Introduction to

Medical Cannabis

Anatomy of Cannabis Plant

Cannabis is a genus of flowering plants in the family Cannabaceae. This family that also includes the hemp plant produces fibrous stalks and offers diverse utility for multiple purposes. A documented historical use of medical cannabis for symptomatic relief has been reported for over 5 centuries. The leaves, flowers, and roots have noted medicinal use throughout the world in: China, India, Israel, the United Kingdom, and Canada. Cannabis leaves and flowers are traditionally consumed in several forms. Cured flower (bud) is more commonly available compared to various types of concentrated, loose or pressed resin extracted directly from the cannabis plant. As the cannabis plant matures from its vegetative state to the flowering phase, the development of trichomes (tiny, crystal-like glands containing cannabinoids and terpenes) will be visible and abundant on the cannabis fan leaves, stems and flowers.

Together, the chemical compounds of cannabinoids and terpenes, an array of natural resinous essential oils, provide physical, psychoactive, and therapeutic effects in a combined, complimentary action. The potency of cured cannabis depends on the wide range of cannabinoids, which are chemical compounds that act in the body to stimulate a “lock-and-key” effect. The popularity of cannabis’ best-known psychoactive properties (the mind-altering, euphoria-inducing “high”) is due to delta-9-tetrahydrocannabinol (THC), and its pain-relief, anti-inflammatory, and anxiety reducing benefits (among others) to the non-psychoactive cannabidiol (CBD). These cannabinoids are naturally found in cannabis so they are also known as phytocannabinoids, or naturally occurring plant cannabinoids; as different chemicals, THC and CBD have different alleviating effects for certain symptoms.

THC and CBD act at specialized and natural receptors found in the body known as the CB1 and CB2 receptors. The term “cannabinoids” broadly applies to the natural phytocannabinoids (chemical compounds organically found in the cannabis plant) and endocannabinoids (chemical compounds which are automatically produced by the body) to make up the Endocannabinoid System (ECS).

The ECS acts as a biological balancing mechanism in the body through various processes (or homeostasis). Through different methods of administration, varying levels of THC and CBD will be available in the body. The onset of effect varies depending on the form of administration, which alters THC and CBD entry into the bloodstream for symptom relief. The two most common methods for consuming cannabis are inhalation (smoking or vaporizing) and ingestion (prescription synthetic capsules or edibles).

Mechanism of Action

THC binds to cannabinoid receptors in the brain

THC interferes with endogenous neurotransmitters

Biological Effects Occur

By the 1960s, scientific research established enough evidence to prove that the Endocannabinoid System (ECS) exists naturally in humans and animals. Because the cannabis plant produces phytocannabinoids that act similarly to the endocannabinoids naturally produced by the human body, this communication system within the body involves receptors that bind to all types of cannabinoids in a lock-and-key effect for symptom relief through multiple pathways. THC and CBD will mimic natural cannabinoids to help regulate the body’s numerous biological responses, including pain.

Minor Cannabinoids

THC and CBD are the most commonly discussed and prevalent phytocannabinoids in the cannabis plant, but they are not the only ones. There are over 100 other minor cannabinoids working simultaneously when consuming cannabis as a whole plant. Currently, there is limited knowledge and understanding of individual effects of these minor cannabinoids due to cannabis being scheduled as a Class 1 Controlled Dangerous Substance by the DEA. This federal designation hinders clinical research being done at larger, substantial scales. The limited studies surrounding these minor cannabinoids have shown promising results so far. A few examples include using cannabinol (CBN) to help with insomnia, cannabigerol (CBG) used a neuro-protective agent, cannabichromene (CBC) to reduce inflammation and tumor growth, and tetrahydrocannabivarin (THCV) to help regulate blood sugar and insulin levels.

Cannabinol

helps with insomnia

Cannabigerol

used as a neuro-protective agent

Cannabichromene

reduces inflammation & tumor growth

Tetrahydrocannabivarin

regulate blood sugar and insulin levels

Know Your Terpenes

Along with your major and minor cannabinoids, every single cannabis plant has a unique odor and fragrance linked to their plant genetics. Terpenes are responsible for the distinct smells of citrus, pine, berry, and even fuel depending on specific strains. Some cannabis plants have been described to have either sweet or skunky undertones and all contribute to the complexity of the plant. Terpenes are produced by the same mechanisms as cannabinoids and can vary in concentrations depending on environmental factors such as temperature, humidity, and soil types.

Having a unique smell is beneficial in being able to identify strains, but research has also shown that terpenes provide medical benefits as well. There have been over 100 terpenes identified and each has been studied to some degree showing positive traits for inflammation, bronchodilation, and antioxidation. Terpenes combined with cannabinoids of the plant work side by side producing what’s known as the entourage effect. This synergistic relationship means that consuming the whole plant will have a larger benefit than using individual cannabinoids. Above are a handful of the most common terpenes found and their medical uses.

Decarboxylation

Cannabinoids in its raw form on the cannabis plant need to be activated in order to produce medicinal benefits. Sometimes, you will see the term “THCa” (Tetrahydrocannabinolic acid) and “CBDa” (Cannabidolic acid) listed when describing cannabis strain potencies. The “a” or acid molecule is removed by adding a heat source to the plant to activate the cannabinoids. Traditionally, using a heat source like a lighter will heat up cannabis beyond 451oF, burning the entire plant up. This process is called combustion and produces smoke that you inhale through the lungs. The cannabinoids are being activated, but the entire plant is burned in the process leading to the added inhalation of toxins and carcinogens.

Newer methods of activating cannabinoids in the cannabis plant is through a process of vaporization. This process involves maintaining the cannabis plant cannabinoids at a steady temperature under the point of combustion of 451oF. This process activates the cannabinoids and releases vapor that is inhaled instead of smoke. Every cannabinoid and terpene has a different temperature at which it is activated, so being able to adjust the temperature of vaporization will produce different flavors, and more importantly, different medicinal effects.

Indica

Sativa

The origin of the commonly mentioned terms Indica and Sativa come from the official scientific plant name. Cannabis Sativa are cannabis plants cultivated in hotter climates usually surrounding the equator. They usually grow taller and are characterized by longer, thinner leaves. Cannabis Indica are cannabis plants cultivated under more harsh environments and typically have broader, wider leaves. However, over time, these two terms have been adapted to describe the physical and cerebral effects typically felt when consuming these plants. This chart highlights some of trait differences between Indica and Sativa cultivars.

Indica

Generally sedating, relaxing & soothing

Better suited for night time usage

Described as more of a “body high”

May help with sleep, relaxation & muscle spasm

Sativa

Generally energetic, uplifting & happy

Better suited for day time usage

Described as more of a “head high”

May help with focus, creativity, and mood

Over the years, cannabis horticulturists have bred both Cannabis Indica and Cannabis Sativa plants together to create a separate class of plants called Hybrids. Hybrids were created to take the desired features of each Indica and Sativa strain and combine them to highlight their best qualities. Hybrids are usually not a perfect 50/50 blend of sativa or indica, but you may hear them referred to as being indica-dominant, or sativa-dominant. They maintain characteristic traits of both their parents to create an entirely new combination of cannabinoids and effects. Usage of these plants will vary and a dispensary technician should be consulted for specific characteristics of these cultivars.

Cannabis Explained from Head to Toe

  • Improves global symptoms of PTSD including enhancing
    sleep quality, reducing frequency of nightmares, and reducing
    hyperarousal severity

  • May prevent or slow the development of Alzheimer’s Disease
    Shown to have an analgesic effect and reduce pain associated
    with migraines

  • Reduces pain perception and improves spasticity in patients
    showing symptoms of Multiple Sclerosis

  • Has been suggested to aid in preventing spontaneous
    epileptic seizures

  • The active components of cannabis interact with the brain’s pleasure centers; constant ingestion has been linked to psychological dependence and addiction. However, it is believed to be significantly less addictive than harder drugs
    (e.g. heroin or cocaine).

  • A 1994 study measured the addictive potential of several common drugs by quantitating the percentage of participants showing dependency.

    According to their data:
    Tobacco: 32% became dependent
    Heroin: 23% | Cocaine: 17% | Alcohol: 15%
    Cannabis: 9% became dependent

Eyes

Cannabis has been shown to transiently lower intraocular pressure (IOP) associated with glaucoma, although not as effectively as prescription medication.

Chest

Cannabidiol (CBD), an active component in cannabis, has been shown to hinder the expression of the transcription factor ID-1, a key regulator of the metastatic potential of breast and other cancers.

Pancreas

In one study, cannabis use was associated with lower fasting insulin levels, reduced insulin resistance, and similar waist circumference.

Intestines

Two compounds in cannabis, THC and CBD, have been shown to improve symptoms of Crohn’s Disease.

Hands

A cannabis-based medicine (CBM), Sativex®, may reduce pain associated with Rheumatoid Arthritis (RA) and significantly suppress disease activity.

Muscles

Studies have shown that cannabis significantly reduces muscle spasticity, a condition characterized by prolonged and involuntary muscle contraction, resulting in stiffness and rigidity.

Cannabis Short-Term & Long-Term Affects (Potential)

Potential Side Effects of

Cannabis Consumption

Unintentionally consuming too much cannabis, or accidentally over-medicating, is rare and most likely to happen to patients who have little to no previous experience. To avoid this risk, use the “Start Low & Go Slow” method: initially, start with a small dose and titrate up (or gradually increase the dose) as needed until symptom-relief is achieved.

Over-medicating with cannabis can trigger acute anxiety or panic, increased heart rate, low blood pressure, dry mouth and red eyes. Overestimating the potency, or strength, of the cannabis may result in unintended over-medicating and the patient may need to reduce the amount of cannabis administered in the future.

Possible Effects of Cannabis

Psychological

  • Hunger
  • Lowered Body Temperature
  • Lowered Immune Response

Psychomotor

  • Impaired Motor Skills
  • Slowed Reaction Time
  • Altered Peripheral Vision

Cognitive

  • Short-Term Memory Damage
  • Impaired Perception
  • Impaired Cognition
  • Impaired Learning Ability

Dependency Potential of Cannabis

Low Risk

With chronic excessively frequent cannabis use, approximately 10% of heavy cannabis users may develop a dependency on cannabis.

Side Effects & Remedies

Coughing

  • Reduce amount of smoke/vapor being inhaled
  • Drink some cold water after coughing subsides

Rapid Heart Beat

  • Usually resolves around 15-20 minutes after consumption
  • Breathe deeply and slowly for a few minutes
  • If accompanied by chest pain, contact an emergency healthcare professional immediately

Dry Mouth

  • Drink beverages like water or lemonade
  • Use citrus flavored gum or lozenges to increase saliva production

Red Irritated Eyes

  • Use over the counter eye lubricant eye drops or ointments

Dizziness / Lightheaded

  • Keep your eyes open and focused on something until symptoms resolve

Short-Term Memory Loss

  • Completely reversible when usage is decreased or stopped completely

Psychoactive Effects

Use the 4-7-8 Technique

  • Sitting comfortably, empty your lungs through the mouth with a whoosh.
  • Close your mouth and fill your lungs by inhaling through your nose on a mental count of four.
  • Hold your breath for a count of seven, then slowly exhale through the mouth, with a whoosh, over a count of eight.
  • Repeat four times or until your symptoms are better.

If you experience any mental changes or physical discomfort of any kind that has not been discussed, notify your certifying prescriber immediately.

 

Some patients initiate cannabis while actively taking prescription medications. You should check with your certifying prescriber or dispensing pharmacist for any drug-drug interactions that may occur while using medicinal cannabis.

 

Stopping, starting, and/or changing any of your medication therapy- including over the counter items is not recommended while using cannabis without the direct supervision of your prescriber.

Cannabis Forms of Administration

There are a broad range of options for routes of administration which patients can choose from based on individual lifestyle choices. Cannabis can be smoked or vaporized.

 

Also, ingested in food or beverages (these edibles can be home-cooked and prepared as “infused” cannabis combined with fat-soluble cooking mediums such as salt-free butter or coconut oil.) Another route is where it can be absorbed sublingually (under the tongue i.e. lozenge). A different route can be used topically (applied locally to the skin on affected areas of the body i.e. creams, lotions or ointments).

Safety profiles have not been established for other potential forms of cannabis delivery including:

 

Transdermal, rectal, and sublingual forms; these options may minimize potential risks experienced with common methods of cannabis administration. Clinical research focusing on cannabinoids has led to several FDA-approved medications that contain synthetic cannabinoid(s) in pill or liquid form.

Vaporizing vs Smoking

Vaporization is a form of inhalation that involves heating cannabis to produce steam or vapor instead of directly burning the cannabis to combustion. The devices (specifically known as vaporizers) are equipped to heat the marijuana to a temperature ranging from 356°F to 374°F in order to vaporize THC without

burning plant materials as “smoke.” Smoking devices that use water filters (i.e. bongs or water pipes) have been shown to involve equal amounts of tar in comparison to smoking cannabis using a glass pipe, blunt, or joint and these water filters do not reduce potential risks of cannabis smoke and inhalation.

Vaporizing

Smoking

Edibles, Beverages & Other Forms

Edibles

Other Forms

Dosing Forms Available

Flower

Also known as nuggets, nugs, or bud. Female flowering part of the cannabis plant that produces cannabinoids. It is usually ground down and smoked/vaporized, or can be infused into oils or butters to prepare edibles with.

Shake

Finely ground cannabis flower that can be consumed or prepared in all the ways regular flower is used right out of the container.

Pre-Rolls

Flower or shake that is rolled into a cigarette form using a filter and unbleached rolling paper, also ready to use out of the bag..

Concentrate Oils

Cannabinoids are extracted and refined from the cannabis plant into a more purified and potent form. They can be smoked, vaporized, used to cook edibles, or applied directly in the mouth as a tincture.

Concentrated dabs/wax/shatter/rosin

Cannabinoids that are extracted and refined from the cannabis plant into extremely high concentrated and potent solid/semi-solid states. They are usually consumed by smoking or vaporization only.

Tropical Formulations

Lotions, ointments, balms, and creams can be great for local application of specific areas of the body for arthritis or pain.

Sublingual tinctures/lozenges

Absorption of cannabinoids through the buccal or sublingual route leads to a quick and clean option..

Capsules

Activated cannabinoids that can be swallowed by mouth similarly to other medications. Dosing options are more precise and can be increased or decreased accordingly.

Suppositories

Applied rectally for patients that do not have the ability to intake anything orally, have severely impaired lung function, or have an inoperable digestive tract..

Transdermal patches

Patches that are applied to the skin that allows for a slow release of cannabinoid(s) throughout the day. Application can be discreet and hidden under clothing.

Onset & Duration

Dosing

One of the primary concerns that every new patient will experience is “how much do I use for my particular condition?” Unfortunately, there are currently no officially recognized therapy protocols or guidelines found like with traditional prescription medications. We encourage patients to follow a concept called microdosing which is simply to “start low, and go slow.” You will start with the smallest dose possible, and gradually increase the dosage in controlled increments until you achieve the desired response for your condition. This fine tuning process will allow you to maximize outcomes while limiting the amount of adverse effects you may experience. Also by using the most minimal amount of medication, you will reduce your out of pocket costs from wasting excess.

 

These are a few tips that can help you get started with microdosing. Start with one small dose. Whether it be 1 puff, 1 lozenge, 1 capsule, or 1 application, keep it simple. Repeat the same dose in 10-15 minutes if symptom relief is not achieved. You should wait between 1-2 hours for orally ingested medicine due to a longer onset of action.

Repeat this step as many times as needed until you do achieve the desired effect. Going forward, this will be your established baseline dose. The next time you need to medicate, start with your baseline dose and medicate as frequently as you feel necessary. Keep in mind, that the higher the dose and more frequently you medicate, the more you are also at risk for adverse effects. From time to time, doses may need to be increased or decreased based on therapeutic relief or unwanted side effects. We encourage and recommend that you keep a cannabis log to document cultivars used, number of doses, frequency of doses, and comments on effects. This will help you take more of a scientific approach to your cannabis therapy and will help the dispensary technicians give additional recommendations if needed.

 

Dosing methods and strain selection will be dependent on your lifestyle habits, tolerance levels, and physical capabilities. The most important takeaway is that you, the patient, be 100% comfortable with using and administering your medical cannabis on your own.

Consumption Method Considerations

Consumption Method

Smoking

Onset of Action

5 – 10 Minutes

Advantages

  • Less expensive upfront costs
  • Convenience

Disadvantages

  • Adverse respiratory effects
  • Strong odor
  • Technical skills required for rolling a blunt or joint, or packing a bowl

Consumption Method

Vaporizing

Onset of Action

5 – 10 Minutes

Advantages

  • Minimal odor
  • Less respiratory effects
  • Healthier than smoking

Disadvantages

  • More expensive upfront costs
  • Requires electrical power source or charging

Consumption Method

Oral

Edibles & Capsules

Onset of Action

Up to 1 – 2 Hours

Advantages

  • No odor after preparation
  • Discreet consumption
  • Longer lasting effects
  • No effects on lung health
  • More precise dosing available

Disadvantages

  • Unpredictable onset and duration
  • Digestive enzymes may increase variability
  • Added time needed to prepare/bake

Consumption Method

Tinctures

Onset of Action

10 – 15 Minutes

Advantages

  • Discreet packaging
  • Precise measured dosing options

Disadvantages

  • Alcohol based
  • Taste may be unpleasant

Consumption Method

Topicals

Onset of Action

10 – 15 Minutes

Advantages

  • No psychoactive effects
  • Therapeutic physical benefits

Disadvantages

  • Odors from product
  • Greasiness on skin

Consumption Method

Suppository

Onset of Action

10 – 15 Minutes

Advantages

  • Great absorption
  • Available for patients with no oral function

Disadvantages

  • Can be messy
  • Uncomfortable administration

Storage Considerations

After purchasing your cannabis, you want to make sure you keep your product in its original packaging removing all the excess air if possible. Your cannabis should be stored in a cool, dark place. Avoid putting your cannabis in the refrigerator or freezer because it can remove too much of the moisture that is needed to have a fresh product. Avoid leaving your cannabis in hot temperatures and/or in direct sunlight because this will cause oxidation and degradation of the active phytocannabinoids leading to a less effective product. There is no exact shelf life or expiration for cannabis products, but keep in mind that the potency of your product will decline over time.

 

There are a few ways to tell if your cannabis flower product has exceeded its shelf life. Some visual cues will include mold formation on the plant appearing

as a white powdery mass. It should immediately be discarded and not consumed due to severe health issues that may occur if it gets into your lungs. When you use your fingers to pick up the plant, it should not crumble or have an overly dry consistency. Smell is also a great indicator of how fresh your flower product is. When you first purchase your cannabis flower, it will have a potent, fresh odor due to the abundance of terpenes. Older cannabis flower will have a musty, chemical-like odor to it and will not have as strong of an odor compared to when you first open it. Lastly, the taste of the product will become less noticeable and have a sour or earthy undertone if it’s too old.

 

Manufactured products like concentrated oils, topical formulations, and tinctures should be stored in a cool, dry place away from a direct heat source or sunlight.

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