reasons. Some of the many ailments being treated with marijuana include: chronic pain, PTSD, depression, sleep disorders, multiple sclerosis (MS), cancer-related ailments, and GI disorders. Some indications are supported by good scientific evidence, but some are not.

reference: Levinsohn EA, Hill KP. Clinical uses of cannabis and cannabinoids in the United States. J Neurol Sci. 2020 Apr 15;411:116717. doi: 10.1016/j.jns.2020.116717. Epub 2020 Jan 30. PMID: 32044684. https://pubmed.ncbi.nlm.nih.gov/32044684/

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QUESTION: Cannabinoids are metabolized by many of the same cytochrome P450 enzymes as warfarin. In fact, THC, CBD and CBN can inhibit the hydroxylation of warfarin, and thus lead to an increase in INR. Do cannabinoids also affect the metabolism of heparin? Is the metabolism of direct oral anticoagulants (DOACs), including rivaroxaban, edoxaban, and apixaban, impacted by cannabinoids?

ANSWER: While cannabinoids do not alter the metabolism of heparin, cannabinoids may impact the metabolism of DOACs. DOAC levels may increase, leading to an increased risk of bleeding.

reference: Jessica Greger, PharmD, Vernice Bates, MD, Laszlo Mechtler, MD, and Fran Gengo, PharmD. A Review of Cannabis and Interactions With Anticoagulant and Antiplatelet Agents. The Journal of Clinical Pharmacology 2019, 0(0) 1–7. https://accp1.onlinelibrary.wiley.com/doi/abs/10.1002/jcph.1557?af=R

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QUESTION: Does CBD interact with receptors other than CB1 or CB2?

ANSWER: Yes. CBD has cannabinoid receptor-independent properties. For example, CBD is an agonist at the TRPV1 receptor and has agonist properties at the 5-HT1A/2A/3A serotonergic receptors. CBD is also a capsaicin analog. CBD has antagonist activity on alpha-1 adrenergic and μ-opioid receptors, too. In addition, CBD has been found to inhibit synaptosomal uptake of noradrenaline, dopamine, serotonin, and gamma-amino butyric acid. CBD also inhibits anandamide uptake.

reference: Levinsohn EA, Hill KP. Clinical uses of cannabis and cannabinoids in the United States. J Neurol Sci. 2020 Apr 15;411:116717. doi: 10.1016/j.jns.2020.116717. Epub 2020 Jan 30. PMID: 32044684. https://pubmed.ncbi.nlm.nih.gov/32044684/

reference: Brown JD, Winterstein AG. Potential Adverse Drug Events and Drug-Drug Interactions with Medical and Consumer Cannabidiol (CBD) Use. J Clin Med. 2019 Jul 8;8(7):989. doi: 10.3390/jcm8070989. PMID: 31288397; PMCID: PMC6678684. https://pubmed.ncbi.nlm.nih.gov/31288397/

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QUESTION: Cannabinoid receptors are located throughout various parts of the CNS, including the basal ganglia, hippocampus, cerebellum and cerebral cortex, and in the peripheral nervous system. Do these receptors have effects on neurotransmitters such as serotonin?

ANSWER: Yes. CB receptor activity not only impacts serotonin, but it also affects acetylcholine, dopamine, glutamate, and GABA, as well as NMDA and opioid receptor systems.

reference: Levinsohn EA, Hill KP. Clinical uses of cannabis and cannabinoids in the United States. J Neurol Sci. 2020 Apr 15;411:116717. doi: 10.1016/j.jns.2020.116717. Epub 2020 Jan 30. PMID: 32044684. https://pubmed.ncbi.nlm.nih.gov/32044684/

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QUESTION: Epidemiological studies indicate that as many as 15% of inflammatory bowel disease (IBD) patients may use cannabinoids to ameliorate some of their symptoms, including improvement in diarrhea, abdominal pain and appetite. Do the studies show that cannabinoids are effective in Crohn’s disease?

ANSWER: Although the findings of studies examining the efficacy of cannabinoids in Crohn’s disease indicate that cannabinoids do not improve inflammatory markers or endoscopic score, the results indicate that THC reduces the Crohn’s disease activity index by >100 points (on a scale of 0–450).

reference: Naftali T, Dor M. Cannabis for the Treatment of Inflammatory Bowel Disease: A True Medicine or a False Promise?. Rambam Maimonides Med J 2020;11 (1):e0008. Review. doi:10.5041/RMMJ.10390. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000156/

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QUESTION: Some cancer patients use medical marijuana to treat various cancer-associated ailments. What are some of the ailments ameliorated by medical marijuana?

ANSWER: According to one study involving 96 cancer patients receiving supportive cancer care, the data support the safety and effectiveness of medical marijuana as a complementary option for improving pain control, appetite and quality of life for cancer patients. The top three adverse events of this study included drowsiness, low energy and nausea. (Note: other studies indicate that chemotherapy-induced nausea and vomiting is ameliorated by medical marijuana.)

reference: Safety and effectiveness of medical cannabis as a complementary option for supportive cancer care: Results from the Cannabis Pilot Project. Antonio Vigano, Saro Aprikian, Popi Kasvis, Virginie Bacis, Amna Al Harrasi, Nathalie M Aubin, MariaLuisa Vigano, and Manuel Borod. Journal of Clinical Oncology 2020 38:15_suppl, 12106-12106.
https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.12106

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QUESTION: What is Sativex®?

ANSWER: Sativex® is a buccal (oral) spray containing Δ-9-THC and CBD (2.7 mg Δ-9-THC and 2.5 mg CBD per spray) and it is indicated for spasticity and neuropathic pain in multiple sclerosis, and as adjunctive analgesia for moderate to severe cancer pain. While Sativex® is approved in several European countries, Canada, and other countries, it has not been approved for medical use in the U.S.

reference: Brown JD, Winterstein AG. Potential Adverse Drug Events and Drug-Drug Interactions with Medical and Consumer Cannabidiol (CBD) Use. J Clin Med. 2019;8(7):989. Published 2019 Jul 8. doi:10.3390/jcm8070989.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6678684/

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QUESTION: According to the results of a survey of breast cancer patients’ use of cannabinoid products, 42% of survey participants had used medical cannabinoid products to relieve symptoms. What symptoms were treated with cannabinoid products?

ANSWER: Members of the Breastcancer.org and Healthline communities were asked to participate in a survey during the period of 12/16/2019 – 1/19/2020. According to the results of the survey, cannabinoids were used to relieve insomnia (70%), pain (59%), anxiety (57%), stress (51%), and nausea/vomiting (46%).

reference: A survey of breast cancer patients’ use of cannabis before, during, and after treatment. Marisa C. Weiss, Julianne Hibbs, Terri W. McHugh, Meghan Buckley, Sharon Larson, Nancye Green, Virginia G. Kaklamani, Rowan T. Chlebowski, and Diana Martinez. Journal of Clinical Oncology 2020 38:15_suppl, e19210-e19210. https://ascopubs.org/doi/10.1200/JCO.2020.38.15_suppl.e19210

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QUESTION: Are cannabinoids an effective analgesic agent in the acute pain setting? Are cannabinoids an effective analgesic agent in the chronic pain setting?

ANSWER: According to the results of multiple randomized controlled trials examining the efficacy of cannabinoids to treat acute pain, THC, nabilone and other cannabinoid-based products were not associated with a reduction in pain, but were associated with adverse side effects, including sedation. In contrast to the lack of efficacy in the acute pain setting, cannabinoids are effective analgesic agents in the chronic pain setting. According to 2 systematic reviews involving a total of 29 randomized controlled trials (RCTs), 22 of the 29 RCTs demonstrated that cannabinoids do have a modest analgesic effect in the management of chronic pain.

reference: Vulfsons S, Minerbi A, Sahar T. Cannabis and Pain Treatment-A Review of the Clinical Utility and a Practical Approach in Light of Uncertainty. Rambam Maimonides Med J. 2020;11(1):e0002. Published 2020 Jan 30. doi:10.5041/RMMJ.10385. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000155/

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QUESTION: What are the common modes of administration of medical marijuana used by cancer patients?

ANSWER: According to a survey completed by 183 cancer patients of an oncology clinic at Sutter Medical Center in Sacramento, California, over 50% reported use of oils and tinctures and 44% used edibles. A smaller percentage consumed cannabis-based products via vaping (26%) or smoking (30%). Topical use was preferred by fewer patients (17%). Over 58% of patients stated they used more than one method.

reference: Patterns of use of medical cannabis in a community oncology clinic. Deepti Behl, Stacy D. D’Andre, and Carol Parise, Journal of Clinical Oncology 2020. 38:15_suppl, e24111-e24111. https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.e24111

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QUESTION: What CBD products, if any, have been evaluated and approved by the FDA?

ANSWER: CBD is marketed in various forms, including oils, capsules, food products, cosmetics/topical lotions and creams, and CBD products are marketed for pets, too. These products are sold in grocery stores, specialty stores, and convenience stores across the US and on the internet. However, only one prescription CBD product has been approved by the FDA. It is called Epidiolex. It is approved to treat rare, severe pediatric epilepsy disorders.

reference: FDA Advances Work Related to Cannabidiol Products with Focus on Protecting Public Health, Providing Market Clarity – March 5 2020. https://www.fda.gov/news-events/press-announcements/fda-advances-work-related-cannabidiol-products-focus-protecting-public-health-providing-market

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QUESTION: On the current (last revised May 2020) US Department of Justice Firearms Transaction Record form, is there a question related to the unlawful use of, or addiction to marijuana, depressants, stimulants, narcotics and other controlled substances?

ANSWER: Yes. There is a question related to drug use. In fact, there is a warning note that reads as follows: “Warning: The use or possession of marijuana remains unlawful under Federal law regardless of whether it has been legalized or decriminalized for medicinal or recreational purposes in the state where you reside.”

reference: U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives OMB No. 1140-0020, Firearms Transaction Record. https://www.atf.gov/firearms/docs/4473-part-1-firearms-transaction-record-over-counter-atf-form-53009/download

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QUESTION: Does consuming a high fat/high calorie meal at the same time as you take liquid CBD orally impact the amount of CBD absorbed into the bloodstream?

ANSWER: Yes. According to studies performed by a pharmaceutical company that manufactures the FDA-approved CBD product called Epidiolex, a high fat/high calorie meal can increase CBD absorption by up to 5 fold.

reference: Epidiolex insert. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/210365lbl.pdf

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QUESTION: It has been estimated that a significant proportion of cancer patients (18.3-40.0%) in the United States use marijuana or cannabinoid-based products. Does the evidence indicate that cannabinoid-based products are effective in treating cancer-related pain? chemotherapy-induced nausea and vomiting? Cancer-related cachexia (wasting)?

ANSWER: According to a study published in the Journal of Clinical Oncology, there is substantial evidence for the effectiveness of marijuana and cannabinoids in treating cancer-related pain; specifically, an oral THC/CBD spray. Also, there is conclusive evidence that marijuana and cannabinoids effectively relieve chemotherapy-induced nausea and vomiting; (specifically, oral THC). However, there is inconclusive evidence about the effectiveness of cannabinoid-based products in treating cancer-related cachexia (wasting).

reference: A systematic review of evidence for cannabis and cannabinoids as adjuvant therapy in palliative and supportive oncology care.
Sebastian Jugl, Shailina Keshwani, Lauren Adkins, Coy D. Heldermon, Almut Winterstein, and Amie Goodin. Journal of Clinical Oncology 2020. 38:15_suppl, 12091-12091 https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.12091

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QUESTION: Do cannabinoids affect the function of the gastrointestinal system?

ANSWER: It appears that cannabinoids affect many functions of the digestive system, including the regulation of the production of digestive enzymes, gastrointestinal motility, and visceral inflammation as well as visceral sensation.

reference: Izzo AA, Sharkey KA. Cannabinoids and the gut: New developments and emerging concepts. Pharmacol Ther 2010 04;126(1879-016; 0163-7258; 1):21-38. https://pubmed.ncbi.nlm.nih.gov/20117132/

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QUESTION: Marijuana use is not associated with a decrease in respiratory drive. Why not?

ANSWER: In the lower brainstem areas that control respiratory function/respiratory drive, cannabinoid receptor expression is low, and this accounts for the lack of decreased respiratory drive and the absence of a risk of fatal respiratory arrest with the use of medical marijuana and pharmaceutical grade cannabinoid drugs.

reference: Herkenham M, Lynn AB, Little MD, et al. Cannabinoid receptor localization in brain. Proc Natl Acad Sci USA. 1990; 87:1932–1936.38. https://pubmed.ncbi.nlm.nih.gov/2308954/

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QUESTION: What is the pharmacokinetic profile of marijuana when it is administered orally?

ANSWER: The psychoactive and physiological effects of orally consumed marijuana typically appear approximately 90 minutes after ingestion, reach their maximum after 2-3 hours and last for about 4-12 hours. However, there is a heterogeneous response to oral marijuana consumption and some individuals may not appreciate the peak effect until 6 hours after consumption.

reference: Grotenhermen F. Clinical pharmacokinetics of cannabinoids. J Cannabis Ther, 2003; 3(1): 3-51. https://www.tandfonline.com/doi/abs/10.1300/J175v03n01_02

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QUESTION: Does marijuana affect appetite and metabolism?

ANSWER: Marijuana has been reported to stimulate appetite. There is a high concentration of CB1 receptors in the areas of the brain that control food intake and satiety, and these findings suggest that there is an association between marijuana consumption and appetite regulation. Additionally, studies suggest that the endocannabinoid system modulates taste sensation as well as the metabolism of lipids and glucose.

references: Di Marzo V, Matias I. Endocannabinoid control of food intake and energy balance. Nat.Neurosci. 2005; 8: 585-589. https://pubmed.ncbi.nlm.nih.gov/15856067/
• Farrimond JA, Mercier MS, Whalley BJ, Williams CM. Cannabis sativa and the endogenous cannabinoid system: therapeutic potential for appetite regulation. Phytother.Res. 2011; 25: 170-188. https://pubmed.ncbi.nlm.nih.gov/21213357/
• Matias I, Bisogno T, Di Marzo V. Endogenous cannabinoids in the brain and peripheral tissues: regulation of their levels and control of food intake. Int.J.Obes.(Lond). 2006; 30 Suppl 1: S7-S12. https://pubmed.ncbi.nlm.nih.gov/16570107/

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QUESTION: Does the dosing of cannabinoid-based drugs need to be adjusted for patients with hepatic disease?

ANSWER: Cannabinoids are metabolized by the liver and excreted through the GI tract and kidney. When considering cannabinoid therapy for patients with severe liver impairment, the dosage may need to be adjusted. For example, according to the prescribing information for an FDA-approved cannabidiol product, “dose adjustment is recommended in patients with moderate (Child-Pugh B) hepatic impairment or severe (Child-Pugh C) hepatic impairment. It may be necessary to have slower dose titration in patients with moderate or severe hepatic impairment than in patients without hepatic impairment. [This drug] does not require dose adjustment in patients with mild (Child-Pugh A) hepatic impairment.”

Epidiolex prescribing information highlights:
https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/210365lbl.pdf

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QUESTION: Does the endocannabinoid system modulate pain without the being triggered by THC or other phytocannabinoids?

ANSWER: Yes. Neural and non-neural cells of injured tissues produce endocannabinoids, including anandamide and 2-AG, and when these endocannabinoids activate the CB receptors, pain signals are modulated. Note: CB1 receptors are abundant in nociceptive and non-nociceptive sensory neurons of the dorsal root ganglion (DRG), the spinal cord, the brain, mast cells, macrophage defense cells, the trigeminal ganglion (TG), and epidermal keratinocytes. Few CB2 receptors are expressed in these regions, but the density of CB2 receptors increases when peripheral nerve damage occurs.

reference: Breijyeh Z,Jubeh B, Bufo SA, Karaman R, Scrano L. Cannabis: A Toxin-Producing Plant with Potential Therapeutic Uses. Toxins (Basel). 2021 Feb 5;13(2):117. doi.10.3390/toxins13020117. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7915118/

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QUESTION: Other than via pills, capsules and liquid preparations, are there any other vehicles by which medical marijuana can be consumed orally?

ANSWER: In addition to pills, capsules and liquid preparations, medical marijuana can be consumed orally by ingesting marijuana-infused edibles, such as baked goods, candies, gummies, chocolates, lozenges, and beverages. It must be noted that the amounts of the various cannabinoids in edibles may not be consistent throughout a single baked product (a cookie, for example) or across a batch of baked products. As a result, it is difficult to estimate the amount of marijuana contained in each portion of edible product.

reference: Barrus DG, Capogrossi KL, Cates SC, et al. Tasty THC: Promises and Challenges of Cannabis Edibles. Methods Rep RTI press. 2016; 2016:10.3768/rtipress.2016.op.0035.1611. http://europepmc.org/article/MED/28127591

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QUESTION: Do some cannabinoids reduce spasticity?

ANSWER: Studies have suggested that some cannabinoids effectively reduce the spasticity associated with multiple sclerosis, and, in fact, the federal drug agencies of several countries (but not the US) have approved a cannabinoid-based formula (50:50 THC:CBD) called Sativex (nabiximols) for the treatment of severe spasticity in multiple sclerosis. The cannabinoids act on the presynaptic CB1 receptors, and the receptor activation reduces massive glutamate release and regulates glutamatergic excitability during spasticity. The American Academy of Neurology proposes that the use of oral cannabinoid extracts or an oromucosal cannabinoid spray (1:1 THC:CBD) by MS patients may reduce symptoms of spasticity.

reference: Yadav V. Bever C. Jr et al. Summary of evidence –based guideline: complimentary and alternative medicine in multiple sclerosis: Report of the guideline development subcommittee of the American Academy of neurology. Neurology 2014. 82(12): 1083-1092. https://pubmed.ncbi.nlm.nih.gov/24663230/

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QUESTION: Is marijuana a sedative or stimulant?

ANSWER: Marijuana is a CNS depressant and may cause drowsiness or somnolence. Its CNS depressant effects are additive with other CNS depressants, including opioids. There is moderate evidence that marijuana or cannabinoids are effective for improving short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnea syndrome, fibromyalgia, chronic pain, and multiple sclerosis.

reference: Kumar RN, Chambers WA, Pertwee RG. Pharmacological actions and therapeutic uses of cannabis and cannabinoids. Anaesthesia. 2001; 56: 1059-1068. https://pubmed.ncbi.nlm.nih.gov/11703238/

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QUESTION: What is the pharmacokinetic profile of marijuana when it is smoked?

ANSWER: When herbal marijuana is smoked via a cigarette or a pipe, THC, CBD and other phytocannabinoids, as well as terpenoids, are vaporized by the heat of combustion and inhaled. Inhaled constituents quickly pass from alveoli into the bloodstream and readily cross the blood-brain barrier. CNS effects appear within seconds to a few minutes of inhalation, reach a maximum after 15-30 minutes, and taper off within 2-3 hours. It must be noted that the amounts of cannabinoids consumed are, in part, dependent upon the patient’s inhalation techniques, including the quality and efficiency of inhalation, duration of inhalation, and spacing of inhalations.

references: Huestis MA. Human cannabinoid pharmacokinetics. Chem Biodivers. 2007;4(8):1770-804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689518/.
• Grotenhermen F. Clinical pharmacokinetics of cannabinoids. J Cannabis Ther, 2003; 3(1): 3-51. https://www.tandfonline.com/doi/abs/10.1300/J175v03n01_02

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QUESTION: What is the pharmacokinetic profile of marijuana when it is smoked?

ANSWER: When herbal marijuana is smoked via a cigarette or a pipe, THC, CBD and other phytocannabinoids, as well as terpenoids, are vaporized by the heat of combustion and inhaled. Inhaled constituents quickly pass from alveoli into the bloodstream and readily cross the blood-brain barrier. CNS effects appear within seconds to a few minutes of inhalation, reach a maximum after 15-30 minutes, and taper off within 2-3 hours. It must be noted that the amounts of cannabinoids consumed are, in part, dependent upon the patient’s inhalation techniques, including the quality and efficiency of inhalation, duration of inhalation, and spacing of inhalations.

references: Huestis MA. Human cannabinoid pharmacokinetics. Chem Biodivers. 2007;4(8):1770-804. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689518/.
• Grotenhermen F. Clinical pharmacokinetics of cannabinoids. J Cannabis Ther, 2003; 3(1): 3-51. https://www.tandfonline.com/doi/abs/10.1300/J175v03n01_02

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QUESTION: What are endocannabinoids?

ANSWER: Endocannabinoids (also called endogenous cannabinoids) are endogenous agonists of the receptors to which delta-9- tetrahydrocannabinol (THC) also binds. Two of the most well studied endocannabinoids are derivatives of arachidonic acid: N-arachidonoylethanolamine (also called anandamide or AEA) and 2-arachidonoylglycerol (2-AG).

reference: Atakan, Z. “Cannabis, a complex plant: different compounds and different effects on individuals.” Therapeutic advances in psychopharmacology 2012; 2(6): 241-54. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736954/

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QUESTION: What are terpenes?

ANSWER: Terpenes are aromatic hydrocarbons and just like the phytocannabinoids, terpenes are manufactured in the glands of the cannabis flower. Terpenes may influence the uptake and effects of phytocannabinoids. The terpenes found in cannabis include limonene, pinene, myrcene, delta-3-carene, eucalyptol and humulene.

reference: Russo EB. Taming THC:potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. Br J of Pharmacolo. 2011;163(7):1344-1364. doi:10.1111/j.1476-5381.2011.01238. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165946/

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QUESTION: THC and CBD have significantly different receptor binding capacities, and thus different pharmacological effects. Are the differences in binding capacity due to different chemical compositions?

ANSWER: THC and CBD actually have the same chemical formula, C21H30O2. They are structural isomers. The key structural difference between the two molecules is that there is an oxygen-containing closed ring in THC that is open in CBD. This one structural difference leads to significantly different receptor binding capacities and thus different pharmacological effects of the two substances.

reference: de Meijer EP, Bagatta M, Carboni A, et al. The inheritance of chemical phenotype in Cannabis sativa L. Genetics. 2003;163(1):335-346. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1462421/

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QUESTION: True or False? CB1 receptors are only found on nerve cells.

ANSWER: False. In addition to the brain, nociceptive and non-nociceptive sensory neurons of the dorsal root ganglion (DRG), and the spinal cord, CB1 receptors are abundant in mast cells, macrophage defense cells, epidermal keratinocytes, adipose, liver, pancreas and skeletal muscle cells.

reference: Breijyeh Z, Jubeh B, Bufo SA, Karaman R, Scrano L. Cannabis: A Toxin-Producing Plant with Potential Therapeutic Uses. Toxins (Basel). 2021 Feb 5;13(2):117. doi.10.3390/toxins13020117 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7915118/

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QUESTION: What is the most common qualifying condition reported by medical marijuana patients?

ANSWER: Currently and historically, the most common qualifying condition reported by medical marijuana patients is chronic pain. In fact, according to Boehnke et al’s analysis of 2016 data, chronic pain was the qualifying condition reported by medical marijuana patients nearly 65 percent of the time.

reference: Boehnke et al. Qualifying Conditions of medical cannabis license holders in the United States. Health Affairs Vol 38, No2: Hospitals, Health IT and more. https://doi.org/10.1377/hlthaff.2018.05266. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.05266

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QUESTION: Epidiolex is an FDA-approved seizure medication derived from plant material (it is not a synthetic CBD product). Is it possible that a patient taking Epidiolex will test positive for THC?

ANSWER: Epidiolex is cannabidiol (CBD) derived from marijuana, not hemp, and therefore there may be traces of cannabinoids other than CBD. Patients using Epidiolex may test positive for marijuana/THC on drug screening.

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QUESTION: Is it a good idea to store THC products in glass jars?

ANSWER: THC has the ability to bind to glass and plastic. Therefore, THC products are often stored in basic or organic solvents in amber silicate glassware to avoid loss.

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QUESTION: Do CBD products that contain less than 0.3 percent THC violate the Controlled Substances Act?

ANSWER: Industrial hemp (which contains less than 0.3 percent THC) is no longer considered to be a controlled substance, but CBD products that contain less than 0.3 percent THC are not legal. The CBD products no longer violate the Controlled Substances Act, but they do violate the Food, Drug, and Cosmetic (FD&C) Act, according to the FDA. Any CBD food or purported dietary supplement products in interstate commerce is in violation of the FD&C Act, according to the principal deputy FDA commissioner.

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QUESTION: What is industrial hemp?

ANSWER: Industrial hemp and marijuana are cultivated from the same species, but industrial hemp has concentrations of THC less than 0.3 percent. Industrial hemp, a high-fiber plant, is used to make various products, including textiles as well as biodegradable plastics. The 2018 Farm Bill, signed into law by President Donald Trump, removed industrial hemp, from the definition of marijuana in the Controlled Substances Act.

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QUESTION: Of all state-approved health conditions, what are the 7 most frequent health conditions for which patients seek to obtain a medical marijuana card?

ANSWER: Chronic noncancer pain, multiple sclerosis and other motor neuron disorders, epilepsy, cancer-related symptoms, mental health disorders (primarily anxiety disorders such as PTSD), glaucoma, and symptoms related to irritable bowel diseases top the list of reasons to apply for a medical marijuana card.

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QUESTION: CBD is legally sold in US supermarkets, pharmacies and convenience stores. CBD is also legally sold in Canada. So, is it legal to transport CBD across the US/Canadian border?

ANSWER: According to Canada’s national laws, “the transporting of cannabis (in any form, including oils containing THC or cannabidiol) into or out of Canada without special authorization from Health Canada is a serious criminal offense. “

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QUESTION: Does the dosing of CBD need to be adjusted in patients with liver disease?

ANSWER: According to the prescribing information packet of Epidiolex (an FDA-approved CBD product),, dose adjustment is recommended in patients with moderate (Child-Pugh B) or severe (Child-Pugh C) hepatic impairment. Dose adjustment in patients with mild (Child-Pugh A) hepatic impairment is not needed.

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QUESTION: Are physicians required to notify the DEA when prescribing Epidiolex (a CBD product derived from the cannabis plant)?

ANSWER: Prior to April 2020, Epidiolex was classified as a schedule V drug under the Controlled Substances Act. On April 6, 2020, the manufacturers of Epidiolex “received notification from the United States Drug Enforcement Administration (DEA) confirming that Epidiolex ® (cannabidiol) is no longer subject to the Controlled Substances Act (CSA).” Since Epidiolex is no longer a controlled substance, physicians are not required to notify the DEA when prescribing the medication. The descheduling of Epidiolex also enables physicians to prescribe this medicine free of the requirements of state prescription drug monitoring programs.

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QUESTION: Is the use of marijuana for medicinal reasons an acceptable explanation for a positive drug test result in ANY Federal agency drug testing program?

ANSWER: As of March 2021, the answer to this question is still ‘NO.’ ALL Federal drug testing programs – regardless whether the programs under the regulatory and legal auspices of the Department of Health and Human Services, the Department of Defense, the Department of Transportation, or the Nuclear Regulatory Commission, or any other Federal agency – have taken the identical stance: Use of Schedule I drugs by individuals in Federally regulated workplaces is unacceptable, and any individual who tests positive for a Schedule I drug will have a positive drug test on his or her record.

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QUESTION: If a patient uses a CBD product, will a THC drug screen be positive?

ANSWER: The answer to this question depends on 2 things: 1.) Is the patient consuming pure CBD or full spectrum CBD. (Full spectrum CBD contains multiple cannabinoids, including THC.) and 2.) The sensitivity of the drug screening test.

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QUESTION: How should cannabis products be stored?

ANSWER: Products should be stored in opaque containers, in a cool dry location, and in a place that is not accessible to children or pets, or individuals who should not be handling the cannabis-based products.

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QUESTION: What are some of the microbial and fungal contaminants that can be present in cannabis products?

ANSWER: Aspergillus and Salmonella and Aflatoxin may be present in cannabis products. It is important to review the certificate of analysis to determine if the cannabis product contains any of these contaminants.

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QUESTION: What should be listed on a Certificate of Analysis (CoA)?

ANSWER: First, a Certificate of Analysis (CoA) should be from an independent and properly certified testing laboratory, and not from the retailer. CoA should show the amount and concentration of major cannabinoids and terpenes present in the tested sample, as well as testing data regarding the lack of (or presence of) microbial organisms, fungal contaminants, the levels of heavy metals, and amount of pesticide and residual solvents.

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QUESTION: Does raw cannabis flower contain CBD or CBDA?

ANSWER: The raw flower contains CBDA (the acid form of cannabidiol). When the raw cannabis material is heated via vaporization, smoking or baking, the CBDA is converted to CBD.

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QUESTION: CBD products are marketed as full spectrum, broad spectrum and CBD isolate products. What are the differences between these products?

ANSWER: While full CBD spectrum products contain a full array of cannabinoids, (including THC) and terpenes, broad spectrum products are manufactured in a way that the product does not contain THC. CBD isolate products are often sold as 99%+ pure CBD and they do not contain other cannabinoids or any terpenes, unless specified on the label.

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QUESTION: How many people in the US die each day from overdoses involving PRESCRIPTION opioids?

ANSWER: According to recent data published by the Center for Disease Control (CDC), approximately 41 people/day are dying from an overdose involving prescription opioids. This CDC website – https://www.cdc.gov/rxawareness/index.html – provides resources for individuals struggling with opioid drug abuse.

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QUESTION: What is Rick Simpson oil (aka RSO)?

ANSWER: Solvent-based concentrates are made by extraction of the plant matter with chemical solvents. In this method, cannabis is soaked in the solvent and then the cannabis is removed by straining. Then, the solvent is boiled off, and a sticky cannabis resin remains. These extracts are often a very dark color (green to black) and contain residuals from the solvents used. These products are sometimes referred to as Rick Simpson Oil (RSO), named after the individual that made this type of extraction popular.

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QUESTION: Some people consume cannabinoids via “dabbing.” Describe this method of consumption.

ANSWER: Basically, with dabbing, a cannabis concentrate is applied to a hot platform and the cannabinoids are volatilized. The vapor then passes through a water-pipe device and is inhaled by the consumer. The hot platform (commonly called “the nail”) is usually constructed from quartz, ceramic or titanium. This nail is heated, often with a blow torch, and after the nail is hot, a small amount of cannabis concentrate is applied. Vaporization of the cannabinoids is immediate. Inhalation by the consumer during application of the cannabis concentrate draws the vapors from around the nail into the water pipe.

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QUESTION: Other than butane, what are some of the chemical solvents used to create cannabis concentrates? Other than using solvents to create cannabis concentrates, what other methods to produce cannabis concentrates can be used?

ANSWER: Hexane, isopentane, isopropyl alcohol, acetone, and propane are used to make cannabis concentrates. In addition to using solvents, concentrates can also be manufactured via a dry method, a water-based method or a CO2 based method.

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QUESTION: Do all medical marijuana legal states allow the sale of products manufactured through butane extraction and supercritical CO2 extraction?

ANSWER: Supercritical CO2 extraction does not leave residual hydrocarbons, while butane extraction does. As a result, some states will allow the sale of supercritical CO2 extraction products, but not allow the sale of butane extracts.

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QUESTION: In addition to butane extraction, supercritical CO2 extraction is another process used to manufacture cannabis extracts. What is the major difference in the end products of the two processes?

ANSWER: Supercritical CO2 extraction does not leave any trace of hydrocarbon solvents in the end product, while butane extraction does. The viscosity of the supercritical CO2 products is less than the viscosity of the butane extraction products. As a result of a lower viscosity, supercritical CO2 extraction process products can be used in vaporizer pens on its own without cutting agents. While products derived from a butane extraction are used in dabbing, products derived from supercritical CO2 extraction are not.

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QUESTION: Some patients may use shatter, budder, crumble, pull-and-snap, and/or wax. Are all of these products exactly the same?

ANSWER: All of these products are cannabis extracts, but it is the specific manufacturing/ processing of the hash oil cannabis products that will determine the consistency of the product. Depending upon the consistency and other physical characteristics, the product will be called shatter, budder, crumble, pull-and-snap or wax.

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QUESTION: Does short term treatment with THC rich cannabis induce clinical remission and improve quality of life in patients with mild to moderately active ulcerative colitis?

ANSWER: Yes, according to a recent study. However, these beneficial clinical effects were not associated with significant anti-inflammatory improvement in the Mayo endoscopic score or laboratory markers for inflammation. These results were derived from a double-blind, randomized, placebo-controlled trial, – 32 patients received either cigarettes containing 0.5 g of dried cannabis flowers with 80mg THC or placebo cigarettes for 8 weeks. Parameters of disease including Lichtiger disease activity index, C reactive protein (CRP), calprotectin, Mayo endoscopic score and quality of life (QOL) were assessed before, during and after treatment.

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QUESTION: In some legal states, edibles, such as candies, baked goods, beverages and condiments (butter and oils) containing THC may be sold. Is 2.5mg of THC in an edible a low dose or high dose of THC to be consumed orally?

ANSWER: The dosing of THC always needs to be adjusted on an individual basis. For reference, 2.5 mg is the lowest dose of dronabinol, a synthetic THC that is FDA-approved.

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QUESTION: When speaking with their clinicians, patients may use the terms “dabs”, “wax”, or “butane honey oil” – what do these terms mean?

ANSWER: Dabs, wax and butane honey oil are all highly concentrated cannabis extracts of THC. These THC products are often smoked or vaporized. Because these THC products are quite highly concentrated, the consumption of only a very small amount may produce a significant effect.

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QUESTION: What is “hashish”?

ANSWER: Hashish is a crude product made up of compacted sticky resin glands of the cannabis plant. The popularity of hashish has been diminished by the availability of cannabis concentrates.

reference: Special Report | February 2018
Contemporary Routes of Cannabis Consumption: A Primer for Clinicians
Jeramy Peters, DO; Joseph Chien, DO
The Journal of the American Osteopathic Association, February 2018, Vol. 118, 67-70. doi: https://doi.org/10.7556/jaoa.2018.020

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QUESTION: Are smoking marijuana and vaporizing marijuana equally efficient? (In other words, are the cannabinoids absorbed to the same extent with smoking vs. vaporizing? )

ANSWER: When ingesting marijuana via a vaporizer, the user absorbs up to 33% of the total cannabinoids present in herbal mixture. When smoking, an individual typically absorbs about 25% of the cannabinoids present in herbal mixture.

reference: Special Report | February 2018
Contemporary Routes of Cannabis Consumption: A Primer for Clinicians
Jeramy Peters, DO; Joseph Chien, DO
The Journal of the American Osteopathic Association, February 2018, Vol. 118, 67-70. doi: https://doi.org/10.7556/jaoa.2018.020

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QUESTION: The amounts of marijuana in a joint, blunt, spliff or bowl are not standardized. How does a clinician estimate the amount of marijuana being used by the patient?

ANSWER: When trying to assess the quantity of marijuana consumed by a patient, multiple questions should be addressed, including: how often and how much the patient typically purchases, how many bowls (or joints, or blunts or spliffs) the patient smokes each time he consumes marijuana, and how many times he uses marijuana before he needs to purchase again. It must be noted that the total amount of cannabinoids present in marijuana is not equal to the amount that is ingested. (when smoking, an individual typically absorbs about 25% of the cannabinoids present in herbal marijuana mixture.) Also, the concentration of the cannabis-based product must be considered, as well.

reference: Special Report | February 2018
Contemporary Routes of Cannabis Consumption: A Primer for Clinicians
Jeramy Peters, DO; Joseph Chien, DO
The Journal of the American Osteopathic Association, February 2018, Vol. 118, 67-70. doi: https://doi.org/10.7556/jaoa.2018.020

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QUESTION: Are smoking marijuana and vaporizing marijuana equally efficient? (In other words, are the cannabinoids absorbed to the same extent with smoking vs. vaporizing? )

ANSWER: When ingesting marijuana via a vaporizer, the user absorbs up to 33% of the total cannabinoids present in herbal mixture. When smoking, an individual typically absorbs about 25% of the cannabinoids present in herbal mixture.

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QUESTION: A patient may be speaking to you about his marijuana consumption, and he may use the terms joints, blunts and spliffs, and bowl. What do these terms mean?

ANSWER: A joint is a cigarette of marijuana, a blunt is a marijuana cigar, and a spliff can refer to marijuana mixed with tobacco, though some people use this term when referring to a cone-shaped joint with a filter. A bowl refers to the chamber of a pipe.

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QUESTION: In patients 60 years old or older, does long term (3 months) marijuana use impact blood pressure?

ANSWER: According to a recent study that was published in the European Journal of Internal Medicine, amongst adults 60 years or older with hypertension, marijuana treatment for 3 months was associated with a reduction in 24-hours systolic and diastolic blood pressure. At 3 months follow-up, the mean 24-hours systolic and diastolic blood pressures were reduced by 5.0 mmHg and 4.5 mmHg, respectively (p<0.001 for both). The nadir for the blood pressure and heart rate was achieved at 3 hours post-administration. The proportion of normal dippers changed from 27.3% before treatment to 45.5% afterward. No significant changes were seen in the different metabolic parameters assessed by blood tests, anthropometric measurements, or ECG exam.

reference: Cannabis is associated with blood pressure reduction in older adults – A 24-hours ambulatory blood pressure monitoring study Ran Abuhasira, Yosef S. Haviv, Merav Leiba, Adi Leiba, Larisa Ryvo, Victor Novack Published:January 20, 2021 DOI: European J of Int. Medicine https://doi.org/10.1016/j.ejim.2021.01.005

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QUESTION: What are the effects of cannabis-based therapies on oxaliplatin-induced peripheral neuropathy among oncology patients?

ANSWER: The results of a retrospective study indicated that the rate of neuropathy was reduced among patients treated with cannabis-based therapies and oxaliplatin. This reduction was more significant in patients who received cannabis-based products prior to treatment with oxaliplatin, suggesting a protective effect. (A large prospective trial examining the effects of cannabis-based products on oxaliplatin-induced neuropathy is planned.)

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QUESTION: In older adults, is there a significant positive association between THC dose and incidence rate ratio for dizziness or lightheadedness and thinking or perception disorder when the THC is combined with CBD?

ANSWER: A systematic review and metaregression analysis published In JAMA (February 2021) evaluated the THC neuropsychiatric symptoms among adults 50 years and older. The authors examined 30 RCTs [Randomized Controlled Trials] using THC-only cannabis-based medicines (CBM) (total THC exposure, 1252.83 person-years) and 24 RCTs using CBMs with different combinations of cannabidiol (CBD) and THC (total THC and CBD exposure, 388.56 person-years). They did find a significant positive association between THC dose and incidence rate ratio for dizziness or lightheadedness (estimate, 0.05; 95% CI, 0.02-0.08; P = .001) and thinking or perception disorder (estimate, 0.07; 95% CI, 0.03-0.11; P < .001) for the THC-ONLY studies, but there were no associations with any other neuropsychiatric adverse effects for the THC and CBD combination studies.

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QUESTION: Can prison inmates use medical cannabis?

ANSWER: In New Mexico, the prison inmates can use cannabis. In 2021, a New Mexico landmark case concluded that inmates CAN use medical cannabis. As stated by the victorious lawyer, ‟the law is clear: You must, under existing law, provide incarcerated persons with the ability to access medical cannabis free from penalty. That’s the law.” Importantly, the ruling specifies that this applies to those on probation, house arrest or in prison.

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QUESTION: In 2020, the 20 member ‘Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain’ developed recommendations for the dosing of cannabinoids for patients suffering with severe pain. What were those recommendations?

ANSWER: According to the recommendations of the ‘Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain,’ patients suffering from severe pain and those patients who have a history of significant prior cannabis consumption can use a 50:50 CBD-THC product and start with a dose of 2.5-5 mg of each compound 1 or 2 times/day.

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QUESTION: In 2020, recommendations for the dosing of THC in the elderly population were developed by the 20 member ‘Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain.’ What were their recommendations for the dosing of THC in the elderly population?

ANSWER: According to the recommendations of the ‘Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain,’ elderly patients, patients with severe co-morbidity or patients who take multiple medications should be managed through a conservative route; start with THC doses at 1 mg/day and the dose should be titrated up slowly.

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QUESTION: What are some of the more common reasons dermatologists recommend cannabinoid-based medicines?

ANSWER: According to the results of a survey of 145 dermatologists, 91 % of dermatologists were in support of medical cannabis use and 13.8 % have recommended it for a dermatologic condition. Atopic dermatitis (45 %) and psoriasis (40 %) were the most common. The most common form of administration was topical (75 %). The main reasons for not recommending medical cannabis were limited knowledge (56 %) and lack of experience (48 %).

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QUESTION: In 2020, the 20 member ‘Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain’ developed recommendations for the dosing of cannabinoids. For what pain conditions are medical cannabinoids a viable option?

ANSWER: According to the global task force, cannabinoids may be effective for neuropathic, inflammatory, nociplastic* and mixed pain conditions. *Nociplastic pain is defined as: “Pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.”

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QUESTION: Have any PRECLINICAL studies shown that cannabinoids have anti-neoplastic (anti-cancer) effects?

ANSWER: Yes – PRECLINICAL studies have shown that cannabinoids exhibit anti -tumor properties in different ADULT cancers, including breast, melanoma, pancreatic, lymphoma, glioblastoma, lung, hepatocellular, colorectal, prostate, and other cancers. This data has been obtained from EXPERIMENTAL models of cancer, including genetically engineered mouse models.

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QUESTION: The use of cannabinoid-based products for medicinal purposes is legal in Canada at the federal level. Is the medicinal use of cannabinoid-based products legal at the federal level in Mexico, too?

ANSWER: Yes, as of January 13, 2021, the use of cannabinoid-based products for medicinal purposes is legal in Mexico. Mexican President López Obrador published regulations for the production, research and use of medicinal marijuana. The federal government’s official gazette published the new regulations that authorize the government to oversee the production of marijuana for research and medicinal purposes. Pharmacies will be allowed to supply cannabis-based medicines to authorized patients. In addition, the regulatory framework permits the importation of seeds, cannabis derivatives to be used in medicinal products, and processed marijuana-based medications to Mexico.

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QUESTION: Does the National Basketball Association (NBA) test their players for cannabis use?

ANSWER: Prior to the 2020-2021 season, the NBA had randomly conducted cannabis testing on players, but the NBA and National Basketball Players Association announced they will stop testing players for cannabis use during the 2020–2021 season in response to the stress and quarantining brought on by the COVID-19 global pandemic, and also based on COVID safety to limit unnecessary contacts,. Although cannabis testing is paused for now, random testing for performance-enhancing drugs will continue.

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QUESTION: As of 2018, what percentage of the population uses marijuana?

ANSWER: The 2018 World Health Organization (WHO) data suggest that approximately 2.5% of the global population (147 million) use marijuana.

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QUESTION: Researchers have evaluated the anti-neoplastic (anti-cancer) effects of cannabinoids. What have the results indicated?

ANSWER: Over the past two decades, PRECLINICAL data indicate that THC, CBD, as well as some synthetic cannabinoids induce apoptosis of cancer cells and inhibit tumor proliferation, metastasis, and angiogenesis. Note: The results of preclinical trials are NOT equivalent to clinical trials.

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QUESTION: What are the two most well-studied endocannabinoids?

ANSWER: The best-characterized endocannabinoids are 2-arachidonoylglycerol (also called 2-AG) and N- arachidonoylethanolamide (also called AEA or anandamide). These endocannabinoids are lipid-based molecules that are synthesized from arachidonic acid from the cellular membrane. These two endocannabinoids are signaling molecules that bind to and stimulate cannabinoid receptors CB1R and CB2R.

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QUESTION: Which US states had the greatest sales of cannabis products in 2020?

ANSWER: Florida, a medical marijuana only state, had more than $1.2 billion in sales, and was the nation’s fourth largest cannabis market. Only California, Colorado and Washington (all medical and recreational use states) out sold Florida.

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QUESTION: CB1 receptors are expressed by neurons in the brain, especially in the cerebral cortex, basal ganglia, cerebellum, and hippocampus. Are CB1 receptors expressed in other parts of the nervous system? Are CB1 receptors present on cells outside of the nervous system?

ANSWER: In addition to being expressed by neurons in the brain, CB1 receptors are also expressed in parts of the peripheral and autonomic nervous system. CB1 receptors are also expressed on several other tissues, including heart, lung, reproductive organs, thymus and spleen.

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QUESTION: Does the consumption of THC and CBD via vaporization impair driving ability?

ANSWER: A recent study published in JAMA examined the magnitude and duration of driving impairment following vaporization of cannabis containing various concentrations of THC and CBD. The results of the study indicated that the impairment of driving after consuming vaporized THC-dominant and 50:50 THC/CBD cannabis compared with placebo was significantly greater at 40-100 minutes but not at 240-300 minutes after vaporization. There were no significant differences between CBD-dominant cannabis and placebo found, but the doses tested may not represent common usage.

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QUESTION: To which receptor do cannabinoids bind that impact pain sensation?

ANSWER: In addition to acting on cannabinoid receptors (CB1 and CB2), cannabinoids may modulate pain by interacting with the G protein-coupled receptor 55 (GPR55) and GPR18 and other G protein-coupled receptors such as serotonin and opioids receptors. Cannabinoids also interact with TRPV-1 receptors. CBD and THC (along with the endocannabinoid, Anadamide) activate glycine receptors, and as a result, lead to analgesia in inflammatory and neuropathic pain.

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QUESTION: Does the anti-fungal agent ketoconazole interact with cannabinoids?

ANSWER: Yes. Ketoconazole Inhibits the metabolism of THC and CBD and can significantly increase concentrations of THC and CBD. In contrast, drugs such as rifampicin, carbamazepine and St John’s Wort induce cytochrome enzyme activity and lower THC and CBD concentrations.

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QUESTION: If a patient is allergic to tomatoes or tobacco, is the patient a good candidate for medical marijuana therapy?

ANSWER: Patients who have previously experienced an allergic reaction to tobacco or tomato are at increased risk for developing an allergy to the products from the cannabis plant.

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QUESTION: Is a “full spectrum” product the same as a “whole plant” product?

ANSWER: No. “Whole plant” products contain fats, waxes and fibrous materials not found in “full spectrum” products.

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QUESTION: What does “full spectrum” marijuana mean? What does “broad spectrum” mean?

ANSWER: Full spectrum means that the product contains all of the original compounds found in the flower of the cannabis plant (cannabinoids, terpenes and flavonoids). In contrast, broad spectrum products are processed in such a manner as to ensure that the final product does NOT contain THC.

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QUESTION: Describe the exact mechanism of action of Epidiolex.

ANSWER: According to the Epidiolex FDA Approved Package Insert, (Greenwich Biosciences, Inc.), the precise mechanism(s) by which Epidiolex exerts its anticonvulsant effects in humans are unknown. It does not appear to be through cannabidiol receptors.

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QUESTION: Have the results of studies examining the impact of maternal marijuana use identified a unique phenotypic congenital anomaly?

ANSWER: Studies evaluating maternal use of marijuana have not found a unique phenotypic signature of prenatal exposure of marijuana. There does appear to be an increased risk of congenital anomalies, particularly gastroschisis, though.

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QUESTION: In 2018, Epidiolex was approved for the treatment of seizures associated with two rare and severe forms of epilepsy, Lennox-Gastaut syndrome (LGS) and Dravet syndrome (DS). Has the FDA approved Epidiolex for any other conditions since 2018?

ANSWER: Yes. On July 31, 2020, the U.S. Food and Drug Administration approved Epidiolex (cannabidiol or CBD) oral solution for the treatment of seizures associated with tuberous sclerosis complex (TSC) in patients one year of age and older.

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QUESTION: Does the use of cannabinoid-based products impact female sexual function, including desire, arousal, lubrication, orgasm, satisfaction, and pain?

ANSWER: According to a study published in the journal Sexual Medicine, an increased frequency of marijuana use is associated with improved sexual function among females. (i.e. – sexual desire increased, arousal increased, orgasm domain increased, and sexual satisfaction increased.) Interestingly, it was noted that chemovar type and method of consumption did not impact outcomes, though.

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QUESTION: Does consuming a high fat/high calorie meal at the same time as you take liquid CBD orally impact the amount of CBD absorbed into the bloodstream?

ANSWER: Yes. According to studies performed by a pharmaceutical company that manufactures an FDA- approved CBD product, a high fat/high calorie meal can increase CBD absorption by up to 5 fold.

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QUESTION: Did the United Nations Commission for Narcotic Drugs vote in December 2020 to accept the World Health Organization’s (WHO) recommendation to remove cannabis and cannabis resin for medicinal purposes from Schedule IV of the 1961 Single Convention on Narcotic Drugs?

ANSWER: Yes, and it was a close one (27 to 25), with the United States and many European nations in favor. The US published a statement about its rationale for the vote – “The vote of the United States to remove cannabis and cannabis resin from Schedule IV of the Single Convention while retaining them in Schedule I is consistent with the science demonstrating that while a safe and effective cannabis-derived therapeutic has been developed, cannabis itself continues to pose significant risks to public health and should continue to be controlled under the international drug control conventions. Further, this action has the potential to stimulate global research into the therapeutic potential and public health effects of cannabis, and to attract additional investigators to the field, including those who may have been deterred by the Schedule IV status of cannabis.”

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QUESTION: The House of Representatives approved the MORE Act. Is marijuana legal now?

ANSWER: The House of Representatives approved the bill called the MORE Act on December 4, 2020, but marijuana is not legal at the federal level. The bill must go to the Senate, and then the White House for the President to sign. Until the President signs it, it’s not a law – it’s just a bill.

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QUESTION: What is the MORE act?

ANSWER: The Marijuana Opportunity, Reinvestment, and Expungement (MORE) Act (HR 3884 / S. 2227) is bipartisan legislation that removes marijuana from the Controlled Substances Act, thus decriminalizing the substance at the federal level and enabling states to set their own policies.

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QUESTION: Do cannabinoids affect cardiac function?

ANSWER: Low doses of cannabinoids have been associated with tachycardia, hypertension and increased contractility (an increased sympathetic response). In contrast, high doses of cannabinoids enhance parasympathetic tone leading to dose-dependent bradycardia and hypotension.

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QUESTION: What percentage of US medical marijuana legal states list cancer as a qualifying condition?

ANSWER: Cancer is listed as a qualifying condition in 100% of the US medical marijuana states, but the patterns of cannabinoid use among patients with breast cancer (one of the most common cancers in the US) is unknown. NOTE: Cannabinoids have been shown to ameliorate some of the symptoms associated with cancer and the side effects associated with some cancer treatments, however, cannabinoids have not been shown to be an effective anti-cancer agent.

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QUESTION: Epidemiological studies indicate that as many as 15% of inflammatory bowel disease (IBD) patients may use cannabinoids to ameliorate some of their symptoms, including improvement in diarrhea, abdominal pain and appetite. Do the studies show that cannabinoids are effective?

ANSWER: There are few studies evaluating cannabinoid use in IBD, and those studies are small. In Crohn’s disease, it has been demonstrated that THC reduces the Crohn’s disease activity index by >100 points (on a scale of 0–450). Also, two small studies involving ulcerative colitis patients showed a marginal benefit. However, no improvement in inflammatory markers or in endoscopic score in either disease was detected.

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QUESTION: The findings of multiple randomized controlled trials (RCTs) indicate that cannabinoids effectively treat chronic pain. Do cannabinoids effectively treat the chronic pain associated with fibromyalgia?

ANSWER: No. According to a Cochrane systematic review published in 2016 on the use of cannabinoids to treat fibromyalgia, there is no convincing, unbiased, high-quality evidence suggesting that a cannabinoid-based medicine (nabilone) is of value in treating people with fibromyalgia. Furthermore, the tolerability of nabilone was low in people with fibromyalgia. Also, the results of a 2019 study where 4 varieties of pharmaceutical grade marijuana were administered by single shot vapor to fibromyalgia patients indicated that none of the 4 marijuana varieties had an effect greater than placebo. (Note: The data from the 2019 study could not be used to extrapolate the long-term effects of cannabinoids on fibromyalgia-associated pain.)

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QUESTION: Some cancer patients use medical marijuana to treat various cancer-associated ailments. What are some of the ailments ameliorated by medical marijuana?

ANSWER: According to one study involving 96 cancer patients receiving supportive cancer care, the data support the safety and effectiveness of medical marijuana as a complementary option for improving pain control, appetite and quality of life for cancer patients. The top three adverse events of this study included drowsiness, low energy and nausea, and were reported in 28% of patients, with 9% having to stop using the medical marijuana. (Note: other studies indicate that chemotherapy-induced nausea and vomiting is ameliorated by medical marijuana.)

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QUESTION: Side effects of short-term cannabinoid-based therapy may differ from person to person, and the same person may experience different side effects at different times. What factors influence the probability and the severity of adverse events?

ANSWER: Many factors influence the likelihood and the severity of adverse events, including the type of cannabinoid preparation; the mode of administration; the dose administered; the patient’s expectations, the patient’s prior experience with cannabinoid-based therapies, and the age of the patient. Drug–drug interactions may also lead to adverse events.

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QUESTION: Side effects of short-term cannabinoid-based therapy may differ from person to person, and the same person may experience different side effects at different times. What factors influence the probability and the severity of adverse events?

ANSWER: Many factors influence the likelihood and the severity of adverse events, including the type of cannabinoid preparation; the mode of administration; the dose administered; the patient’s expectations, the patient’s prior experience with cannabinoid-based therapies, and the age of the patient. Drug–drug interactions may also lead to adverse events.

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QUESTION: What is Sativex®?

ANSWER: Sativex® is a buccal (oral) spray containing Δ-9-THC and CBD (2.7 mg Δ-9-THC and 2.5 mg CBD per spray) and it is indicated for spasticity and neuropathic pain in multiple sclerosis, and as adjunctive analgesia for moderate to severe cancer pain. While Sativex® is approved in several European countries, Canada, and other countries, it has not been approved for medical use in the U.S.

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QUESTION: Other than feeling “high” what are some of the reported psychological CNS-related side effects associated with cannabinoid use?

ANSWER: Psychological side effects associated with cannabinoid use include: restless/anxiety/nervousness, depressed mood, dysphoria, confusion, dissociation, hallucinations, hyperactivity, weird dreams, paranoia and psychosis.

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QUESTION: Are cannabinoids an effective analgesic agent in the acute pain setting?

ANSWER: No. According to the results of multiple randomized controlled trials examining the efficacy of cannabinoids to treat acute pain, THC, nabilone and other cannabinoid-based products were not associated with a reduction in pain, but were associated with adverse side effects, including sedation.

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QUESTION: What are the common modes of administration of medical marijuana used by cancer patients?

ANSWER: According to a survey completed by 183 cancer patients of an oncology clinic at Sutter Medical Center in Sacramento, California, over 50% reported use of oils and tinctures and 44% used edibles. A smaller percentage consumed cannabis-based products via vaping (26%) or smoking (30%). Topical use was preferred by fewer patients (17%). Over 58% of patients stated they used more than one method.

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QUESTION: What CBD products, if any, have been evaluated and approved by the FDA?

ANSWER: CBD is marketed in various forms, including oils, capsules, food products, cosmetics/topical lotions and creams, and CBD products are marketed for pets, too. These products are sold in grocery stores, specialty stores, and convenience stores across the US and on the internet. However, only one prescription CBD product has been approved by the FDA. It is called Epidiolex. It is approved to treat rare, severe pediatric epilepsy disorders.

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QUESTION: On the current (last revised May 2020) US Department of Justice Firearms Transaction Record form, is there a question related to the unlawful use of, or addiction to marijuana, depressants, stimulants, narcotics and other controlled substances?

ANSWER: Yes. There is a question related to drug use. In fact, there is a warning note that reads as follows: “Warning: The use or possession of marijuana remains unlawful under Federal law regardless of whether it has been legalized or decriminalized for medicinal or recreational purposes in the state where you reside.”

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QUESTION: Does consuming a high fat/high calorie meal at the same time as you take liquid CBD orally impact the amount of CBD absorbed into the bloodstream?

ANSWER: Yes. According to studies performed by a pharmaceutical company that manufactures the FDA-approved CBD product called Epidiolex, a high fat/high calorie meal can increase CBD absorption by up to 5 fold.

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QUESTION: What psychiatric condition is most often listed as a qualifying condition for medical marijuana?

ANSWER: The psychiatric diagnosis most often listed as a qualifying condition by the medical marijuana legal US states is PTSD, but other psychiatric diagnoses include Tourette syndrome, Alzheimer’s disease, and autism.

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QUESTION: Is marijuana use linked to higher hospital mortality in COPD patients?

ANSWER: Actually, no. According to a nationwide population-based study, patients diagnosed with COPD who reported using marijuana had less risk of in-hospital mortality and pneumonia than non-users. The results from this study, which was performed by Yale physicians, indicated that marijuana use was associated with a 37.6% reduction in the odds of dying in the hospital (OR 0.624, 95% CI 0.407-0.958, P=0.0309) among COPD patients. This same study also found that COPD patients who admitted to using marijuana had an 11.8% lower risk of pneumonia (OR 0.882, 95% CI 0.806-0.964, P=0.0059). Note: these findings may be a correlation rather than a causation, according to some clinicians not associated with the study. Also, the authors performed a retrospective analysis of COPD-associated hospitalizations over the years 2005-2014. (Pre-COVID)

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QUESTION: Is there a governmental office to which patients can report any adverse effects from CBD products?

ANSWER: Yes, even though CBD (with the exception of Epidiolex) is not approved by the FDA, patients can report any adverse effects from CBD products to the FDA’s MedWatch program.

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QUESTION: To date, has the FDA approved cannabis for the treatment of any psychiatric condition?

ANSWER: No. However, the FDA has approved 1 cannabis-derived medication (CBD) called Epidiolex and 2 cannabis-related medications (dronabinol and nabilone) for specific indications. Dronabinol is a synthetic THC product that is used as an antiemetic agent. It is approved for treating or preventing nausea and vomiting caused by chemotherapeutic agents, and as an appetite stimulant for individuals with AIDS. Nabilone is a synthetic that is structurally similar to THC. It is approved for treating chemotherapy induced nausea and vomiting.

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QUESTION: What percentage of Americans support marijuana legalization?

ANSWER: In a 2019 Pew Research Center survey, 67% of Americans supported marijuana legalization. Since that 2019 survey, more US states have legalized recreational marijuana.

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QUESTION: Does ketamine interact with cannabinoids?

ANSWER: Yes. Ketamine is a CYP3A4 substrate, and thus may inhibit the metabolism of cannabinoids, including THC. This, in turn, can increase blood levels of cannabinoids and possibly lead to fatal dysrhythmias, heart attack, or stroke, according to the American Heart Association. Also, ketamine levels may increase which can lead to negative effects, including agitated delirium, respiratory depression (ketamine is primarily an NMDA antagonist, but it may also bind to mu and the sigma receptors.)

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QUESTION: What is the most common reason for cannabinoid use among cancer survivors?

ANSWER: The most common reason for cannabinoid use among cancer survivors was pain. Other common reasons why cancer survivors used cannabinoids include sleeping problems and anxiety.

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QUESTION: What are the most common reasons older adults use cannabis-based products?

ANSWER: According to an anonymous survey of 568 adults age 65 or older, the majority (78%) used cannabinoids for medical purposes only, with the most common targeted conditions/symptoms being pain/arthritis (73%), sleep disturbance (29%), anxiety (24%), and depression (17%). Of note, only 41% reported that their healthcare provider knew that they use cannabinoids for medicinal purposes.

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QUESTION: Are symptoms of OCD significantly reduced after smoking or vaporizing marijuana?

ANSWER: Data from an app that tracks the changes of medical marijuana patients’ symptoms as a function of different doses and strains of cannabis across time was analyzed. The results indicate that inhaled cannabinoids appear to have short-term beneficial effects on symptoms of OCD. However, tolerance to the effects on intrusions may develop over time.

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QUESTION: Which US states have legalized adult-use marijuana possession and have also legalized adult-use marijuana sales?

ANSWER: As of October 10, 2020, the following 11 US states had legalized adult use marijuana possession and adult use marijuana sales: Alaska, California, Colorado, Illinois, Maine, Massachusetts, Michigan, Nevada, Oregon, Vermont, and Washington. Washington DC and Guam have also legalized adult use marijuana sales. In November 2020, Arizona, Montana, New Jersey and South Dakota legalized recreational marijuana, too.

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QUESTION: Are there any US states that do NOT deny solid organ transplants for patients that use marijuana for medicinal purposes?

ANSWER: Legislation has passed in at least 7 US states (California, Washington, Illinois, Arizona, Delaware, New Hampshire, and Maine) that explicitly forbids denial of transplantation listing on the basis of an individual’s use of medical marijuana. *Of note, transplant recipients take immunosuppressive drugs, and inhaled smoked or vaporized marijuana can expose the consumer to life-threatening pulmonary infections (Aspergillosis, for example). Typically, most US state solid organ transplant programs have recommended that individuals with active drug or alcohol abuse not undergo transplantation.

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QUESTION: Does THC stimulate the sympathetic or parasympathetic system?

ANSWER: Tetrahydrocannabinol stimulates the sympathetic nervous system while inhibiting the parasympathetic nervous system. After THC consumption, there may be increases heart rate, myocardial oxygen demand, supine blood pressure, and platelet activation. (Of note, THC is associated with endothelial dysfunction and oxidative stress.)

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QUESTION: What is the half life of CBD? How does it compare to the half life of THC?

ANSWER: The half life of CBD is 18-32 hours, which is similar to the half life of THC of 20-30 hours. Both CBD and THC are distributed to fatty tissues and highly perfused organs such as brain, heart, lung, and liver.

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QUESTION: At what point during gestation are endocannabinoid receptors expressed in the fetus?

ANSWER: Endocannabinoid receptors are first expressed in the fetus at 5 to 6 weeks’ gestation.

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QUESTION: Did past-month cannabis use among pregnant US women increase or decrease during the 15 year span of 2002 to 2017?

ANSWER: Past-month cannabis use among pregnant US women more than doubled from 2002 (3.4%) to 2017 (7.0%).

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QUESTION: Is prenatal exposure to cannabis associated with child outcomes?

ANSWER: The results of a cross-sectional analysis published in a September 2020 JAMA Psychiatry journal, indicate that prenatal exposure does impact child outcome. This particular cross-sectional analysis involved 11,489 children (655 exposed to cannabis prenatally) and the findings indicate that prenatal cannabis exposure after maternal knowledge of pregnancy was associated with greater psychopathology (i.e., internalizing, externalizing, attention, thought, and social problems, as well as psychotic-like experiences) during middle childhood, even after accounting for potentially confounding variables.

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QUESTION: Does marijuana use during pregnancy affect the birth weight of the baby?

ANSWER: Yes. According to a 2018 study by Campbell et al., marijuana use during pregnancy triples the likelihood of having a low birth weight baby, even after adjusting for factors such as socioeconomic status, medical history, and other substance use such as tobacco smoking

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QUESTION: What percentage of 12th graders in the US have used marijuana at least once in their life?

ANSWER: According to the National Institute on Drug Abuse’s Monitoring the future, nearly one half of all 12th-graders in the United States have used marijuana in their lifetime, with more than one third during the past year, and almost one quarter in the past month.

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QUESTION: What percentage of individuals who misuse prescription opioids seek treatment?

ANSWER: Only 8% of individuals who misuse prescription opioids seek treatment. Of note, approximately 80% of heroin users first misused prescription opioids.

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QUESTION: How does CBD impact the cardiovascular system?

ANSWER: CBD reduces heart rate and blood pressure, and improves vasodilation in models of endothelial dysfunction. Also, CBD reduces inflammation and vascular hyperpermeability in diabetic models.

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QUESTION: Compared to previous years, has the number of opioid deaths since the COVID pandemic increased or decreased?

ANSWER: Since the beginning of the COVID-19 pandemic, a dramatic increase in the number of opioid overdose deaths has been reported. According to a recent report put out by the American Medical Association, opioid overdose deaths have increased in more than 35 states since the pandemic began. This surge is believed to be multifactorial, and due to isolation, economic issues, disruptions to the drug trade and other factors.

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QUESTION: How many adolescents in the US misused opioids in 2018?

ANSWER: In 2018, 699,000 adolescents between the ages of 12 and 17 misused opioids, with the vast majority misusing prescription opioids. Of these 699,000 adolescents, 108,000 had opioid use disorder.

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QUESTION: Does substance use disorder increase the risk for COVID-19?

ANSWER: Yes, according to an analysis of electronic health records (EHR). As reported by Nora D. Volkow, MD, director of the National Institute on Drug Abuse, and colleagues, the evaluation of over 73 million electronic health records, the risk of COVID-19 was far greater among patients diagnosed with a substance use disorder in the past year compared with the general population after adjusting for age, gender, race, and insurance type.

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QUESTION: Does the oral administration of CBD alter plasma concentrations of diazepam?

ANSWER: CBD can alter the toxicity or efficacy of other drugs through inhibition of certain enzymes. For example, increases in the plasma concentration of diazepam have been reported when the diazepam is coadministered with Epidiolex (a CBD product).

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QUESTION: Has the use of a transdermal gel for regional and systemic delivery of CBD been evaluated for the treatment of epilepsy?

ANSWER: Yes. A transdermal gel for regional and systemic delivery of CBD (Zynerba Pharmaceuticals) is in clinical development for treatment of epilepsy, developmental and epileptic encephalopathy, fragile-X syndrome, and osteoarthritis. NOTE: As of September 2020, the company’s website indicates that the product is not yet approved by government regulatory bodies, including the United States Food and Drug Administration (FDA) and other agencies, and must be tested to see if it is an effective and safe treatment.

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QUESTION: Is cannabidiol in compounded topical pain creams safe to use?

ANSWER: According to the National Academies of Science, Engineering and Medicine’s 2020 publication A Review of the Safety and Effectiveness of Select Ingredients in Compounded Topical Pain Creams, “there is insufficient evidence on the safety of topical application of cannabidiol. However, if systemic absorption to therapeutic levels is achieved through topical application, there is potential for side effects similar to other routes of administration (e.g., oral).”

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QUESTION: Does cannabidiol in compounded topical pain creams penetrate the skin of animals?

ANSWER: According to the National Academies of Science, Engineering and Medicine’s 2020 publication, A Review of the Safety and Effectiveness of Select Ingredients in Compounded Topical Pain Creams, “there is limited preclinical evidence to suggest that cannabidiol penetrates animal skin. Modifications to the ingredient or excipient may increase aqueous solubility and increase absorption.”

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QUESTION: In PRECLINICAL studies, it has been shown that cannabinoids induce apoptosis of cancer cells. Do cannabinoids induce apoptosis of normal non-malignant cells?

ANSWER: According to the results of PRECLINICAL studies, including in vitro studies and and studies in mice, cannabinoids induce apoptosis of cancer cells without causing negative effect on the viability of normal non-malignant cells. In some mouse models, it has been noted that cannabinoids act synergistically with standard anti-cancer drugs or radiation therapy to reduce tumor growth. These studies have not detected overt signs of toxicity in the treated animals. NOTE: The observations noted in culture or animal models do NOT always readily translate into clinical benefit.

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QUESTION: Most of the currently available scientific evidence for anti-neoplastic activity of cannabinoids is derived from PRECLINICAL models, including in vitro studies and studies involving mouse models. What have the results of these PRECLINICAL studies indicated?

ANSWER: These PRECLINICAL studies have reported that THC and some other cannabinoids can activate the CB1 and CB2 receptors on the surface of cancer cells and impact the intracellular signaling pathways of the cancer cells. Some effects include (1) apoptosis of the cancer cells (2) the blockade of cancer cell proliferation (3) inhibition of tumor angiogenesis and (4) inhibition of metastasis. NOTE: the results of PRECLINICAL studies do NOT always correlate with CLINICAL outcome/benefit.

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QUESTION: Clinical trials evaluating the use of human monoclonal antibodies against interleukin 1 and interleukin 6 to treat cytokine storm syndrome in COVID-19 patients are underway or in the planning stage. Are there any possible significant pharmacodynamic interactions between monoclonal antibodies and CBD?

ANSWER: Yes. The combination of monoclonal antibody agents, including eculizumab and sarilumab, or other immuno/myelosuppressive agents with CBD may potentiate the risk of infection.

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QUESTION: Nelfinavir is an HIV-1 protease inhibitor. Patients who have HIV may be taking this drug and may also be using cannabinoids to treat some of the symptoms associated with the HIV infection. Does Nelfinavir interact with CBD? (Of note, Nelfinavir may also inhibit SARS-Cov-2 replication.)

ANSWER: The combination of Nelfinavir and CBD may lead to an increase risk of diarrhea and/or headache.

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QUESTION: Dexamethasone, a commonly used corticosteroid to treat various inflammatory conditions, has been recommended for use in COVID-19 patients with severe respiratory symptoms (according to data from Randomized Evaluation of COVID-19 Therapy (RECOVERY) trial). Does THC interact with dexamethasone? Does CBD interact with dexamethasone?

ANSWER: Both THC and CBD have possible pharmacodynamic interactions with dexamethasone. While the combination of THC and dexamethasone may lead to an increase in euphoria, the combination of CBD and dexamethasone may lead to a potentiation of immunosuppression and an increase in risk of infection, and could increase the risk of headache.

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QUESTION: Darunavir with cobicistat has been used to treat HIV and it has also been trialed for the treatment of COVID-19 infection. Are there any possible pharmacodynamic interactions between CBD and Darunavir/ Cobicistat?

ANSWER: Yes, this drug combination may increase headache and/or diarrhea.

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QUESTION: What is the most common qualifying condition reported by medical marijuana patients?

ANSWER: Currently and historically the most common qualifying condition reported by medical marijuana patients is chronic pain. In fact, according to an analysis by Boehnke et al, chronic pain was the qualifying condition reported by medical marijuana patients nearly 65 percent of the time (according to 2016 data).

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QUESTION: Hydrochloroquine has been trailed as a therapy for COVID-19 infections. Does this drug interact with CBD? If so, what are the potential consequences?

ANSWER: The combination of CBD and hydrochloroquine may lead to an increase of headache and/or diarrhea risk.

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QUESTION: Baricitnib, a drug approved for the treatment of rheumatoid arthritis, may reduce COVID-19 viral entry and mitigate inflammation. (A clinical trial evaluating this drug has begun in Italy .) Does CBD interact with Baricitnib?

ANSWER: Yes. A possible pharmacodynamic interaction between Baricitnib and CBD may develop, and there may be an increased effect on tumor necrosis factor. There may also be an increased risk of serious infection, malignancy or thrombosis.

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QUESTION: There may be pharmacokinetic and pharmacodynamic drug–drug interactions between cannabinoids and medications used to treat COVID infections. Azithromycin may have anti-viral activity and has been co-administered with hydroxychloroquine in a RCT of COVID treatment. Does Azithromycin interact with CBD?

ANSWER: Yes, a possible pharmacodynamic interaction may occur and lead to an increase risk for diarrhea.

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QUESTION: Did the number of naloxone prescriptions increase, decrease or stay the same during the time span of 2010 to 2018?
ANSWER: According to research conducted by the Urban Institute, prescriptions for naloxone increased by more than 70-fold from 2010 to 2018. (3,300 to 236,000 prescriptions). The most significant increase in naloxone prescriptions occurred after 2016.

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QUESTION: What have been the most frequently filled prescriptions at US pharmacies in 2020? Are most of them prescriptions for pain relief?

ANSWER: According to research conducted by GoodRx, an online platform that provides users with coupons for discounts on prescription drugs, the 10 most frequently filled prescriptions are: Atorvastatin, Lisinopril, Albuterol, Levothyroxine, Amlodipine, Gabapentin (for the treatment of nerve pain or seizures in adults), Omeprazole, Glucophage, Losartan, and Hydrocodone/acetaminophen (for the treatment of moderate to severe pain.)

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QUESTION: Greater social acceptance of marijuana may result in some prospective parents to reason that it could be used to treat morning sickness. Does marijuana use have any implications for fetal neurodevelopment?

ANSWER: A study evaluating the association between maternal marijuana use during pregnancy and child neurodevelopmental outcomes posed the following question: “Was there an association between cannabis exposure in pregnancy and child neurodevelopmental outcomes in a Canadian cohort?” The results of this retrospective study in Canada found that children exposed to marijuana in utero had a moderately elevated risk of developing autism spectrum disorder. Autism incidence was 4.0 per 1,000 person-years among children exposed to cannabis in pregnancy versus 2.42 among unexposed children (adjusted hazard ratio [HR] 1.51, 95% CI 1.17-1.96)

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QUESTION: In 2020, the 20 member ‘Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain’ developed recommendations for the dosing of cannabinoids. These recommendations were presented at a virtual meeting. One of their recommendations addressed the use of medicinal cannabinoids in patients with severe pain. What were the recommendations for the dosing of cannabinoids for patients suffering with severe pain?

ANSWER: According to the recommendations of the ‘Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain,’ patients suffering from severe pain and those patients who have a history of significant prior cannabis consumption can use a 50:50 CBD-THC product and start with a dose of 2.5-5 mg of each compound 1 or 2 times/day.

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QUESTION: In 2020, the 20 member ‘Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain’ developed recommendations for the dosing of cannabinoids. These recommendations were presented at a virtual meeting. One of their recommendations addressed the use of medicinal cannabinoids in elderly patients. What were the recommendations for the dosing of THC in the elderly population?

ANSWER: According to the recommendations of the ‘Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain,’ elderly patients, patients with severe co-morbidity or patients who take multiple medications should be managed through a conservative route; start with THC doses at 1 mg/day and the dose should be titrated up slowly.

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QUESTION: In 2020, the 20 member ‘Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain’ developed recommendations for the dosing of cannabinoids. These recommendations were presented at a virtual PAINWeek meeting. One of their recommendations included “Treat the majority of patients along the “routine” scale.” What does this mean?

ANSWER: Treating the majority of patients along the “routine” scale means to start with a dose of 5 mg of cannabidiol (CBD) twice daily, and tetrahydrocannabinol (THC) should only be added if the patient does not respond to at least 40 mg of CBD daily. If THC is added, the starting dose should be 2.5-mg daily. THC doses should be capped at 40 mg daily.

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QUESTION: In 2017, the National Academies of Sciences, Engineering and Medicine (NASEM) published The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. According to this report, are cannabinoids an effective treatment for chronic pain?

ANSWER: According to this report, “There is conclusive or substantial evidence that cannabis or cannabinoids are effective for the treatment of chronic pain in adults (cannabis).”

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QUESTION: Do cannabinoids decrease or increase g.i. motility?

ANSWER: The pharmacological actions of cannabinoids include decreased gastrointestinal motility, secretion, and emptying.

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QUESTION: Does dronabinol increase appetite in HIV/AIDS patients?

ANSWER: There is limited to moderate evidence to suggest that dronabinol, a synthetic pharmaceutical preparation of delta-9-tetrahydrocannabinol, may be effective in stimulating appetite and weight gain among patients suffering from HIV wasting syndrome. In 1992, the US Food and Drug Administration approved dronabinol for the treatment of AIDS-related anorexia.

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QUESTION: What is the most prevalent side effect of opioids in cancer patients?

ANSWER: Constipation is reported as the most prevalent and most disabling side effect of opioids in both cancer and non-cancer pain patients, with a prevalence as high as 90%.

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QUESTION: What are conduction-based vaporizers?

ANSWER: Conduction-based vaporizers heat herbal cannabis on a surface that is warmed, such as a metal plate, which then allows compounds to passively volatilize. Meanwhile, the consumer generates a steady inhalation, similar to the technique used by asthma patients with metered-dose inhalers or nebulizers to achieve pulmonary administration.

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QUESTION: What physiological systems are affected by the endocannabinoid system?

ANSWER: In addition to regulating neuronal excitability and inflammation in pain circuits, the endocannabinoid system has been shown to play a regulatory role in movement, appetite, hypothalamic-pituitary-adrenal axis modulation, immunomodulation, mood, blood pressure, bone density, tumor surveillance, neuroprotection and reproduction. The endocannabinoid system has also been shown to affect sensory perception, cardiac output, cerebral blood flow and intraocular pressure.

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QUESTION: What does cannabinergic mean?

ANSWER: Any drug that modifies or interacts with the endocannabinoid system is ‘cannabinergic’.

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QUESTION: What is the pharmacological profile of buccally administered cannabinoids?

ANSWER: With buccal administration, a mix of cannabinoids can be sprayed on to the oral mucosa and the medicine is absorbed through the mucous membranes. Peak plasma concentrations usually occur within 2-4 hrs after administration. When compared to inhalation of cannabinoids, buccal administration of cannabinoids is associated with lower blood levels of cannabinoids because absorption is slower, redistribution into fatty acids occurs rapidly and some of the cannabinoids undergo first pass metabolism.

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QUESTION: Nabiximols (a cannabinoid medicine containing THC and CBD) is approved in many European countries for the treatment of neuropathic pain, spasticity and bladder dysfunction in patients suffering from multiple sclerosis. What are the potential drug interactions between nabiximols and analgesic medications?

ANSWER: The nabiximols product monograph cautions prescribers against combining nabiximols with amitriptyline or fentanyl because these drugs are metabolized by the same enzymes as nabiximols. Potential drug interactions with other opioids (oxycodone, tramadol and methadone) also exist.

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QUESTION: What is the purpose of urine drug testing?

ANSWER: Urine drug tests typically screen for the patient’s prescribed opioids and the commonly abused drugs: cocaine, amphetamines, alcohol, barbiturates, opiates and benzodiazepines. Although a urine drug test can confirm if the patient is taking the prescribed opioid, it cannot determine if the patient is taking the prescribed dose.

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QUESTION: What are the drugs that are inhibitors to cytochrome P450 and therefore decrease the metabolism of cannabinoids?

ANSWER: THC is oxidized by the cytochrome P450 (CYP) mixed-function oxidases 2C9, 2C19 and 3A4 1. Therefore, substances that inhibit these CYP isoenzymes (e.g. fluoxetine, cimetidine, clarithromycin, ketoconazole, verapamil, indinavir, among others) can potentially increase the bioavailability of THC, and thus increase the chance of experiencing THC-related side effects.

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QUESTION: Why do NSAIDS relieve pain?

ANSWER: NSAIDs reduce the production of prostaglandin E2 (PGE2) and prostacyclin (PGI2), which mediate pain and inflammation.

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QUESTION: Describe the process of vaporization of cannabis.

ANSWER: Vaporization is a smokeless delivery system in which warm air or heat of 180°C to 200°C, rather than a flame, is used to convert cannabinoids and other compounds into a fine mist that can be inhaled. Due to their volatility, cannabinoids will vaporize at temperatures of 180°C to 200°C, but will not combust and therefore few combustion by-products such as soot or polycyclic aromatic hydrocarbons are produced. As temperatures increase, the amount of cannabinoids released increases, and the amount of combustion by-products increases, too.

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QUESTION: The pharmacological properties of cannabigerol have been investigated. What have the studies shown?

ANSWER: Cannabigerol (CBG) is the phytocannabinoid precursor molecule, and demonstrates weak partial agonism at CB1 and CB2. In in vitro studies, CBG displays analgesic and anti-erythemic effects. CBG also displays anti-hypertensive activity.

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QUESTION: The pharmacological properties of tetrahydrocannabivarin have been investigated. What have the studies shown?

ANSWER: Tetrahydrocannabivarin (THCV) is a CB1 antagonist at low doses, but displays weak agonistic effects at high doses. In obese mice models, THCV reduced appetite, produced weight loss and decreased body fat and leptin concentration.

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QUESTION: What is the pharmacologic profile of cannabis when it is vaporized?

ANSWER: The pharmacologic profile of cannabis when it is vaporized is similar to the profile when it is smoked. Psychoactive effects appear within 90 seconds, reach a maximum after 15-30 minutes, and taper off within 2-3 hours.

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QUESTION: What is the pharmacologic profile of cannabis when it is smoked?

ANSWER: When herbal cannabis is smoked, the active ingredients in cannabis are vaporized by the heat of combustion and inhaled. Inhaled constituents quickly pass from alveoli into the bloodstream and readily cross the blood-brain barrier. Psychoactive effects appear within 90 seconds, reach a maximum after 15-30 minutes, and taper off within 2-3 hours. This short onset of action makes dose titration possible, by spacing inhalations at 90-second intervals.

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QUESTION: The pharmacological properties of cannabichromene have been investigated. What have the studies shown?

ANSWER: Cannabichromene (CBC) is a potent anadamide uptake inhibitor and thus may modulate the endocannabinoid system similarly to CBD. In mice studies, it has been shown that CBC has anti-inflammatory properties and analgesic activity. CBC has other pharmacological properties, as well.

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QUESTION: The pharmacological properties of cannabinol have been investigated. What have the studies shown?

ANSWER: Cannabinol (CBN) is the oxidative by-product of THC and appears after long storage. It is a weaker partial agonist at CB1 and CB2 as compared to THC. In in vitro studies, it has been found that cannabinol is anticonvulsant and anti-inflammatory, and stimulates bone formation.

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QUESTION: It is the mixture of phytocannabinoids, terpenes and other active components present in a cannabis product that ultimately determines the therapeutic effects and side effects. Does CBD affect THC absorption and tolerance?

ANSWER: CBD has long been thought to influence the effects of THC. This thinking was extended to consider that CBD potentiates some of the beneficial effects of THC, as it reduces the psychoactive effects of THC and thus could improve tolerability. CBD may counteract some of the functional consequences of CB1 receptor activation in the brain. This effect has been used to explain why high CBD:THC cannabis use is less associated with the development of psychotic symptoms compared to low CBD:THC cannabis. Also, CBD is thought to interact with the cytochrome p450 enzymes that metabolize THC and thus may alter the metabolism and influence the effects of the THC consumed. It has been proposed that THC and CBD act synergistically in therapeutic use.

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QUESTION: Does methadone alter cardiac conduction?

ANSWER: Yes. Methadone is known to prolong QTc intervals in up to 16% of patients. Studies have shown a linear dose response curve, with higher doses leading to a higher propensity for QTc prolongation. This has led to an FDA “black box” warning for methadone and the recommendation for routine ECG monitoring.

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QUESTION: How have medical advances altered opioid use in cancer patients?

ANSWER: Cancer is no longer considered a “terminal disease.” Because of significant advances in surgical, radiation, and chemotherapeutic treatments, more than 50% of cancer patients are living greater than 2 years after the diagnosis of cancer. This allows for more cancer patients to develop chronic pain. All of these factors have led to more cancer patients taking opioids long-term.

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QUESTION: What are terpenes (or terpenoids)?

ANSWER: Terpenes are aromatic components produced in the glandular part of the cannabis plant’s flower bud. Terpenes are manufactured by many plants (not just the cannabis plant) and can be found in many food products, including coffee beans, ginger and cinnamon. Often, it is the terpenes that are responsible for a plant’s odor.

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QUESTION: Does smoking marijuana impact the metabolism of theophylline?

ANSWER: It may. Reports have indicated that smoking marijuana may increase the clearance of theophylline. Note: this effect appears to be a direct result of the hydrocarbons found in marijuana smoke rather than the cannabis-based products, as there is a lack of evidence for enzyme induction when cannabis-based drugs are consumed via oral ingestion.

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QUESTION: Do the hydrocarbons in marijuana smoke impact drug metabolism?

ANSWER: Possibly. Similar to cigarette smoke, the hydrocarbons in marijuana smoke appear to induce the activity of some cytochromes, including CYP1A2.

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QUESTION: What criteria should be used when selecting a CBD hemp product?

ANSWER: According to a 2019 Mayo Clinic publication, the following 4 questions should be asked, and the answers to each of the questions should be “yes” :
1. Does the hemp product meet the quality standards of the Current Good Manufacturing Practices Certification from the FDA, or the European Union, Australian or Canadian organic certification, or the National Science Foundation International Certification?
2. Does the manufacturer have an independent review adverse event reporting system?
3. Is the product certified organic or ecofarmed?
4. Have the company’s products been lab tested to confirm THC levels to be < 0.3% and to confirm that no pesticides or heavy metals are present?

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QUESTION: Is full spectrum CBD the same as whole plant CBD?

ANSWER: No. Whole plant CBD contains fats, waxes and fibrous materials not found in full spectrum CBD.

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QUESTION: Is the plasma concentration of Epidiolex (CBD) affected by co-administration of high fat/high calorie food?

ANSWER: Yes. It has been that if CBD is co-administered with a high fat/high calorie meal, the plasma concentration of CBD may increase by as much as 5-fold.

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QUESTION: Describe the exact mechanism of action of Epidiolex.

ANSWER: According to the Epidiolex FDA Approved Package Insert, (Greenwich Biosciences, Inc.), the precise mechanism(s) by which Epidiolex exerts its anticonvulsant effects in humans are unknown. It does not appear to be through cannabidiol receptors.

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QUESTION: Epidiolex has been approved for the treatment of seizures associated with two rare and severe forms of epilepsy, Lennox-Gastaut syndrome (LGS) and Dravet syndrome (DS). Has the FDA approved Epidiolex for any other conditions?

ANSWER: Yes. On July 31, 2020, the U.S. Food and Drug Administration approved Epidiolex (cannabidiol or CBD) oral solution for the treatment of seizures associated with tuberous sclerosis complex (TSC) in patients one year of age and older.

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QUESTION: The International Association for the Study of Pain (IASP) has updated the definition of pain. What is their new definition of pain?

ANSWER: After 40+ years, the IASP has revised their definition of pain to reflect advances in our understanding of pain. The revised definition emphasizes that tissue damage is not required. The updated definition of pain is: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” The revised definition also includes 6 notes:
1.) Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors
2.) Pain and nociception are different phenomena, and pain cannot be inferred solely from activity in sensory neurons
3.) Through life experiences, people learn the concept of pain
4.) A person’s report of an experience as pain should be respected
5.) Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being
6.) Verbal description is only one of several behaviors to express pain, and an inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain

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QUESTION: What is oliceridine (Olinvyk)? Is it a new FDA-approved opioid?

ANSWER: According to an August 7, 2020 FDA news release, “the FDA approved Olinvyk (oliceridine), an opioid agonist for the management of moderate to severe acute pain in adults, where the pain is severe enough to require an intravenous opioid and for whom alternative treatments are inadequate. Olinvyk is indicated for short-term intravenous use in hospitals or other controlled clinical settings, such as during inpatient and outpatient procedures. It is not indicated for at-home use.” https://www.fda.gov/news-events/press-announcements/fda-approves-new-opioid-intravenous-use-hospitals-other-controlled-clinical-settings

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QUESTION: What is the safety profile of Olinvyk?

ANSWER: According to an August 7, 2020 FDA news release, “The safety profile of Olinvyk is similar to other opioids. As with other opioids, the most common side effects of Olinvyk are nausea, vomiting, dizziness, headache and constipation. Olinvyk should not be given to patients with significant respiratory depression; acute or severe bronchial asthma in an unmonitored setting or in the absence of resuscitative equipment; known or suspected gastrointestinal obstruction; or known hypersensitivity to the drug. Prolonged use of opioid analgesics during pregnancy can result in neonatal opioid withdrawal syndrome.” “Olinvyk carries a boxed warning about addiction, abuse and misuse; life-threatening respiratory depression; neonatal opioid withdrawal syndrome; and risks from concomitant use with benzodiazepines or other central nervous system depressants. Unlike other opioids for intravenous administration, Olinvyk has a maximum recommended daily dose limit of 27 milligrams.” https://www.fda.gov/news-events/press-announcements/fda-approves-new-opioid-intravenous-use-hospitals-other-controlled-clinical-settings

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QUESTION: Changes in fetal growth have been described in some epidemiological studies examining the impact of maternal use of marijuana. Do the long‐term patterns of physical growth appear to be affected?

ANSWER: No, long-term physical growth does not appear to be affected. In contrast, long‐term impacts on psychological health have been noted and include increased rates of depressive symptoms and anxiety as well as delinquency.

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QUESTION: Does the use of cannabinoid-based products impact female sexual function?

ANSWER: According to a study published in the journal Sexual Medicine, an increased frequency of marijuana use is associated with improved sexual function among females. Interestingly, it was noted that chemovar type and method of consumption did not impact outcomes, though.

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QUESTION: CBD and medical marijuana are legal in Florida and California. Do the major amusement parks in these states and other legal marijuana states allow medical marijuana patients to carry CBD and medical marijuana into the amusement parks?

ANSWER: With a few exceptions, the answer is no. Medical marijuana and CBD products are not allowed in Disney parks and resorts (including hotels, shopping and restaurants). Six Flags, Universal, and Cedar Fair also prohibit all forms of legal cannabinoid products, including CBD. In contrast, Sea World properties (which include all Busch Gardens and Sea World parks) allow visitors to carry CBD—but no forms of medical marijuana with significant amounts of THC.

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QUESTION: According to an estimate by the United Nations, what percentage of the world’s population used cannabis products in 2016?

ANSWER: The UN estimated that in 2016, 3.9% of the world’s population used cannabis products. (3.9% of the world population is equivalent to ~ 192.2million people)—The UN’s data suggest that there was an increase of 16% compared with estimates of the previous decade.

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QUESTION: Does the Food and Drug Administration (FDA) currently certify the levels of THC contained within CBD products?

ANSWER: Actually, no. The FDA does not regulate the CBD products sold in convenience stores, grocery stores and on line. Although they are labeled as containing no THC, some may actually contain a small amount of THC. (Note: The FDA does monitor the CBD product called Epidiolex.)

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QUESTION: Has the FDA approved any drugs that contain a purified drug substance derived from cannabis?
ANSWER: Yes. Epidiolex oral solution contains purified cannabidiol that has been extracted from the cannabis plant, and this drug has been approved by the FDA. The FDA has also approved medications, such as marinol, that contain synthetic THC.

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QUESTION: Do cannabinoids induce clinical remission or affect inflammation in inflammatory bowel disease patients?

ANSWER: According to a systematic review with meta-analysis of the efficacy of cannabis and cannabinoids for inflammatory bowel disease, cannabis/cannabinoids do not induce clinical remission or affect inflammation in IBD patients. (No effect on inflammatory biomarkers was observed.) However, in this systematic review it was found that cannabis/cannabinoids significantly improved patient-reported symptoms and quality of life. (Clinical symptoms (abdominal pain, general well-being, nausea, diarrhea, and poor appetite) all improved with cannabis/cannabinoids on Likert-scales.) This systematic review involved 15 nonrandomized studies and 5 randomized controlled trials.

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QUESTION: In July of 2020, the FDA announced that labeling for opioid analgesics and medicine to treat opioid use disorder (OUD) must be updated. What do the updates entail?

ANSWER: The updates include that naloxone availability be routinely discussed as part of prescribing opioid analgesics and OUD medicines. The labelling changes also recommend that health care professionals consider prescribing naloxone when they prescribe medicines to treat OUD. Additionally, the labeling changes recommend “that health care professionals consider prescribing naloxone to patients being prescribed opioid pain medicines who are at increased risk of opioid overdose… A naloxone prescription should also be considered for patients prescribed opioids who have household members, including children, or other close contacts at risk for accidental ingestion or opioid overdose.”

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QUESTION: Do cannabinoid-based medicines impact the deposition of Amyloid β peptide in Alzheimer’s disease?

ANSWER: According to the results of a systematic review, the findings of 9 animal studies indicated that cannabis-based medicines might modulate Amyloid β modifications and inhibit the progression of Alzheimer’s disease. (The maximum and minimum cannabinoid dosages, mostly CBD and THC in animal studies, were 0.75 and 50 mg/kg, respectively. The cannabinoids (CBD and THC) were injected for 10 to 21 days.)

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QUESTION: What is the most common mode of CBD administration?

ANSWER: According to a 2017–2018 online survey evaluating modes of CBD administration, the most common method of CBD administration was sublingual, followed by vaping, oral ingestion of capsules and liquids, smoking, edibles, and topical administration.

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QUESTION: In what dosage forms are pharmaceutical fentanyl products supplied?

ANSWER: Pharmaceutical fentanyl products are currently available in the following dosage forms: oral transmucosal lozenges (AKA fentanyl “lollipops”), buccal tablets and sublingual tablets, sublingual sprays, nasal sprays, transdermal patches, and injectable formulations.

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QUESTION: Chronic pelvic pain affects up to 15% of women in the United States. Cannabinoid receptors are expressed on reproductive tissues (including the uterus) and non-reproductive pelvic tissues. Do patients with chronic pelvic pain use cannabinoid-based products to ameliorate their symptoms?

ANSWER: The conclusions of a survey of 122 chronic pelvic pain female patients indicated that up to 23% report using cannabinoid-based products as an adjunct to their prescribed therapies. The patients use a variety of formulations and doses of cannabinoid-based products, and most report daily or weekly use. Most users report improvement in symptoms, but did acknowledge that side effects are common.

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QUESTION: Describe the chemical makeup of endocannabinoids.

ANSWER: Endocannabinoids are ester, ether, and amide derivatives of long chain polyunsaturated fatty acids. Arachidonic acid is an example of a polyunsaturated fatty acid in endocannabinoids.

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QUESTION: How is the endocannabinoid system linked to the opioid system?

ANSWER: Opioid receptors and CB receptors are located within the same neurons within the CNS. In addition, cannabinoids activate kappa and delta receptors to initiate a release of endogenous opioids.

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QUESTION: Does the co-administration of THC and alcohol impact serum THC levels?

ANSWER: Yes. According to a study by Hartman in 2015, alcohol may increase serum THC levels.

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QUESTION: Some producers of cannabinoid products will provide a certificate of analysis (CoA) from an independent and certified testing laboratory. What information is typically displayed on a CoA?

ANSWER: CoAs typically indicate the amount and concentration of major cannabinoids and terpenes present, and data regarding the presence of microbial/ fungal contaminants, levels of heavy metals, and presence and concentration of pesticide and solvent residues.

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QUESTION: Drug screens are sometimes done in the pre-operative. Is it clinically useful to do a drug screen for the presence of cannabinoids or cannabinoid metabolites?

ANSWER: Drug screens for the presence of cannabinoids and metabolites of cannabinoids will not inform the healthcare provider of the recency of marijuana use, as cannabinoids can remain in the body for several weeks.

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QUESTION: Does CBD isolate contain any other cannabinoids or terpenes?

ANSWER: CBD isolate is CBD in its molecular form, and is typically sold as 99+% pure. Unless indicated on the label, products made with CBD isolate do not contain any other cannabinoids or terpenes.

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QUESTION: What does “broad spectrum” mean?
ANSWER: Broad spectrum and full spectrum are not synonymous. Broad-spectrum products are processed in such a manner as to ensure that the final product does NOT contain THC.

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QUESTION: What does “full spectrum” marijuana product mean?

ANSWER: Full spectrum means that the product contains all of the original compounds found in the flower of the cannabis plant (cannabinoids, terpenes and flavonoids).

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QUESTION: Have the results of studies conducted between 2003-2017 indicated that cannabinoids are effective at treating chronic non-cancer pain?

ANSWER: Yes. Lynch and Ware published 2 systematic reviews (SR). One SR evaluated trials from 2003 to 2010 and the other SR evaluated trials from 2010 to 2014. Of the 29 RCTs evaluated in the 2 SRs, 22 of them demonstrated that cannabinoids have a modest analgesic effect and are safe in the management of chronic pain. The modes of administration explored in these 29 SRs included: smoking, oromucosal and oral. All 6 smoked cannabis trials showed a positive analgesic response.

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QUESTION: Epidemiological studies indicate that as many as 15% of inflammatory bowel disease (IBD) patients may use cannabinoids to ameliorate some of their symptoms, including improvement in diarrhea, abdominal pain and appetite. Do the studies show that cannabinoids are effective?

ANSWER: There are few studies evaluating cannabinoid use in IBD, and those studies are small. In Crohn’s disease, it has been demonstrated that THC reduces the Crohn’s disease activity index by >100 points (on a scale of 0–450). Also, two small studies involving ulcerative colitis patients showed a marginal benefit. However, no improvement in inflammatory markers or in endoscopic score in either disease was detected.

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QUESTION: The findings of multiple RCTs indicate that cannabinoids effectively treat chronic pain. Do cannabinoids effectively treat the chronic pain associated with fibromyalgia?

ANSWER: No. According to a Cochrane systematic review published in 2016 on the use of cannabinoids to treat fibromyalgia, there is no convincing, unbiased, high-quality evidence suggesting that a cannabinoid-based medicine (nabilone) is of value in treating people with fibromyalgia. Furthermore, the tolerability of nabilone was low in people with fibromyalgia. Also, the results of a 2019 study where 4 varieties of pharmaceutical grade marijuana were administered by single shot vapor to fibromyalgia patients indicated that none of the 4 marijuana varieties had an effect greater than placebo. (Note: The data from the 2019 study could not be used to extrapolate the long-term effects of cannabinoids on fibromyalgia-associated pain.)

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QUESTION: Some cancer patients use medical marijuana to treat various cancer-associated ailments. What are some of the ailments ameliorated by medical marijuana?

ANSWER: According to one study involving 96 cancer patients receiving supportive cancer care, the data support the safety and effectiveness of medical marijuana as a complementary option for improving pain control, appetite and quality of life for cancer patients. The top three adverse events of this study included drowsiness, low energy and nausea, and were reported in 28% of patients, with 9% having to stop using the medical marijuana. (Note: other studies indicate that chemotherapy-induced N/V and anxiety are ameliorated by medical marijuana.)

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QUESTION: Side effects of short-term cannabinoid-based therapy may differ from person to person, and the same person may experience different side effects at different times. What factors influence the probability and the severity of adverse events?

ANSWER: Many factors influence the likelihood and the severity of adverse events, including the type of cannabinoid preparation; the mode of administration; the patient’s expectations, the patient’s prior experience with cannabinoid-based therapies, and the age of the patient. Drug–drug interactions may also lead to adverse events.

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QUESTION: According to the results of a survey of breast cancer patients’ use of cannabinoid products before, during, and after treatment, 42% of survey participants had used medical cannabinoid products to relieve symptoms. What symptoms were treated with the cannabinoid products?

ANSWER: Members of the Breastcancer.org and Healthline communities were asked to participate in a survey during the period of 12/16/2019 – 1/19/2020. Among the 832 respondents who completed screening, 725 met the eligibility criteria, and 612 (84%) completed the survey. According to the results, the symptoms for which cannabinoids were used included insomnia (70%), pain (59%), anxiety (57%), stress (51%), and nausea/vomiting (46%). The results also indicated that cannabinoids were used prior to treatment in 24%, during treatment in 79%, and after treatment in 54%. Of subjects reporting cannabis use during treatment: 86% used it during chemotherapy, 71% during HER2 therapy, 65% during hormonal therapy, 49% during breast radiation, and 47% during radiation for metastatic sites. Post-surgical use was reported in 51% after mastectomy alone, 40% after lumpectomy, and 38% after mastectomy/reconstruction.

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QUESTION: Other than feeling “high” what are some of the reported psychological CNS-related side effects associated with cannabinoid use?

ANSWER: Psychological side effects associated with cannabinoid use include: restless/anxiety/nervousness, depressed mood, dysphoria, confusion, dissociation, hallucinations, hyperactivity, weird dreams, paranoia and psychosis.

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QUESTION: Are cannabinoids an effective analgesic agent in the chronic pain setting?

ANSWER: In contrast to the lack of efficacy in the acute pain setting, cannabinoids are effective analgesic agents in the chronic pain setting. According to 2 systematic reviews involving a total of 29 RCTs, 22 of the 29 RCTs demonstrated that cannabinoids have a modest analgesic effect in the management of chronic pain. The following modes of administration were examined in the RCTs: smoked cannabis (6 trials), oromucosal and oral cannabis extract (11 trials), nabilone (8 trials), dronabinol (2 trials), THC-11 acid analogue (2 trials), and fatty acid amide hydrolase inhibitor (1 trial).

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ANSWER: Are cannabinoids an effective analgesic agent in the acute pain setting?

ANSWER: No. According to the results of multiple RCT examining the efficacy of cannabinoids to treat acute pain, THC, nabilone and other cannabinoid-based products were not associated with a reduction in pain, but were associated with adverse side effects, including sedation.

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QUESTION: What are the common modes of administration of medical marijuana used by cancer patients?

ANSWER: According to a survey completed by 183 cancer patients of an oncology clinic at Sutter Medical Center in Sacramento, California, over 50% reported use of oils and tinctures and 44% used edibles. A smaller percentage consumed cannabis-based products via vaping (26%) or smoking (30%). Topical use was preferred by fewer patients (17%). Over 58% of patients stated they used more than one method.

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QUESTION: It has been estimated that a significant proportion of cancer patients (18.3-40.0%) in the United States use cannabis or cannabinoid-based products. Does the evidence indicate that cannabinoid-based products are effective in treating cancer-related pain? chemotherapy-induced n/v? cancer-related cachexia?

ANSWER: According to a study published in the Journal of Clinical Oncology, there is substantial evidence for the effectiveness of cannabis and cannabinoids in treating cancer-related pain; specifically, oromucosal THC/CBD spray. Also, there is conclusive evidence that cannabis and cannabinoids effectively relieve chemotherapy-induced nausea and vomiting; (specifically, oral THC). However, there is inconclusive evidence about the effectiveness of cannabinoid-based products in treating cancer-related cachexia.

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QUESTION: Does the administration of marijuana affect insulin levels in humans?

ANSWER: In a DBRCT involving 20 participants, it was found that marijuana consumed via oral, smoked, or vaporized routes affected blood concentrations of some metabolic hormones, including insulin. In fact, the results of this study indicate that acute marijuana use blunted the insulin spike associated with the consumption of a brownie.

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QUESTION: Are there any special considerations for patients who consume cannabinoid-based products and are undergoing plastic surgery?

ANSWER: Yes. On occasion, plastic surgeons administer atropine and/or epinephrine during a procedure. Both of these medications can increase heart rate, and cannabinoids may potentiate the increase in heart rate.

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QUESTION: Cannabinoid receptors have been located in the central nervous system and the peripheral nervous system, as well as on immune cells. Have cannabinoid receptors been isolated in reproductive tissues/cells?

ANSWER: In addition to cannabinoid receptors being identified in the hypothalamus and the pituitary gland, cannabinoid receptors have also been identified on ovary, endometrial tissue, testes, and spermatozoa. In fact, research suggests that marijuana may alter the release of FSH and LH, ovulation, sperm motility, fertilization, as well as placentation.

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QUESTION: What are K2 and Spice?

ANSWER: K2 and Spice are synthetic cannabinoid “designer drugs” that are intended to mimic the effects of THC. These synthetic cannabinoids are sold as “herbal incense” at convenience stores/gas stations, smoke shops and via the internet. They are produced in powder form, and then often dissolved in solvents, so they can be applied to dry plant material to make the “herbal incense” products.

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QUESTION: Heroin is processed from morphine, an extract from the poppy plant. Heroin is often depicted as a white powder. Is heroin sold in forms other than white powder?

ANSWER: In addition to white powder, heroin is sold as a brownish powder, or as a black sticky/tar-like substance (AKA black tar heroin). Heroin is either sold in pure form or is “cut” with other drugs (quinine, for example) or with other white powdery substances, including sugar, starch or powdered milk.

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QUESTION: Respiratory depression is associated with the overdose of opioids or benzodiazepines. Is respiratory depression associated with an overdose of cannabinoids? Why or why not?

ANSWER: Respiratory depression is not associated with cannabinoid use because CB1 receptors are not located in the midbrain, the part of the brain responsible for respiratory drive.

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QUESTION: As of January 2020, how many Americans were using marijuana-based products for medicinal purposes?
ANSWER: It has been estimated that more than 2 million Americans use marijuana for medical reasons. Some of the many ailments being treated with marijuana include: chronic pain, PTSD, depression, sleep disorders, multiple sclerosis (MS), cancer-related ailments, and GI disorders. Some indications are supported by good scientific evidence, but many are not.

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QUESTION: Rohypnol® is the trade name for the benzodiazepine called unitrazepam. Has this drug ever been approved by the Food and Drug Administration for medical use in the United States?

ANSWER: No, but outside the US, Rohypnol® is prescribed to treat insomnia. Rohypnol® has been referred to as a date rape drug or roofies. Before 1997, Rohypnol® was manufactured as a white tablet, and when mixed in liquids, it was colorless, tasteless, and odorless. In 1997, the manufacturer responded to concerns about the drug’s role in sexual assaults, and reformulated the drug. Now, Rohypnol® is produced as an olive green tablet with a speckled blue core that when dissolved in light-colored drinks will change the color of the liquid to blue. Of note, generic versions of the drug may not contain the blue dye.

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QUESTION: What is the Chemical Diversion and Trafficking Act (CDTA) of 1988?

ANSWER: The CDTA is an Act that regulated 12 (drug manufacturing) precursor chemicals, eight essential chemicals, tableting machines, and encapsulating machines. The Act imposed recordkeeping and import/export reporting requirements on transactions involving these regulated products. One of the goals of this Act was to reduce the supply of methamphetamine. As of 2020, the DEA regulates more than 40 chemicals that are often used in the production of illicit drugs.

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QUESTION: Cannabinoids are metabolized by many of the same cytochrome P450 enzymes as warfarin, including CYP3A4, CYP2C9, and CYP2C19. THC, CBD and CBN can inhibit the CYP2C9-mediated hydroxylation of warfarin, and thus lead to an increase in INR. Do cannabinoids also affect the metabolism of heparin? Is the metabolism of direct oral anticoagulants (DOACs), including rivaroxaban, edoxaban, and apixaban, impacted by cannabinoids?

ANSWER: While cannabinoids do not alter the metabolism of heparin, cannabinoids may impact the metabolism of DOACs. DOACs are substrates of P-gp and are absorbed by the gut through the P-gp efflux transporter. Cannabinoids may bind to P-gp membrane transporters and alter DOAC metabolism. DOAC levels may increase, leading to an increased risk of bleeding.

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QUESTION: CBD is a CB1 antagonist and a negative allosteric modulator at CB2. Does CBD interact with receptors other than CB1 or CB2?

ANSWER: Yes. CBD has cannabinoid receptor-independent properties. For example, CBD is an agonist at the TRPV1 receptor and has agonist properties at the 5-HT1A/2A/3A serotonergic receptors. CBD is also a capsaicin analog. CBD has antagonist activity on alpha-1 adrenergic and μ-opioid receptors, too. In addition, CBD has been found to inhibit synaptosomal uptake of noradrenaline, dopamine, serotonin, and gamma-amino butyric acid. CBD also inhibits anandamide uptake.

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QUESTION: Cannabinoid receptors are located throughout various parts of the CNS, including the basal ganglia, hippocampus, cerebellum and cerebral cortex, and in the peripheral nervous system. Do these receptors have effects on neurotransmitters such as serotonin?

ANSWER: Yes. CB receptor activity not only impacts serotonin, but it also affects acetylcholine, dopamine, glutamate, and GABA, as well as NMDA and opioid receptor systems.

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QUESTION: The Controlled Substances Act (CSA) regulates five classes of drugs. What are they?

ANSWER: The Controlled Substances Act (CSA) regulates five classes of drugs, including narcotics, depressants, stimulants, hallucinogens and anabolic steroids. All controlled substances have abuse potential or they are immediate precursors to substances that have abuse potential. Note: Alcohol and tobacco are specifically exempt from
control by the CSA.

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QUESTION: Methamphetamine is a Schedule II highly addictive stimulant. What is methamphetamine’s mechanism of action that leads to the “rush” and “high”?

ANSWER: It is believed that the “rush” and the “high” associated with amphetamine use result from the release of very high levels of dopamine into areas of the brain that regulate feelings of pleasure.

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QUESTION: Methadone, morphine and heroin are all narcotics. Do they all have a similar chemical structure?
ANSWER: No. Morphine and heroin (which is derived from morphine) have a similar structure. Methadone, which is a synthetic narcotic, does not have a similar structure to morphine.

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QUESTION: Methamphetamine is a controlled substance and is classified as a Schedule II drug. Schedule II drugs have a high potential for abuse and have an accepted medical use. What medical use(s) does methamphetamine have?

ANSWER: As of April 2020, there is only one legal “meth” product, and it is sold under the name Desoxyn®. It has very limited use in the treatment of obesity and ADHD.

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QUESTION: Is the analgesic potency of hydromorphone more or less than the potency of morphine?

ANSWER: Hydromorphone is (2 to 8 times) more potent than morphine but not as potent as fentanyl.

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QUESTION: Chronic pelvic pain affects up to 15% of women in the United States. Cannabinoid receptors are expressed on reproductive tissues (including the uterus) and non-reproductive pelvic tissues. Do patients with chronic pelvic pain use cannabinoid-based products to ameliorate their symptoms?

ANSWER: The conclusions of a survey of 122 chronic pelvic pain female patients indicated that up to 23% report using cannabinoid-based products as an adjunct to their prescribed therapies. The patients use a variety of formulations and doses of cannabinoid-based products, and most report daily or weekly use. Most users report improvement in symptoms, but did acknowledge that side effects are common.

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QUESTION: In what dosage forms are pharmaceutical fentanyl products supplied?

ANSWER: Fentanyl pharmaceutical products are currently available in the following dosage forms: oral transmucosal lozenges (AKA fentanyl “lollipops”), buccal tablets and sublingual tablets, sublingual sprays, nasal sprays, transdermal patches, and injectable formulations.

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QUESTION: Fentanyl, morphine and heroin are all analgesics. Which one of the three is the most potent analgesic?

ANSWER: Fentanyl is the most potent analgesic of the three. It is about 100 times more potent than morphine and 50 times more potent than heroin, as an analgesic agent.

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QUESTION: What are common street names for marijuana?

ANSWER: Often, marijuana concentrates look similar to honey with either a brown or gold color, and many of the street names refer to the golden brown color. The terms wax, ear wax, honey oil, budder, butane hash oil, butane honey oil (BHO), shatter, dabs (dabbing), black glass, and errl have all been used to refer to marijuana concentrates.

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QUESTION: What is hashish?

ANSWER: Hashish (AKA hash) is a THC-rich resin from the cannabis plant. This resin is collected and processed into various forms, including balls, cakes or cookies. Pieces of hashish can be broken off, and placed in pipes or cigarettes for smoking. Some individuals mix hashish with tobacco. Hashish products are considered to be Schedule I substances.

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QUESTION: What is the most common route of administration for the synthetic cannabinoids K2 or Spice?

ANSWER: K2 and Spice are used for recreational purposes, and smoking is the most common route of administration. Spraying or mixing the synthetic cannabinoids on dried plant material allows one to smoke it (using a pipe, a water pipe, or rolling the drug-laced plant material in cigarette papers). Also, liquid synthetic cannabinoids have been designed to be vaporized via e-cigarettes.

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QUESTION: Does marijuana use alter the sexual intercourse experience?

ANSWER: An online survey posed questions regarding various aspects of sexual experience and how those aspects were impacted by marijuana use. The results indicated that marijuana helped individuals relax, heightened their sensitivity to touch, and increased intensity of feelings, thus enhancing their sexual experience, while others found that marijuana interfered by making them sleepy and less focused or had no effect on their sexual experience.

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QUESTION: CB1 receptors are located on neurons in the CNS and PNS. Are CB1 receptors also located on cardiomyocytes?

ANSWER: Yes. CB1 receptors are located in cardiomyocytes, vascular endothelial cells as well as smooth muscle cells. Activation of these CB1 receptors may lead to oxidative stress, inflammation, fibrosis, vasodilation, and negative inotropy.

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QUESTION: Some cannabinoid-based medicines are used to treat chemotherapy-induced n/v. Have cannabinoid-based medicines been shown to be effective in the treatment of post-op n/v?

ANSWER: The results of studies indicate that neither nabilone or intravenous THC is effective for post-op n/v. Even premedication with nabilone was ineffective at treating post-op n/v.

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QUESTION: Does ketamine interact with the endocannabinoid system?

ANSWER: Yes. Ketamine induces the release of endocannabinoids.

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QUESTION: Do CB1 and CB2 agonists facilitate endogenous opioid signaling?

ANSWER: Yes. In fact, CB1 and CB2 agonists increase the concentrations of endogenous opioids.

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QUESTION: Is the endocannabinoid system linked to the opioid system?

ANSWER: Yes. Opioid receptors and CB receptors are located within the same neurons within the CNS. In addition, cannabinoids activate kappa and delta receptors to initiate a release of endogenous opioids.

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QUESTION: How do cannabinoids modulate pain sensation? In other words, describe the mechanism of action of cannabinoids.

ANSWER: Endocannabinoids are synthesized in the postsynaptic neuron in response to stimuli such as pain, stress and inflammation. Endocannabinoids travel in a retrograde fashion and activate the presynaptic CB receptors. Antinociceptive effects occur when either endocannabinoids or phytocannabinoids activate presynaptic inhibitory CB1 receptors. Stimulation of CB1 receptors (G protein coupled receptors (Gi,Go)) leads to a reduction of cAMP production via the inhibition of adenylyl cyclase. This results in an action on voltage gated calcium and potassium channels – there is a depression of neuronal excitability and a reduction of neurotransmitter release.

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QUESTION: A study by Jamal et al. published in the European Journal of Anaesthesiology reported that marijuana users required a higher dose of morphine s/p abdominal surgery. They estimated that there was a 23% increased opioid dose requirement. Have the results of studies examining the opioid requirements s/p orthopedic surgery also shown that marijuana users require more opioids than patients who do not use marijuana?

ANSWER: In a retrospective study including 3793 patients, patient-reported postoperative outcomes of 155 marijuana users were compared with those of 155 non-users. The results indicate that pre-operative marijuana users had higher pain scores at rest and on movement but did not consume more post-operative opioid analgesics. The cannabinoid users also reported a greater incidence of post-operative sleep impairment.

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QUESTION: CBD is a negative allosteric modulator. What does that mean?

ANSWER: A negative allosteric modulator changes the shape of the receptor and, as a result, reduces the binding ability of components that typically bind to the receptor. In the case of cannabinoids, CBD alters the shape of CB1 receptors, and THC along with endogenous cannabinoids do not bind to the CB1 receptor to the same degree as they do when CBD is not present.

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QUESTION: Some producers of cannabinoid products will provide a Certificate Of Analysis (CoA) from an independent certified testing laboratory. What information is typically displayed on a CoA?

ANSWER: CoAs typically indicate the amount and concentration of major cannabinoids and terpenes present, and data regarding the presence of microbial/ fungal contaminants, levels of heavy metals, and presence and concentration of pesticide and solvent residues.

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QUESTION: What medications alleviate the symptoms of marijuana withdrawal?

ANSWER: There are no general guidelines to treat the symptoms of marijuana withdrawal, but it has been reported that benzodiazepines and synthetic THC products used for the treatment of chemotherapy induced N/V may help alleviate some of the symptoms.

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QUESTION: What does “broad spectrum” mean?

ANSWER: Broad-spectrum products are processed in such a manner as to ensure that the final product does NOT contain THC.

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QUESTION: What does “full spectrum” marijuana product mean?

ANSWER: Full spectrum means that the product contains all of the original compounds found in the flower of the cannabis plant (cannabinoids, terpenes and flavonoids).

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QUESTION: Over 2 million Americans with cardiovascular disease use marijuana. Warfarin interacts with marijuana. Do statins interact with cannabinoids?

ANSWER: Yes. Statins and cannabinoids are metabolized by the same liver enzymes. The co-administration of cannabinoids and statins can lead to a decrease in statin metabolism. As a result, the potency of the statins may increase, and lead to hypotension.

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QUESTION: Although Illinois and Nevada have both legalized the use of medical and recreational marijuana, it is illegal to take marijuana on a flight from Chicago to Las Vegas. The reason – airspace is regulated by the federal government and marijuana is illegal under federal law. Do any US airports have “marijuana amnesty boxes” for the disposal of marijuana?

ANSWER: Yes. In addition to 2 airports in Chicago, Mc Carran International Airport in Las Vegas and the Colorado Springs Airport have installed amnesty boxes for passengers who need to surrender their marijuana before boarding a flight.

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QUESTION: What are the precursors for the most commonly naturally occurring phytocannabinoids?

ANSWER: The precursors for THC, CBD and CBC are olivetolic acid and geranyl pyrophosphate. These precursors undergo a condensation reaction which results in the formation of cannabigerolic acid (CBGA). A cyclase enzyme converts CBGA into either tetrahydrocannabinolic acid (THCA) or cannabidiolic acid (CBDA) or cannabichromenic acid (CBCA). Then, heat decarboxylates these cannabinoids into THC, CBD or CBC, respectively.

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QUESTION: True or false? Cannabinoids impact NMDA, opioid AND gamma amino butyric acid (GABA) receptors.

ANSWER: True. Not only do cannabinoids act at NMDA, opioid AND gamma amino butyric acid (GABA) receptors, but they also have activity at receptors such as adenosine, serotonergic, adrenergic, nicotinic acetylcholine, glycine, and PPAR receptors, and ion channels such as TRPV.

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QUESTION: Are pupillary responses to light affected by marijuana?

ANSWER: Yes – marijuana may impair pupillary responses.

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QUESTION: Is the legalization of medical marijuana associated with an increase in sexual activity?

ANSWER: Yes, according to researchers from the University of Connecticut and Georgia State University, the legalization of medical marijuana is associated with an increase in sexual activity. Of note, the study also determined that there’s a decrease in the use of contraceptives and an increase in the number of births following the enactment of medical marijuana policies. This study was published in the Journal of Health Economics.

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QUESTION: What is the definition of drug diversion?

ANSWER: In the National Academies of Sciences, Engineering & Medicine’s Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence (2020), drug diversion is defined as the transfer of regulated prescription drugs from the legal market to illegal markets. The sharing of drugs with other individuals for medical or nonmedical purposes is NOT considered to be drug diversion. (The sharing of drugs is drug misuse.)

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QUESTION: Is it legal to carry marijuana on a Greyhound bus?

ANSWER: No. Greyhound Lines bans alcohol and drugs (including marijuana) “anywhere on the bus (including in your checked baggage).”

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QUESTION: Animal research studies on CBD’s potential therapeutic effects often employ rodents. Is CBD administered to rodents the same way CBD is administered to humans?

ANSWER: No. CBD is commonly administered to rodents either via intraperitoneal injection or via the oral route. In contrast, CBD has been studied in humans using oral administration or inhalation, but not via intraperitoneal. The pharmacokinetics of these various routes of administration differ and therefore the blood concentrations of CBD may differ.

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QUESTION: Has the use of CBD been evaluated for the treatment of heroin addiction?

ANSWER: Yes. Dr. Yasmin Hurd, director of the Addiction Institute of Mount Sinai in NYC led a double-blind study of 42 recovering heroin addicts and found that CBD reduced both cravings and cue-based anxiety, both of which can cycle people back into using heroin.

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QUESTION: Does CBD modulate 5-HT1A receptor activity?

ANSWER: Yes, and this modulation may directly improve hyperarousal/insomnia symptoms in PTSD patients.

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QUESTION: Is the US VA Office of research and Development conducting any clinical trials that evaluate the use of CBD for the treatment of PTSD?

ANSWER: Yes. A RCT evaluating the efficacy of using CBD as an adjunctive to prolonged exposure therapy (PE therapy)) was started in March 2019 and will conclude on September 30,2023. The trial will compare PE + CBD to PE + placebo in a sample of 136 military Veterans with PTSD at the VA San Diego Medical Center.

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QUESTION: Is it legal to transport marijuana on Amtrak’s railway?

ANSWER: Amtrak has a strict policy: “The use or transportation of marijuana in any form for any purpose is prohibited, even in states or countries where recreational use is legal or permitted medically.”

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QUESTION: Do any medical marijuana legal states accept out-of-state medical marijuana authorizations?

ANSWER: Yes. About twenty states accept out-of-state medical marijuana authorizations, BUT reciprocity laws vary from state to state. In some states, visitors are required to sign up for the medical marijuana program 30 days in advance and pay a $50 nonrefundable fee. The state’s purchasing limit may differ for permanent vs. temporary residents. In Oregon, for example, residents can possess up to 24 ounces, while visitors are allowed only one ounce.

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QUESTION: Does the CBD molecule contain an aromatic ring?

ANSWER: Yes, it does. The CBD molecule contains a cyclohexene ring and an aromatic ring (a phenolic ring). Of interest, the rings are located in planes that are almost perpendicular to each other.

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QUESTION: Describe the chemical makeup of endocannabinoids.

ANSWER: Endocannabinoids are ester, ether, and amide derivatives of long chain polyunsaturated fatty acids. Arachidonic acid is an example of a polyunsaturated fatty acid in endocannabinoids.

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QUESTION: Does chronic use of THC and/or CBD by individuals with multiple sclerosis impact cerebral glucose metabolism?

ANSWER: The results of “The Effects of Chronic Δ-9-Tetrahydrocannabinol (THC) and Cannabidiol (CBD) use on Cerebral Glucose Metabolism in Multiple Sclerosis: A Pilot Study” published in 2019 in ‘Applied Physiology, Nutrition and Metabolism‘ indicate that “Compared to non-users, THC-users had hypermetabolism of three regions (p < 0.039, d >1.17) in left temporal areas, while CBD-users had hypometabolism of five regions (p < 0.032, d > 1.31) in left temporal areas.”

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QUESTION: True or False? According to the results of a survey conducted by the FDA, about 90% of US adults understand that FDA-approved prescription drugs may cause harm.

ANSWER: False. The results of the survey indicate that 42.9% of consumers were not able to accurately report that FDA‐approved prescription drugs may cause harm.

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QUESTION: The FDA approves the language used on package inserts of prescription drugs. Does the FDA also approve the language of “direct-to -consumer” ads?

ANSWER: Actually, no. The language, including the risk or benefit statements, used in “direct to consumer” ads is not FDA-approved.

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QUESTION: Based on data from the 2016 to 2017 National Survey on Drug Use and Health and the U.S. Department of Health and Human Services, do more people in the US smoke marijuana or tobacco cigarettes”

ANSWER: According to the 2016 to 2017 National Survey on Drug Use and Health, more than 39 million people smoke marijuana, and according to data from the U.S. Department of Health and Human Services, 34.3 million people smoke tobacco cigarettes. Recent trends show that the number of marijuana smokers is rising while the number of cigarette smokers is declining.

—

QUESTION: CB1 receptors are located on neurons in the CNS and PNS. Are CB1 receptors also located on cardiomyocytes?

ANSWER: Yes. CB1 receptors are located in cardiomyocytes, vascular endothelial cells as well as smooth muscle cells. Activation of these CB1 receptors may lead to oxidative stress, inflammation, fibrosis, vasodilation, and negative inotropy.

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QUESTION: Smoking and vaporizing marijuana may induce an increase in heart rate. Is smoking marijuana associated with other cardiac electrical effects?

ANSWER: Yes. THC may increase catecholamine levels and therefore may theoretically increase the likelihood of arrhythmias. Various cardiac electrical effects have been described in observational studies. Atrial fibrillation was one of the more commonly reported arrhythmias. Other marijuana-associated arrhythmias reported include atrial flutter, atrioventricular block/asystole, sick sinus syndrome, ventricular tachycardia, and Brugada pattern.

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QUESTION: Some cannabinoid-based medicines are used to treat chemotherapy-induced n/v. Have cannabinoid-based medicines been shown to be effective in the treatment of post-op n/v?

ANSWER: The results of studies indicate that neither nabilone or intravenous THC is effective for post-op n/v. Even premedication with nabilone was ineffective at treating post-op n/v.

—

QUESTION: Do cannabinoid-based medicines have a higher NNT (number needed to treat) than opioids for pain relief? Than pregabalin? Than tricyclic antidepressant (TCA) agents?

ANSWER: According to recent systematic reviews and meta-analyses (from 2016-2018), cannabinoid -based medicines have a higher NNT than opioids, pregabalin and TCAs. It was also noted that there was a higher risk of adverse events associated with cannabinoid-based medicines compared to opioids, pregabalin and TCAs.

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QUESTION: The 2017 National Academies of Sciences, Engineering and Medicine’s (NASEM)review on the health effects of cannabinoid-based medicines concluded that there was conclusive or substantial evidence for the use cannabis or cannabinoids for the treatment of pain in adults. Do other national regulatory bodies have similar conclusions to the NASEM’s conclusion?

ANSWER: Actually, no. The Health Products Regulatory Authority of Ireland does not support the use of cannabinoid-based medicines for the treatment of chronic pain. Also, the European Pain Federation’s recent position paper recommended cannabinoid-based medicines be considered for chronic neuropathic pain only as a third line agent. Furthermore, the European Pain Federation found that the results of the studies examining chronic non-cancer pain indicated that there was insufficient evidence for the use of cannabinoid-based medicines for the treatment of non-neuropathic chronic non-cancer pain.

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QUESTION: Does ketamine interact with the endocannabinoid system?

ANSWER: Yes. Ketamine induces the release of endocannabinoids.

—

QUESTION: Do CB1 and CB2 agonists facilitate endogenous opioid signaling?

ANSWER: Yes. In fact, CB1 and CB2 agonists increase the concentrations of endogenous opioids.

—

QUESTION: Do opioid antagonists impact the effects of cannabinoids?

ANSWER: Yes. For example, it has been shown that the administration of opioid antagonists block some of the effects of THC.

—

QUESTION: Is the endocannabinoid system linked to the opioid system?

ANSWER: Yes. Opioid receptors and CB receptors are located within the same neurons within the CNS. In addition, cannabinoids activate kappa and delta receptors to initiate a release of endogenous opioids.

—

QUESTION: True or false? Cannabinoids impact NMDA, opioid AND gamma amino butyric acid (GABA) receptors.

ANSWER: True. Not only do cannabinoids act at NMDA, opioid AND gamma amino butyric acid (GABA) receptors, but they also have activity at receptors such as adenosine, serotonergic, adrenergic, nicotinic acetylcholine, glycine, and PPAR receptors, and ion channels such as TPRV.

—

QUESTION: How do cannabinoids modulate pain sensation? In other words, describe the mode of action of cannabinoids.

ANSWER: The endocannabinoid system, consisting of the cannabinoid₁ receptor (CB₁R) and cannabinoid₂ receptor (CB₂R), endogenous cannabinoid ligands (endocannabinoids), and metabolizing enzymes, is present throughout the pain pathways. Endocannabinoids, phytocannabinoids, and synthetic cannabinoid receptor agonists have antinociceptive effects in animal models of acute, inflammatory, and neuropathic pain. CB₁R and CB₂R located at peripheral, spinal, or supraspinal sites are important targets mediating these antinociceptive effects. The mechanisms underlying the analgesic effects of cannabinoids likely include inhibition of presynaptic neurotransmitter and neuropeptide release, modulation of postsynaptic neuronal excitability, activation of the descending inhibitory pain pathway, and reductions in neuroinflammatory signaling. The large body of preclinical evidence in support of cannabinoids as potential analgesic agents is supported by clinical studies demonstrating their efficacy across a variety of pain disorders.

—

QUESTION: EXPERIMENTAL pain studies indicate that cannabinoids may be an effective therapy for acute and chronic pain. Have the results of CLINICAL studies also shown that cannabinoids are effective at alleviating acute and chronic pain?

ANSWER: In contrast to experimental studies, the results of clinical trials with cannabinoids provide only moderate-quality evidence for the relief of chronic pain. Also, the analgesic effects of cannabinoids have not been found to be superior to placebo in acute pain. In addition, pre-operative and peri-operative marijuana use may increase post-operative perceived pain.

—

QUESTION: A study published in the European Journal of Anaesthesiology, by Jamal et al. reported that marijuana users required a higher dose of morphine s/p abdominal surgery. They estimated that there was a 23% increased opioid dose requirement. Have the results of studies examining the opioid requirements s/p orthopedic surgery also shown that marijuana users require more opioids than patients who do not use marijuana?

ANSWER: In a retrospective study including 3793 patients, patient-reported postoperative outcomes of 155 marijuana users were compared with those of 155 non-users. The results indicate that pre-operative marijuana users had higher pain scores at rest and on movement but did NOT consume more post-operative opioid analgesics. The cannabinoid users also reported a greater incidence of post-operative sleep impairment.

Trump Budget Slashing Gutted Coronavirus Emergency Response

Trump’s hated of “everything Obama” has already harmed America.

Now, it’s harming Public Health.

That man is a genuine threat to the security of the United States. He simply has NO understanding of the complexity of the matters placed before him on the platter of the Presidency. He is utterly out of his league.

Consider this sampling of inane things he’s said about coronavirus (COVID-19):

First, it was, “We have it all under control.”

Followed closely by, “It’s very small problem in this country.”

And on its heels was, “The Coronavirus is very much under control in the USA.”

Which was later accompanied by, “We have it totally under control. It’s going to be fine.”

As things progressed, and it because clear that it was only a matter of time before Americans were affected, he said in Davos, Switzerland that, “We do have a plan, and we think it’s going to be handled very well.”

Now that the fecal matter has started to hit the fan, he decided to make a rare, live, emergency telecast to address the nation, and said that, “I have decided to take several strong but necessary actions to protect the health and well-being of all Americans.”

He also said in that emergency live telecast address to the nation that, “We declared a public health emergency and issued the highest level of travel warning.”

In the same breath, he said, “To keep new cases from entering our shores, we will be suspending all travel from Europe to the United States for the next 30 days.”

Just last year, he:
• Cut the budgets of the Centers for Disease Control, and other Public Health-related budgets,
• Firing the government’s entire pandemic response chain of command, including those of the
––National Security Agency,
––National Security Council,
––Health and Human Services,
––Department of Homeland Security,
• Gutting the entire management infrastructure of the White House, and
• Killing the Complex Crises Fund

…DESPITE all that budget bloodshed like Sweeney Todd, The Demon Barber of Fleet Street, he had the unmitigated gall and audacity to say that, “We are at a critical time in the fight against the virus.”

And sadly, it’s highly doubtful that anyone truly believes him when he said, “I will always put the well-being of America first.”

It’s not as if anyone believes him now, anyway. Members of the Cabinet are in fear of him, that they’ll lose their jobs being fired by Tweet, so they simply turn into jelly, and keep their ideas to themselves… since he knows how to run everything, anyway. So what difference does it truly make?

The next thing is to GET HIM OUT OF OFFICE!

But, moreover, this article goes in-depth to show and explain the things he’s done which have had a horrific effect upon Public Health -and- National Security.

That is NOT how to “Make America Great Again.”

Come November, you know what to do.

VOTE HIM OUT!!!

Trump Has Sabotaged America’s Coronavirus Response

By Laurie Garrett
January 31, 2010
https://foreignpolicy.com/2020/01/31/coronavirus-china-trump-united-states-public-health-emergency-response/

When Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization (WHO), declared the Wuhan coronavirus a public health emergency of international concern on Thursday, he praised China for taking “unprecedented” steps to control the deadly virus. “I have never seen for myself this kind of mobilization,” he noted. “China is actually setting a new standard for outbreak response.”

The epidemic control efforts unfolding today in China—including placing some 100 million citizens on lockdown, shutting down a national holiday, building enormous quarantine hospitals in days’ time, and ramping up 24-hour manufacturing of medical equipment—are indeed gargantuan. It’s impossible to watch them without wondering, “What would we do? How would my government respond if this virus spread across my country?”

For the United States, the answers are especially worrying because the government has intentionally rendered itself incapable. In 2018, the Trump administration fired the government’s entire pandemic response chain of command, including the White House management infrastructure. In numerous phone calls and emails with key agencies across the U.S. government, the only consistent response I encountered was distressed confusion. If the United States still has a clear chain of command for pandemic response, the White House urgently needs to clarify what it is

If the United States still has a clear chain of command for pandemic response,
the White House urgently needs to clarify what it is – not just for the public but for the government itself,
which largely finds itself in the dark.

When Ebola broke out in West Africa in 2014, President Barack Obama recognized that responding to the outbreak overseas, while also protecting Americans at home, involved multiple U.S. government departments and agencies,

11 Year Study Finds Opioid Deaths Down In Medical #Marijuana States

In an article entitled “Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010” published August 25, 2014 in the Journal of the American Medical Association, researcher and primary author, Dr. Marcus A. Bachhuber, MD, with the Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, 423 Guardian Dr, 1303-A Blockley Hall, Philadelphia, PA 19104 (marcus.bachhuber@gmail.com), and others concluded that, “The present study provides evidence that medical cannabis laws are associated with

Why I Advocate 100% Marijuana Legalization

Let there be NO MISTAKE: Based upon a preponderance of scientific evidence, logic, reason, and numerous substantiating rationales, I openly advocate for, and am a proponent of the 100% full and total legalization of marijuana (aka cannabis) for adult recreational, and medical use.

And as a triple-degree, BSN-prepared Registered Nurse, Nationally Certified EMT, State Certified Volunteer Firefighter, and First Responder, I am a long-time Licensed Healthcare Professional, and presently possess, and have possessed unblemished active licenses to practice in numerous states, and internationally.

While I have “worn other hats” in Nursing, the bulk of my professional healthcare career has been in Critical Care. Working in Critical Care is the type of stressful job in which one keeps the Grim Reaper at bay by the hour. And I have been fortunate to have worked at some of the nation’s, and world’s premiere, and leading healthcare research institutions. It is research that drives much of such care, to ensure the best possible outcomes for the individuals for whom we care. Thus, keeping abreast of current research findings on many topics within, and without Critical Care, healthcare, and public policy related to healthcare in general, is a special interest and forté of mine.

As well, I am also a United States

National Academies #Marijuana Findings @theNASEM

Many have heard or read about United States Attorney General Jeff Sessions’ ignorant remark about marijuana, and many of us have heard or read numerous claims about cannabis, ranging from “it cures cancer” to “it makes you hungry,” and almost everything between. But if you want to make an effective argument for or against anything, you need facts. And the following information from the National Academies of Sciences, Engineering, and Medicine is THE MOST authoritative, up-to-date volume on the subject of cannabis. You would be wise to cite this research when you lobby your local, state or national legislator to legalize (or not) marijuana. (I am a legalization proponent & advocate for the 100% legalization, regulation, and taxation of adult recreational & prescriptive medical use of marijuana.)

Now, with the 2017 release of “The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research” by the Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda, Board on Population Health and Public Health Practice Health and Medicine Division, A Report of the National Academies of Science, we have one of THE MOST to-date conclusive pieces of EVIDENCE for/against cannabis consumption, either medically, and/or recreationally. It is AUTHORITATIVE, and unbiased. Bear in mind, this is findings of SCIENTIFIC MEDICAL RESEARCH.

An independent examination of the report was carried out in accordance with institutional procedures and all review comments were carefully considered. A committee of experts was convened to conduct a comprehensive review of the literature regarding the health effects of using cannabis and/or its constituents that had appeared since the publication of the 1999 IOM (Institute of Medicine) report.

From their review, the committee arrived at nearly 100 different research conclusions related to cannabis or cannabinoid use and health.

Committee members formulated four recommendations to address research gaps, improve research quality, improve surveillance capacity, and address research barriers.

Categories, including subtopics, are as follows:

Therapeutic effects
• Chronic pain; cancer, chemotherapy-induced nausea/vomiting; anorexia and weight loss; irritable bowel syndrome; epilepsy; spasticity related to multiple sclerosis or spinal cord injury; Tourette syndrome; amyotrophic lateral sclerosis; Huntington’s disease; Parkinson’s disease; dystonia; dementia; glaucoma; traumatic brain injury; addiction; anxiety; depression; sleep disorders; post-traumatic stress disorder; schizophrenia and other psychoses

Cancer
• Lung cancer; head and neck cancer; testicular cancer; esophageal cancer; other cancer

Cardiometabolic risk
• Acute myocardial infarction; stroke; metabolic dysregulation, metabolic syndrome, prediabetes, and diabetes mellitus

Respiratory disease
• Pulmonary function; chronic obstructive pulmonary disorder; respiratory symptoms (including chronic bronchitis); asthma

Immunity
• Immune function; infectious disease

Injury and death
• All-cause mortality; occupational injury; motor vehicle crash; overdose injury and death

Prenatal, perinatal, and postnatal exposure to cannabis
• Pregnancy complications for the mother; fetal growth and development; neonatal conditions; later outcomes for the infant

Psychosocial
• Cognition (learning, memory, attention, intelligence); academic achievement and educational outcomes; employment and income; social relation- ships and other social roles

Mental health
• Schizophrenia and other psychoses; bipolar disorders, depression; suicide; anxiety; post-traumatic stress disorder

Problem cannabis use
• Cannabis use disorder

Cannabis use and abuse of other substances
• Abuse of other substances

Weight Of Evidence Categories for Conclusions are ranked High-to-Low-and-None as Substantial, Moderate, Limited Evidence, and No or Insufficient Evidence to Support the Association for therapeutic effects, and other health effects.

Here are: 
Conclusions—Therapeutic Effects of Cannabis and Cannabinoids

There is conclusive or substantial evidence that cannabis or cannabinoids are effective:
• For

Want More #Sex? Smoke More #Cannabis!

NPR recently reported about research that seems to point to one benefit of daily use of cannabis.

Increased sexual activity.

I continue to maintain that:
a.) People NEED & OUGHT to have MORE SEX, and;
b.) Cannabis NEEDS & OUGHT to be legalized, taxed & regulated.

Because:
a.) No one ever had an orgasm while “mad” or “angry,” and;
b.) I’ve neither read nor heard of anyone being “mad” or “angry” while high.

Fact is, research is continuing to show that increasingly, people are ANGRY at/because of many things, some of which are outside the locus of their immediate control, and that correspondingly, people are having sexual encounters less often – including married couples (for the benefit of those who believe that sexual activity belongs only among married couples). STOP ANGER! Get high! Have sex!

There’s SIGNIFICANTLY MORE argument to be made AGAINST ETOH (ethanol alcohol, aka “beverage” alcohol) than against cannabis.

Researchers Find Frequency of Sex Rises With Marijuana Use

“Surveys of 50,000 people found that those who smoked marijuana had sex more often than those who

Q: How is #ALpolitics similar to Portland, OR?

Portland, Oregon and Birmingham, Alabama couldn’t be further apart in many ways – geographically, and politically, particularly. However, recent research show that one attitude in particular is very similar.

And that is, resident’s thoughts about

Keep Your Horse And Your Heart Healthy: A How To Guide

In the late-1970s, a pioneering medication was discovered in Japan which was made from a single microorganism.

Isolated at the Kitasato Intitute, Tokyo, Japan, it came from a single Japanese soil sample, and has had an immeasurably beneficial impact in improving the lives and welfare of billions of people worldwide. And, despite continued research since, it has only been found in Japan.

While it was originally introduced as a veterinary medication and found to kill a phenomenally wide range of internal and external parasites in livestock and companion animals, it was quickly discovered to be ideal in combating two of the world’s most devastating and disfiguring diseases which have plagued the world’s poor throughout tropical regions for centuries. It’s now being used free-of-charge as the exclusive tool in campaigns to eliminate both diseases globally, and has also been used to successfully overcome several other human diseases, with new uses for it continually being found.

Few medications can seriously lay claim to the title of ‘Wonder Drug’, and penicillin and aspirin are two that have perhaps had the greatest beneficial effect on the health and well-being of Humankind. But this medication can also be considered alongside those worthy contenders, based on its versatility, safety and the beneficial impact that it has had, and continues to have, worldwide — especially on hundreds of millions of the world’s poorest people.

The medication treats

Government–Mandated Waste Drives Up Prescription Drug Co$t$

 

Just Like Food “Expiration” Dates, Drug “Expiration” Dates Are Also Fake… And It’s Co$ting You BIGTIME

Hospitals and pharmacies are required to toss expired drugs, no matter how expensive or vital. Meanwhile the FDA has long known that many remain safe and potent for years longer.

The box of prescription drugs had been forgotten in a back closet of a retail pharmacy for so long that some of the pills predated the 1969 moon landing. Most were 30 to 40 years past their expiration dates – possibly toxic, probably worthless.
But to Lee Cantrell, who helps run the California Poison Control System, the cache was an opportunity to answer an enduring question about the actual shelf life of drugs: Could these drugs from the bell-bottom era still be potent?

Cantrell called Roy Gerona, a University of California, San Francisco, researcher who specializes in analyzing chemicals. Gerona had grown up in the Philippines, and had seen people recover from sickness by taking expired drugs with no apparent ill effects.

“This was very cool,” Gerona says. “Who gets the chance of analyzing drugs that have been in storage for more than 30 years?”

Pharmacist and Toxicologist Lee Cantrell tested medicines that had been “expired” for decades. Most of them were still potent enough to be on shelves today. (Lee Huffaker for ProPublica)

The age of the drugs might have been bizarre, but the question the researchers wanted to answer wasn’t.

Pharmacies across the country in major medical centers and in neighborhood strip malls routinely toss out tons of scarce and potentially valuable prescription drugs when they hit their expiration dates.

Gerona and Cantrell, a pharmacist and toxicologist, knew that the term “expiration date” was a misnomer. The dates on drug labels are simply

Your Child May Not Truly Be Allergic To Penicillin

Reported penicillin allergies in children usually inconsistent with true allergy

Jul 3, 2017

Clinical Essentials from Pediatrics

Takeaway
• Parent-reported penicillin allergy symptoms in children presenting to the emergency department (ED) are likely inconsistent with true, immunoglobulin E-mediated allergy when evaluated by the 3-tier penicillin allergy questionnaire.

• Data demonstrate that the true incidence of penicillin allergy is 0.004%-0.015%.

Why this matters
• Because of time constraints and invasiveness associated with standard allergy testing, an allergy pediatric questionnaire may optimize first-line penicillin use in children presenting with the ED with parent-reported penicillin allergies.

• Data suggest that the majority of reported pediatric penicillin allergy symptoms (eg, maculopapular rash, hives, vomiting, diarrhea) are actually low risk for true allergy.

Study design
• This study evaluated 597 children between the ages of

Are you over 65 & taking statin meds? Know anyone who is? It may not be worth it.

If you’re a prescriber, consider this research. If you’re a patient, or know someone who is, consider this for your, or their well-being.

—//—

Statins Have No Primary CVD Prevention Benefit To Older Patients

Takeaway
Statins offer no benefit for the primary prevention of cardiovascular disease (CVD) in adult patients aged ≥65 y.

Why this matters
“[S]tatins may be producing untoward effects in the function or health of older adults that could offset any possible cardiovascular benefit,” say the study authors.

Study design
Researchers conducted post hoc secondary data analyses of patient data from a randomized, open-label clinical trial (N=2867; age, ≥65 y; 49.4% women; all without evidence of atherosclerotic cardiovascular disease); patients were assigned to either a treatment group receiving pravastatin sodium 40 mg/d or a usual care (UC) group.
Funding: National Heart, Lung, and Blood Institute; AstraZeneca; Bristol-Myers Squibb; Pfizer; National Center for Advancing Translational Sciences; The Stroke Foundation.

Key results
Hazard ratios for all-cause mortality in the treatment group vs the UC group were

Rethinking Addiction

Perhaps you’ve studied the 12-Step program, or perhaps you’ve practiced it. I have done both. Practicing it was not as a matter of addiction, or any such thing for myself, but instead, was a part of my personal spiritual growth and development.

Over the years, I’ve heard commentary, or news features which interviewed people with divergent perspectives on 12-Step programs, most notably which were skeptical of them, and were thoughtfully seeking answers themselves for the “whys and wherefores” of substance abuse, whether it’s long-term or temporary, and whether it is a genetic fault, or if it is a personality or character flaw in response to external or internal stressors. In other words, it’s the classic “Heredity vs Environment” argument.

As I have come to view it, there is validity for both sides, but I think the stronger case is made for a combination of environment and character flaw, instead of genetic defect.

—/—

“In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent. That is just a rough estimate, but it’s the most precise one I’ve been able to find.”

https://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/

The Irrationality of Alcoholics Anonymous
By Gabrielle Glaser, April 2015 Issue
Its faith-based 12-step program dominates treatment in the United States. But researchers have debunked central tenets of AA doctrine and found

End ObamaCare’s Health Insurance Monopoly

Fact is, “ObamaCare” – which is properly known as the Patient Protection and Affordable Care Act, or ACA for short – though it’s monikered with POTUS Obama’s name, was largely a Republican brainchild from the über-conservative Heritage Institution.

The cornerstone of the act is predicated upon two items which are the very heart of the act: 1.) Guaranteed Coverage, and; 2.) Community Rating.

In was, in essence

How And Why Insurance Companies Control Your Medical Care

Some have accurately, and justifiably observed that the Affordable Care Act, also colloquially known as “ObamaCare,” is a big fat, sloppy wet kiss to the Big Insurance industry and their for-profit, Wall $treet corporate masters, because their profits have continued to soar since it’s inception. Note that UnitedHealth Group reported a profit of $11 billion (on revenues of more than $157 billion) in 2015, up from $10.3 billion (on revenues of $131 billion) in 2014. Consider also how Anthem’s business changed in just one recent year. At the end of 2014, the majority of Anthem’s revenues still came from its Commercial Health Insurance customers. During 2015, however, revenues from their commercial operations actually declined 4.2%, to $37.6 billion, while revenues from their government operations skyrocketed 21%, to $40.1 billion. A significant reason why, is because of the big investments Insurance Companies continue to make in House and Senate campaigns. As a result, the Insurance Industry’s tentacles will likely only get deeper into both the Medicare and Medicaid programs.

Medical equipment is pictured on the wall of an examination room inside a Kaiser Permanente health clinic located inside a Target retail department store in San Diego, California November 17, 2014. Four clinics are scheduled to open to provide pediatric and adolescent care, well-woman care, family planning, and management of chronic conditions like diabetes and high blood pressure for Kaiser members and non-members. REUTERS/Mike Blake (UNITED STATES – Tags: HEALTH BUSINESS SOCIETY) Fair Use

by Christy Ford Chapin

It’s that time of year again. Insurance companies that participate in the Affordable Care Act’s state health exchanges are signaling that prices will rise dramatically this fall.

And if insurance costs aren’t enough of a crisis, researchers are highlighting deficiencies in health care quality, such as unnecessary tests and procedures that cause patient harm, medical errors bred by disjointed or fragmented care and disparities in service distribution.

While critics emphasize the ACA’s shortcomings, cost and quality issues have long plagued the U.S. health care system. As my research demonstrates, we have these problems because insurance companies are at the center of the system, where they both finance and manage medical care.

If this system is so flawed, how did we get stuck with it in the first place?

Answer: Organized physicians.

As I explain in my book, “Ensuring America’s Health: The Public Creation of the Corporate Health Care System,” from the 1930s through the 1960s, the American Medical Association, the foremost professional organization for physicians, played a leading role in implementing the insurance company model.

What existed before health insurance companies?

Between the 1900s and the 1940s, patients flocked to what were called “prepaid physician groups,” or “prepaid doctor groups.”

Prepaid groups offered inexpensive health care because

.@PastorAmyTRC: I Had A Late Term #Abortion and “I never had a second thought about the right thing to do.”

Church Pastor: The Truth About My Late-Term Abortion

by Amy Butler, October 26, 2016, 7:55PM EDT

“Trump’s words drove me to tears, and to write my painful story for the first time.”

Elections are supposed to be about real people — and not the ones whose names appear on the ballot. They are supposed to be about all of us, the policies that will impact our lives in tangible ways and the choices we make about the country we want to be.

The Rev. Dr. Amy Butler is the Senior Minister of The Riverside Church in New York City. Prior to this call, Pastor Amy served as Senior Pastor of Calvary Baptist Church in Washington, D.C. Pastor Amy holds degrees from Baylor University (BA ‘91, MA ‘96); The International Baptist Theological Seminary (BDiv ‘95); and Wesley Theological Seminary (DMin ‘09).

But this year, we have watched a major candidate for our country’s highest office demean and slander whole categories of American citizens. We have watched him make offensive, outrageous claims about real people and real decisions that everyday Americans face. People like me. Decisions like mine.

What sent me to my computer to write is late-term abortion. As I heard Donald Trump talk about babies being “ripped” from their mothers’ wombs, as if ending a pregnancy is a reckless, irresponsible afterthought, my outrage poured down my face in angry tears. In those moments, Trump, who has never been pregnant and presumably has navigated this far in his life without undertaking any difficult, gut-wrenching, gray-area decisions, used my own pain — deep, deep pain — to advance his political agenda.

But his words won’t tell my story, so I’ll tell it here. I don’t often speak about this experience. And I’ve never written about it until now.

The late-term abortion I chose was the end of a dream. The pain was so real and so consuming that navigating my way through the grief, I never thought that I would have the happy, healthy family that I do today. It was one of the most agonizing experiences of my life and

Late Term #Abortion #Politics On #DebateNight

A few thoughts on a Presidential Debate topic by Moderator Chris Wallace of Fox News, with candidates Hillary Clinton (D) and Donald Trump (R) from the third, and final debate held last night at the University of Nevada, Las Vegas, Wednesday, 19 October 2016:

1.) Tweet from Dr. Jen Gunter, MD: “There is no such thing as a ninth month abortion – I’m a doctor who trained in late term abortions”
https://twitter.com/DrJenGunter/status/788912646330257408

2.) A portion of her blog entry (linked herein) on the topic from the Debate states: “Trump’s statement, as incorrect as it may be, supports the fallacy of the due-date abortion. It is a common anti-choice narrative that

How prevalent is psychiatric disorder following natural disasters?

What implications does this have for survivors of Hurricane Katrina, California Wildfires, Earthquakes, the September 11, 2001 Terrorist Attack on the World Trade Center, or any other disaster?

—

Psychiatric Disorders And Suicidal Tendencies In Survivors Of Natural Calamities

The Lancet Psychiatry
September 10, 2015

Survivors Of Natural Calamities Require Early Interventions To Alleviate Psychiatric Disorders

Background
Survivors of natural disasters are thought to be at an increased risk of psychiatric disorders, however the extent of this risk, and whether it is linked to pre-existing psychopathology, is not known. We aimed to establish whether Swedish survivors of tsunamis from the 2004 Sumatra–Andaman earthquake had increased risks of psychiatric disorders and suicide attempts 5 years after repatriation.

Methods
We identified Swedish survivors repatriated from southeast Asia (8762 adults and 3742 children) and 864 088 unexposed adults and 320 828 unexposed children matched for

Research: #Exercise Significantly Improves Anti-#Depression Therapy

For those whom are searching for adjunct, supplemental, or alternative therepeutic milieus, scientists and researchers have made some wonderful discoveries, and share the findings before the release of their research paper!

—

Randomized controlled trial of physical exercise as augmentation to antidepressant therapy for late-life major depression in primary care

August 4, 2015

Summary
Progressive physical exercise plus sertraline anti-depressant therapy achieves higher rates of depression remission than non-progressive therapy plus sertraline, or sertraline alone in primary care patients with late-life major depression.

Study Design
121 primary care patients were randomized to

Study: Cannabis Legalization Does Not Increase Underage Use

Consumption Of Marijuana With Respect To The Passage Of Respective State Medical Marijuana Laws

The Lancet Psychiatry – Jul 20, 2015

    The Passage Of Medical Marijuana Laws Could Improvise Medical Usage Of Marijuana, With Due Investigation

 

Background

 Adolescent use of marijuana is associated with adverse later effects, so the identification of factors underlying adolescent use is of substantial public health importance. The relationship between US state laws that permit marijuana for medical purposes and adolescent marijuana use has been controversial. Such laws could convey a message about marijuana acceptability that increases its use soon after passage, even if implementation is delayed or the law narrowly restricts its use. We used 24 years of national data from the USA to examine the relationship between state medical marijuana laws and adolescent use of marijuana.

Methods

Using a multistage, random-sampling design with

Sodomy: A prime example of what’s wrong with #ALpolitics

A dear friend who is a long-time retiree, aged 78 years, entire subsistence is from a meager pension (earned from a lifetime of work in a unionized organization), supplemented with a paltry Social Security check.

She’s lived through breast cancer surgery (mastectomy) & reconstruction, other major surgeries (knee replacements) and procedures, and lives in a trailer which she owns, situated upon a lot which she rents. She has resided there many, many years.

To save money, she recently

Alabama State Senator Larry Stutts sued for malpractice… again

Alabama State Senator Larry Stutts has once again been named in another malpractice lawsuit in which a patient of his retained placental tissue, and suffered excessive bleeding following delivery of her baby.

The new case is oddly reminiscent of an older case in which Stutts was named defendant, in which his patient retained placental tissue and suffered excessive bleeding, and later died. The new case’s Plaintiff, Greta C. Cooper, did not die.

Read the PDF file of the 2015 Lawsuit against state Sen Larry Stutts

The suit alleges, among other things, that Stutts failed to order powerful antibiotics to be administered EXCLUSIVELY by Licensed Professional Nurses, and that two RNs with Gentiva Home Health Services in Russellville, Alabama, then taught the Plaintiff’s husband how to administer the medication, and that as a result of his failure to properly order, blood levels of the medication were also not taken which resulted in overdose toxicity.

Dr. Larry Stutts, DVM, MD (R), who was first a veterinarian, then became an Obstetrician/Gynecologist (OBGYN), upset 32-year veteran Alabama Senate District 6 State Senator Roger Bedford (D) by 67 votes in the 2014 November General Election. Stutts is also president of Colbert Obstetrics and Gynecology, PC (his private medical practice), located at 1120 S Jackson Hwy #104, Sheffield, AL 35660, (256) 386-0855.

Alabama District 6 State Senator Dr. Larry Stutts, DVM, MD

Alabama State Senate District 6 encompasses all of Franklin County, and portions of Colbert, Marion, Lauderdale and Lawrence Counties in NW Alabama.

Interestingly, Sutts wasn’t the GOP’s original candidate for the Senate District 6 race. Jerry Mays was the original GOP candidate, but dropped out of the primary. In response to Mays’ decision, on March 20, 2014, State Republican Party Chairman Bill Armistead announced that the Alabama Republican Party Candidate Committee had met and named Larry Stutts, who resides in Tuscumbia, to replace Mays candidacy. Stutts had never been in any elected political office.

Stutts is the same physician who was years earlier named in another lawsuit in which his patient Rose Church – a newlywed, and healthy 36-year-old Registered Nurse – died, which in turn,

Medical News You Can Use: “I hate you; you’re stupid” Edition – Brain Stimulation Reduces Racial Prejudice

Brain Stimulation Reduces Racial Prejudice

Racial discrimination remains to be a pressing issue across the globe. In a study published in “Brain Stimulation“, Dutch researchers have now demonstrated that racial prejudice can be reduced with brain stimulation.

Scientists at the University of Leiden, Leiden, Netherlands, conducted an experiment in 60 healthy volunteers. Half of the group received transcranial direct current stimulation (tDCS) with a low intensity current administered by electrodes placed on the frontal part of the scalp. The other half received sham treatment.

During the treatment, the participants were

Is God an Abortionist?

The Bible never mentions abortion.

It doesn’t suggest it, nor does it even hint at it.

The Bible doesn’t forbid prostitution.

In fact, there are many things the Bible doesn’t even mention.

But it does forbid eating pork, shrimp, oysters, mussels, clams, cheeseburgers, wearing clothing made with cotton/polyester blended  fabric, that a man should marry his brother’s wife if the brother dies before impregnating her, and several hundred other nonsensical rules, regulations and laws – almost all of which were religiously based upon ignorance.

At the time the Bible was written (approximately 4000 BC/BCE), there was no understanding of Germ Theory (1864). No one understood Bernoulli’s Principle (1783). In fact Bernoulli wasn’t even born then. No one understood the physics and principles of lift, low pressure, high pressure, or how weather systems occurred. Even the beer and wine that was made then was thought to have been made magically – as if it were some kind of mystical gift from the gods, a god, or the God. They had no idea – were literally clueless – that it was through fermentation, because

Medical News You Can Use: “Dr. Atkins Was Right” Edition – Carbs Make You Fat, Not Just Inactivity

Researchers: Diet To Blame For Obesity, Not Lack Of Physical Activity

Lack of physical activity is not to blame for the prevalence of obesity, but rather the wrong diet, report physicians from the United States, United Kingdom, and South Africa who published their findings in the “British Journal of Sports Medicine.” However, they emphasized that even regular exercise cannot compensate for poor dietary habits.

Excess consumption of sugar and carbohydrates is mainly responsible for obesity, say the experts. Even 40% of people with a normal BMI will consequently have metabolic abnormalities normally associated with obesity.

But it is problematic that the public firmly believes that development is exclusively due to lack of physical activity. That misconception is due almost exclusively to

Medical News You Can Use: Sleep Apnea Can Harm Children’s Learning

Disruption Of Sleep In Children Could Hamper Memory Processes

Sleep disordered breathing can hamper memory processes in children, according to a new study presented at the Sleep and Breathing Conference held in April in Barcelona, Spain. The research found that disrupted sleep had a negative effect upon different memory processes and how children learn.

Sleep apnea can also negatively affect growing children.

A team of researchers from the University of Szeged and Eötvös Loránd University in Hungary analyzed 17 children with sleep disordered breathing aged between 6 and 12 years. They looked at different memory processes compared to a control group of 17 children of similar age without any sleep disorders.

A story recall task was used to measure memories that can

Medical News You Can Use: “Can I Please Get Some SLEEP!?!” Edition – Children’s Hospitals Lack Standards

As anyone who has been in a hospital – either as patient, or visitor – can attest, hospitals are NOT a place where rest occurs. And THAT! is a crying shame! For healing restoration can ONLY occur with proper rest, and that means SLEEP!

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Study Reveals An Absence Of Consistent Standards In Children’s Hospital Environments

The sound, light and temperature levels in European pediatric hospital wards often vary, highlighting the lack of consistent environmental standards, according to a new study presented at the Sleep and Breathing Conference held in April in Barcelona, Spain.

Quietude aids healing and restoration

Children and parents often suffer sleep deprivation when the environment on a ward is disruptive, which can affect disease recovery and quality of life in hospitalized children. There are no general consistent recommendations covering sound, light, and temperature levels to help guide hospitals across Europe.

Researchers measured these three factors in five pediatric wards in

Medical News You Can Use: “Musician’s Friend” Edition – Wind Instruments Lower Sleep Apnea

Playing A Wind Instrument Could Help Lower The Risk Of Sleep Apnea

A study performed in India suggests wind instrument musicians are at lower risk for Sleep Apnea. Seen here, a B-flat trumpet.

A new study has found that wind instrument players have a reduced risk of developing obstructive sleep apnea. The findings, presented at the Sleep and Breathing Conference held in April in Barcelona, Spain suggest that this could be considered beneficial to those individuals who are at high risk of developing sleep apnea.

Researchers in India conducted lung function testing in

Medical News You Can Use: Statins Increase Diabetes In White Males

Statins Increase Risk Of Type 2 Diabetes By 46%

Taking statins significantly increases the likelihood of developing type 2 diabetes. According to a Finnish study published in “Diabetologia,” the risk is 46% higher.

In their study, researchers from the University of Eastern Finland and Kuopio University Hospital included 8,850 men aged from 45 to 73, who had not been diagnosed with diabetes at the beginning of the study. During the observational period of almost six years,

Medical News You Can Use: Household Animals Can Pass Along Diseases

Household Animals Can Pass Along Diseases

While there are many positive effects of keeping household pets, they can also pass along diseases. In a study published in the “Canadian Medical Association Journal,” Canadian and American researchers warned that animals are able to transmit numerous pathogens to their owners.

Scientists from The Ohio State University in Columbus, and the University of Ottawa in Ontario performed a meta-analysis of existing literature, which mainly included reports on individual cases but contained no systematic studies.

For healthy people, the risk of contracting a disease was low if the animals were adequately kept and hygiene guidelines followed. However, children younger than 5, adults older than 65, people who are ill, and pregnant women were at increased risk of developing a zoonotic disease. Moreover, researchers found in that group of people the diseases may be more severe, symptoms may last longer, and the risk of complications was higher.

Practically all household pets can transmit pathogens. Transmission occurs through bites and scratches, contact with feces, when cleaning cages, or when an animal licks a person.

Dogs and cats can transmit the diarrhea pathogen Campylobacter jejuni, and cats also pass on Bartonella bacteria. Infection with resistant bacteria such as ESBL, MRSA or Clostridium difficile, is possible between humans and animals in both directions.

Parasites, such as worms, are usually contracted from dogs and cats. Cats can also pass on the bacteria Toxoplasma gondii, which can lead to serious birth defects in unborn children, or even miscarriage. Amphibians and reptiles commonly transmit salmonella. According to U.S. studies, about 11% of all salmonella infections in those under age 21 are caused through contact with those animals.

In general however, the companionship provided by household pets has more positive than negative effects. Dogs, in particular, contribute to protecting toddlers against allergies and respiratory infections. Furthermore, canines have positive effects on the psyche and especially have positive effects because owners get more exercise by taking the animal out.

Medical News You Can Use: The “Pour Some Sugar On Me!” Edition

Maple Syrup May Make Bacteria More Susceptible To Antibiotics

According to Canadian researchers, maple syrup may have the potential to make bacteria more susceptible to antibiotics, thus leading to lower usage of the medicines. That is the finding of a study recently published in “Applied and Environmental Microbiology.” The syrup extract also contributed towards destroying biofilms.

Using common maple syrup, researchers at McGill University in Montreal produced an extract

Open Letter to Alabama Governor Robert Bentley, MD

Open Letter to Governor Bentley
October 10, 2014 at 12:45pm

Governor Bentley,

I need to go to the doctor. But I can’t. For some reason I still can’t understand you turned down Federal money set aside for people like me.

On June 24, 2014, on my way to see a doctor to determine disability benefits, I had a car accident. My car was totaled and my lip busted. I had hit the steering wheel with my face.

I still almost refused the ambulance ride because I was afraid of the bill. It took a street full of people to convince me to go. I had my lip sewn up, some scans done. I was sent home with a neck brace.

I have $12,000 in bills now, and my disability was denied. I am more disabled now than before the accident. I am waiting on an appeal with no medical care and no income. That hospital bill will never get paid. I wonder how many other people in this state are in the same situation. Sometimes I think

The Future of Computing, the Internet & Healthcare

“Mature” applications’ resurrection will hinge upon touch-screen technology which will further cement the GUI as a future power broker, and external scripts -which presently have numerous problems inherent to their own shortcomings- will become inherently integrated within the framework of an OS while HTML will morph into a similarly integrative & secure distributive computing platform (P2P), which proof of concept has been demonstrated by BitTorrent & Tor.

Should a “Mental Health Tax” be placed on Marijuana?

Let’s talk about drug abuse.

Abuse of any kind is improper use, or dependency. In some cases, so-called “recreational” use is “abuse,” for there is no other kind of use, since a drug may be already illegal.

For the greatest part, those drugs, which are sometimes mistakenly called ‘narcotics’ (technically, narcotics are derivatives of and synthetic chemical relatives to the opium plant) are already illegal, and include LSD and other hallucinogens, heroin, methamphetamine (as “crystal meth”), etc. And, at the Federal level, like it, or not, agree or disagree, marijuana is included in that list.

Further, alcohol must be included in the list of abused substances, simply because we know that people’s lives can be, and are destroyed by alcohol abuse, directly and indirectly.

There’s a database of information based upon hospital admissions related to drug abuse. It’s called the Treatment Episode Data Set, or TEDS, and the information is collected anonymously by each facility in a state that receives “State alcohol and/or drug agency funds (including Federal Block Grant funds) for the provision of substance abuse treatment.”

It is not an exhaustive data set by any means, and there are limitations upon it, yet it does provide some reliable degree of accuracy to the extent, scope and nature of the problem. Consequently, information in “the tables focus on treatment admissions for substance abusers.”

In other words, someone abuses a substance on the list to the extent that they need some degree of care, including hospitalization, and that anonymous information about their admission gets collected and reported. For the purposes of that report, anonymous information is age, sex, ethnicity/race and drug(s) which led to the need for treatment.

The TEDS list of abused drugs are:

How Honest is Your Doctor?

If you had an option, would you rather pay $10/month, or $80/month for a prescription medication that accomplished/did the exact same thing?

Research shows that the results of the 2 differently priced medicines have never been shown to be any better in any way.

Which would you choose?

Why?

What if your doctor prescribed the more expensive medication for you based on the fact that

Psychiatric Madmen? New manual makes everyone mentally sick.

Perhaps an alternate title for this would be “We’re in it for the money.”

See also another related entry entitled “Mental Health Profession has Mental Health problems.”
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“We’re all mad here”

Medication misuse is out of control in the US and more psychiatric labelling in DSM-5 will not help.

by Allen Frances | Tuesday, 21 May 2013

That’s the message of the new edition of the bible for American psychiatrists, DSM-5. Diagnostic inflation is about to become hyperinflation.

“We are all mad here” explains the Cat to Alice when she wonders about the strangeness of Wonderland. Well, life is starting to follow art. If people make the mistake of following DSM-5, the new diagnostic manual in psychiatry that was published on Saturday, pretty soon all of us may be labelled mad.

When I worked on the taskforce for DSM-4, we were very concerned about taming diagnostic inflation – but we only partly succeeded. Then four years ago, I became aware of the excessive enthusiasm around all the new diagnoses being proposed for DSM-5, including many that were untested. I hate to rain on anyone’s parade, but I knew this would be disastrous for the millions of people who were likely to be mislabelled, stigmatised and given excessive treatment.

In the US, the “sick” are distinguished from the “well” by the diagnostic and statistical manuals developed by the American Psychiatric Association.

The problem is that definitions of mental disorders are already written too loosely and are applied much too carelessly by clinicians, especially by the GPs who do most of the prescribing of psychiatric drugs.

And things are about to get much worse. Under DSM-5 diagnostic inflation looks set to become hyperinflation and will lead to an even greater glut of unnecessary medication. I would qualify for a bunch of the new labels myself – and you might too.

The grief I felt when my wife died would now be called “major depressive disorder”; forgetfulness in older age “mild neurocognitive disorder”; my gluttony now “binge eating disorder”; and my hyperactivity “attention deficit disorder”. As for my twin grandsons’ temper tantrums, this could be misunderstood as “disruptive mood dysregulation disorder”. And if you have cancer and your doctor thinks you are too worried about it, there’s “somatic symptom disorder.” It goes on, but you get the idea.

About half of Americans already qualify for a mental disorder at some point in their lives and the rates keep skyrocketing, especially among kids. In the past 20 years, the prevalence of autism has increased, childhood bipolar has multiplied 40-fold and attention deficit disorder has tripled.

One consolation: the kids are not suddenly getting much sicker – human nature is pretty stable. But the way we label symptoms follows fickle fashions, changing quickly and arbitrarily. And freely giving out inaccurate diagnoses can

NYC Seeks to Curb Painkiller Abuse With Hospital Limits

It’s only “deadly” if it’s misused or abused.

And yet, the idea is an excellent one because it limits potential for misuse and abuse by fraud.

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New York City is seeking to curb abuse of potentially addictive and deadly painkillers such as Oxycontin and Vicodin with new limits on how widely the drugs should be prescribed.

Emergency departments at New York’s public hospitals will only prescribe a three-day supply of opioid painkillers, won’t refill lost or stolen prescriptions and shouldn’t prescribe long-acting versions of the drugs, according to voluntary guidelines the city issued today.

The move is aimed at

Fit for Human Consumption, or Rat Poison? High Fructose Corn Syrup Continually Indicted in Obesity Epidemic.

Fit for Human Consumption, or Rat Poison? How many foods use High Fructose Corn Syrup? The answer might surprise you. Or, it may not. Originally uploaded by SouthernBreeze

In the last several years, obesity has become a rampant epidemic in the United States. While there are doubtless many causes, it is my opinion that a wholesale change in our dietary practices – and I specifically do not mean to refer to increased portion sizes, consumption or intake – but rather to an ingredient which has become all too common in commercially prepared food… which, if we were honest with ourselves, is most of what we consume.

For example, the majority of Americans do NOT grow their own vegetables, raise their own groceries (meat, dairy, poultry, eggs, pork, etc.), nor do they eat homegrown, locally grown, or even “freshly prepared” vegetables, even if those vegetables were imported to the United States. Consider even pineapples, for example. Once, the exceeding majority of the world’s supply of pineapples were grown in Hawaii. The highest quality pineapples are sold to Japanese markets, where they pay top price for the highest quality fruit. Not so in the United States, where American customers balk at high prices, even if it’s associated with higher quality.

Historically, Hawaii was the world’s largest pineapple producer and source for pineapples. Relatively recently however, rapacious corporate profit seekers abandoned Hawaii for cheaper production (translate “cheap labor” & “no health & safety regulation”), and there now remain only two fresh pineapple operations remaining in Hawaii: one on Maui, and another on Oahu. And that quandary is an entirely separate, yet related, problematic issue.

However, much of what we eat has been commercially processed in volume. And I mean in HUGE volumes! In America’s factory food processors, a fairly common ingredient is

Reaching the End of Life: What Do We & Loved Ones REALLY Need?

Recollecting, one of my patients was similarly diagnosed, suffering terminal lung cancer of the small cell carcinoma type, and had one lung removed. He had presented to the ED (Emergency Department) with extreme hypoxia (lack of oxygen), to such an extent that his lips had a distinctive blue cast to them. His oxygenation was so exceedingly poor, that he would turn in bed, and his sats (oxygen saturation level) would drop to 70% – neither a good, nor one that would sustain life.

In conversation with him, I asked him what he wanted to have happen to him, how he wanted things to turn out for him. He wasn’t under any misguided notion about his state of well-being or health and wanted to depart the ICU.

He said, “I want to go home to die.”

I responded by saying, “We want you to go home too. Let’s see what we can do to get you back there.” At that point, I began some very simple teaching about his breathing. He was a habitual mouth breather, and he knew it. I’d glance up at him, and his mouth would be gaping open as he watched teevee. Problem was, that every time his mouth opened, his sats dropped, even though he was receiving high flow O2 therapy via specialized nasal cannula.

So I instructed him that by keeping his mouth closed and breathing through his nose, his sats would increase. And barring any other unforeseen circumstance, were his sats to consistently maintain above 90%, that would be the greatest step toward his objective to go home.

At the end of my shift, he was consistently satting 98%.

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Doctors are practicing irrational medicine at the end of life

by Monica Williams-Murphy, MD on September 22nd, 2012, in Physician

I just took care of a precious little lady, Ms. King (not her real name), who reminded me that, too often, we doctors are practicing irrational medicine at the end of life. We are like cows walking mindlessly in the same paths; only because we have always done things the same way, never questioning ourselves. What I mean is that we are often too focused on using our routine pills and procedures used to address abnormal lab values or abnormal organ function, to rightly perceive what might be best for the whole person, or even what may no longer be needed. Our typical practice habits may in fact become inappropriate medical practiceat life’s end.Ms. King was a case in point: She was a 92-year-old nursing homepatient on hospice for metastatic breast cancer. Ms King had been transferred to the ER for a sudden drop in blood sugar, presumably due to her oral diabetes medication. Her appetite had apparently been trailing off, as is common at the end of life, and her medication appeared to have become “too strong.” Her glucose level had been corrected by EMS during her trip from the nursing home to the Hospital, so when I came into see Ms King she was at her ‘baseline.’I opened the door to bed 24 and a grinning little white-haired lady peered at me from over her sheet. “Hi,” she said greeting me first.“Hi, Ms King,” I smiled back at her and picked up her hand.

She reached over with her free hand to pat me on my forearm, “You sure are a cute little doctor,” she said smiling.

I couldn’t hold back a little laughter. “Well, you sure are a cute patient too,” I smiled and winked at her.

She winked back at me.

“Wow, this is the most pleasant 90-year-old I have cared for in a while,” I thought to myself.

As we chatted it became clear to me that she had some mild dementia but had no pain or complaints at the time. She just said, “I think I had a ‘spell’” ( a “Southernism” for some type of unusual and undefined episode of feeling ill or fainting); and “I’m not hungry” when I offered her food.

Leaving her room still smiling after our pleasant exchange, I went back to look at her medical record from the nursing home and two things immediately struck me:

Former Tennessee Senator & Cardiothoracic Surgeon Bill Frist, MD enters healthcare dialogue

Face it. Sooner or later, you’re going to die. Death is a part of life. Making a decision about whether or not you want to be connected to belts, tubes, hoses & pumps to circulate your blood, food & oxygen when your body would have naturally expired is essentially what the discussion is about.

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The Bill Frist ℞

By: Brett Norman
September 16, 2012 11:06 PM EDT

Meet former Sen. Bill Frist, a renegade “Obamacare”-loving Republican who is in the mood for some real bipartisanship.

Yes, the same Frist who as Senate majority leader led an army into the culture wars over Terri Schiavo and whose efforts in 2004 to unseat his then-rival, Minority Leader Tom Daschle, led to a nasty — and personal — Washington battle royal.

Now, Frist is pushing for a national conversation on end-of-life care and dismissing “caricatured”talk of death panels. He’s committing Republican heresy in endorsing elements of the loathed Affordable Care Act. He’s standing shoulder to shoulder with Daschle in search of a bipartisan way to tackle one of the thorniest problems around: how to get control of health care costs before they sink the economy.

Frist is pushing for a national conversation on end-of-life care. | AP Photo

The Frist-Daschle reconciliation, in particular, is a source of amazement to some longtime Washington observers.

“I didn’t think they would ever talk again,” said Bill Hoagland, a budget expert and former aide to Frist who has joined the duo on a health cost control initiative at the Bipartisan Policy Center. “I was surprised, pleasantly, that they would work together.”

Daschle told POLITICO, “He’s been a very important partner and I would say has become a friend in spite of the fact that we’ve had a difficult history.”

“That is past and we now find much more in common than not,” he added. “We both know that we need to find a consensus way forward.”

Frist, a heart and lung transplant surgeon who is now focused on research and policy, is working on

News for the “Medical Marijuana”/420 crowd: Israeli firm grows “highless” marijuana strain

What if the so-called “medical marijuana” proponents could have their cake, and eat it to?

That is, what if they could have the “benefits” they claim they derive from smoking marijuana, while NOT having its intoxicating effects?

Would they still smoke it?

That would tell the story.

It certainly would.

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What a drag, Israeli firm grows “highless” marijuana

A worker tends to cannabis plants at a plantation near the northern Israeli city of Safed June 11, 2012. REUTERS-Baz Ratner

By Maayan Lubell SAFED, Israel | Tue Jul 3, 2012 9:48am EDT

(Reuters) – They grow in a secret location in northern Israel. A tall fence, security cameras and an armed guard protect them from criminals. A hint of their sweet-scented blossom carries in the air: rows and rows of cannabis plants, as far as the eye can see.

It is here, at a medical marijuana plantation atop the hills of the Galilee, where researchers say they have developed marijuana that can be used to ease the symptoms of some ailments without getting patients high.

A worker tends to cannabis plants at a plantation near the northern Israeli city of Safed June 11, 2012. Credit: REUTERS/Baz Ratner

“Sometimes the high is not always what they need. Sometimes it is an unwanted side effect. For some of the people it’s not even pleasant,” said Zack Klein, head of development at Tikun Olam, the company that developed the plant.

Cannabis has more than 60 constituents called cannabinoids. THC is perhaps the best known of those, less so for its medical benefits and more for its psychoactive properties that give people a “high” feeling.

A worker tends to cannabis plants at a plantation near the northern Israeli city of Safed June 11, 2012. Credit: REUTERS/Baz Ratner

But cannabis also contains Cannabidiol, or CBD, a substance that some researchers say has

“Physician, heal thyself.”

For many years, patients have increasingly complained that physicians “bedside manner” toward their infirm patients has been less than compassionate.

Such charges have led to decreased patient satisfaction, among other undesirable results.

So, what we really wanna’ know is…

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Can Doctors Learn Empathy?

June 21, 2012, 2:52 pm, By PAULINE W. CHEN, M.D.

My colleague loved performing surgery as much as anyone I had ever met. Every morning he bounded into the hospital, full of energy and cheerful anticipation of the day’s surgical schedule, his prominent mouth stretched into a broad grin.

“Too bad his foot is always in it,” another doctor whispered one day as our colleague passed by.

The sad truth was that despite his gusto, patients often complained about our colleague. He was brusque when the moment required sensitivity, flip when the conversation was grave, and heavy-handed when the situation called for a light touch. Just a few days earlier, we were shocked to learn he’d bluntly told an elderly war hero in the hospital for his diabetes, “I need to cut off your leg.”

“He sure doesn’t lack

Pradaxa & Xarelto: Are they worth the risks & costs?

What dangers lurk ahead for new “blood thinner” medications?

Could we unwittingly be participating in our own destruction?

Not only that, but these new medications are exorbitantly expensive, as well.

Are they worth it in the long run?

Should we continue to use the ready stand-by?

The new meds have no antidote. The old one does.

Too little too late, or too much too soon?

Are we playing with fire?

Only time will tell.

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Insight: Top heart doctors fret over new blood thinners

6:50am EDT, 14 June 2012

By Ransdell Pierson

NEW YORK (Reuters) – For millions of heart patients, a pair of new blood thinners have been heralded as the first replacements in 60 years for warfarin, a pill whose hardships and risks have deterred many from using the stroke-prevention medicine.

But growing complaints of risks and deaths tied to the new crop of drugs have made some top U.S. cardiologists hesitant to prescribe them. Some are proposing a more rigorous monitoring regimen for when they are used.

Most concerns revolve around Pradaxa, a twice daily pill from Boehringer Ingelheim that was approved by the U.S. Food and Drug Administration in October 2010 to prevent strokes in patients with an irregular heartbeat called atrial fibrillation. It was the first new oral treatment for that use since warfarin was introduced in the 1950s.

“The good news is

New Hope in Cancer Treatment May Soon Be Widely Available

In a nutshell, cancer is simply a case of good and normal cells which have “gone bad,” which are typically characterized by rapid reproduction of those mutated cells, accompanied by the development of its own network of blood vessels to feed its growth (angiogenesis).

The initial findings in this research are indeed promising.

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Drug Helps Defense System Fight Cancer

June 1, 2012 By ANDREW POLLACK

CHICAGO — One of the great frustrations for researchers in the war on cancer is that the body’s own defense system does not do a better job fighting the disease. Tumors, it turns out, have a molecular shield that repels attacks from the immune system.

Now, a new study says, an experimental drug is showing promise in disabling that shield, unleashing the immune system and causing shrinkage of some lung, skin and kidney cancers that had defied treatment with existing drugs.

“We are seeing responses in heavily treated patients — three different cancers, one drug,” Dr. Suzanne L. Topalian, a melanoma specialist at Johns Hopkins University and lead investigator in the study, said in an interview. “This is a group of patients whose life expectancy was measured in a few months.”

The results are from