Webinar Recap: Medical Marijuana: Panacea or Snake Oil

On March 22, Elite Continuing Education hosted Medical Marijuana: Panacea or Snake Oil, presented by Bradley Gillespie, Pharm D.

Although not well-supported by clinical research, the availability of medical marijuana is increasing. Additionally, generalized legalization of recreational marijuana is also on the upswing, paralleling overall increases in use. As a result, clinicians are more likely than ever to encounter marijuana usage in their practice settings.

Questions we didn’t have time to answer:

Are more people using medical marijuana with the increased opioid regulations?
There are currently increases in attention to the regulation of opioids as well as increases in jurisdictions allowing medical marijuana. Further, the overall usage of medical and recreational marijuana is increasing. While these increase may be associated phenomena, I have not seen any research demonstrating a positive linkage.

As a nurse and a nurse in the home health arena for many years, my concerns are centered around my exposure to the smoke while on duty and my licensing board.
That concern is valid. My suggestion would be to present facts of your situation in a clear and concise letter to my licensing board.

Have you seen marijuana used in children with ADHD and/or symptoms of 22Q duplication syndrome? If so, is it helpful?
There are proponents of these indications. I have not seen convincing data to confirm safety and efficacy in these populations. That cannot be viewed as either a positive, or a negative, just an observation that no one has done the clinical studies required to prove anything.

How can we justify the use of marijuana in the smoked form as we seek to reduce the use of tobacco smoking, especially in public areas and the risk of second-hand smoke?
I do not think that we can. While marijuana smoke has not been characterized to the extent of tobacco smoke, there are indications that it is dangerous. As such, for health reasons, I personally cannot condone smoked marijuana.

I don’t see any thoughts about the use of marijuana for patients on chemotherapy, especially related to the N/V that occurs; would that be the same as using it for the N/V in those patients with HIV/AIDS?
I did not run across convincing data confirming this indication. With that said, it seems possible that if it works in HIV/AIDS, it may work for chemotherapy patients.

I have personally effectively weaned off of benzodiazepines which were dosed for 10 ish years (unfortunately). I achieved this with low dose THC drops. Low enough to avoid psychotropic effects.
I am pleased that this worked for you. Much of the data is anecdotal and not proven. Nonetheless, I am not so bold as to say that marijuana products are bad for all patients.

I read about a new “soda” that has THC in it as a “mild” intoxicating agent as an alternate to alcohol. It’s called California Dreaming, I believe. What is your take on this product?
I just heard of it the day before the webinar. I took a quick look at some stuff on the internet. A couple things come to mind. While on one hand, it could be lumped into all other edible marijuana products. A concern that I have is that it could easily be misleading to people, similar to that of some candy preparations. It is also imprortant to keep in mind that like all “legal” marijuana, it is still prohibited under federal law. At this point, it is unclear what stance DEA and DOJ will take on mass-marketed marijuana. My guess is that they would go after it. Time will tell.

There is a rise in young alcoholics who are bottoming out early since they began early use. With the legalization of marijuana, I can see this being used as an alternative. Does it effect the same neurochemicals in the brain as does alcohol? Also, I just saw that alcohol can enhance the intoxicating effects. I am concerned about the effect on driving as people can not drink alcohol and drive, you can not smoke a joint and drive, but no one would be alerted if you drank a can of the THC soda or any other means of ingesting it while you drive since people eat and drive all the time.
I am not sure on the neurochemical question. While there is some overlap, there are so many neurotransmitters in play, it is difficult to characterize the complete overlap. With that said, there is certainly a known synergistic impairment with alcohol and marijuana. So far as the ability to drink a marijuana-infused soda while driving, I agree quite doable. At the same time, not much different than consuming a number of edible marijuana products whilst driving.

I still am curious about its effect on the neurochemicals in the brain. Alcohol effects gaba receptors especially. Does the presenter know the area in the brain effected by marijuana or its products THC and CDB?
Cannabinoid receptors are found throughout the brain. These receptors are intended to be activated by an endogenous cannabinoid called anadamide. THC agonizes these receptors causing a number of effects, notably the release of dopamine, which subsequently triggers the brain’s reward and pleasure centers.
So far as parts of the brain, key impacted regions include:

  • Hippocampus, within the temporal lobe critical to short-term memory. THC can change the way that information here is processed, potentially altering judgement
  • Cerebellum, at the back of the brain is useful for regulating coordination and muscular activity. THC can interfere with this activity, resulting in slowed reaction times
  • Basal ganglia, at the base of the brain works to control unconscious muscle movements. THC interference here can impair motor coordination

If there is an anti-inflammatory effect then why increased cardiovascular effects? I would think it would be the opposite.
I agree that the anti-inflammatory effect could have the potential to dampen the atherosclerotic process and possible vasodilation. I believe that in this context, the CV impact would be through increases in cardiac output (heart rate and possibly contractility). It is critical to note that these impacts are slight, and not fully characterized.

In general, do you know how workplaces handle those who have qualified for medicinal use? What if a person has a professional license and is approved for medicinal use, would this mean a loss of their license?
I have not tackled this question. With that said, as an example of benzodiazepines, another common screened for drug of abuse, I am told that a prescribers order can be used to justify a positive test result in some cases. While this may be useful in placating a medical board in some cases, I expect that it varies largely from case to case. It may be useful to gauge the position of a board prior to submitting a knowingly positive sample for analysis.

In speaking with other pharmacists they have spoken about anecdotal evidence of tumor shrinkage/disappearance using Rick Sipson & Snergy hemp oil. Have you heard about this medicinal use?
No, although this is in line with a variety of pre-clinical data that is available in the literature. It certainly would not surprise me. With that said, before I could be convinced, I would like to see beneficial human outcome data. At the same time, in some cases (for example, no other treatment options), I could support usage in some situations.

Are there concerns regarding mixing medical marijuana with chemo therapy – e.g. 5 FU?
I have not read about many well-controlled marijuana-drug interaction studies. With that said, marijuana is known to modulate a number of common isoenzymes employed for drug metabolism. CYP1A2, CYP3A4, CYP2C9, and CYP2C19 enzymes are known to be affected by marijuana use. So far as FU, 80% to 85% is catabolized to inactive metabolites by dihydropyrimidine dehydrogenase (DPD). While not suggestive of an impact, it cannot be ruled out. With that said, the impact of marijuana on so many diverse enzymes, suggests that the potential to interact with any number of medications is real. In the absence of solid data, it is prudent to be wary of drugs relying the cytochorme P450 system for metabolism, with a special emphasis on CYP3A4, CYP2C9 or CYP1A2.

The psychiatrists I’ve worked with are seeing an increase in psychosis with synthetic marijuana use – some of it non-reversible. Thoughts?
I have heard the same. The problem with me understanding synthetic marijuana, is that the available products are in a near constant state of flux. This certainly complicates predicting what to expect from them.

Indica and Sativa are both available where it is legal. Which would be more useful medically?
Most likely Sativa. Indica contains contains only traces of pharmacologically active cannabinoids.

Is “tolerance” developed in patients using THC? How much dosage increase and how frequently?
I think so. As an example, many of the dysphoric events associated with marijuana are more likely to be observed in treatment-naïve patients. So far as how much usage is required to get there, while I do not know, I would venture a guess that it varies from person to person.

Our hospital was recently concerned about creating a policy on patients who are taking medical marijuana when they are admitted to the hospital, and when we need to administer their regularly scheduled meds. Any experience or suggestions on creating this policy?
I do not have experience here. With that said, it sounds complex. The first being the practice of requiring all patients to consume only hospital-provided medications. I am not sure how common this is, but I have seen it applied without much exception. I am sorry, but I am not qualified to get too far involved into this discussion.

Please explain the acronym CBD again.
Cannabidiols (CBD) related to THC, do not confer euphoria, may be pharmacologically important.

What about vaping?
Vaping marijuana certainly has its adherents. While it may be safer, I do not think that there is solid data to support this. I refer you to the case of vaping tobacco, where it has recently been shown that vaping, still introduces carcinogenic compounds to the body.

What, if any, parameters are being developed for Chronic Pain Management?
While there are true believers of marijuana for chronic pain, the data is inconsistent. I am not aware of parameters being developed for these indications, at least not in the mainstream.

How are insurance companies dealing with coverage of medical marijuana as it is Federally illegal?
From what I can tell, the majority of insurance companies are not covering medical marijuana because a lack of FDA approval. With that said, Canadian health insurance has covered it for years.

What research is being conducted to have safe and effective medication on the market?
Many players are attempting to show the safety and efficacy of medical marijuana. Unfortunately, much of the efforts that I am seeing are not at a scale adequate to provide the sort of data needed to guide safe usage.

Why are more well-controlled studies not being conducted?
While I cannot be sure, my guess is that the main proponents of medical marijuana lack the funds to conduct large, pivotal clinical trials.

When you refer to synthetic THC, do you mean processed THC like the one used in vaporizers?
Thank you for asking. What I was referring to was synthetically made analogues, specifically designed to confer certain activities. In other words, pharmaceutical preparations made by pharmaceutical concerns.

Where I live, there are no legal forms of marijuana. But in the resident clinic where I work, most of the pregnant mothers smoke it for nausea control and have no interest in cutting back. I would love to have more information on neurons development.
As a starting point, I would direct you to the ACOG position: American College of Obstetrics and Gynecology (2015). Marijuana use during pregnancy and lactation. Retrieved from https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Marijuana-Use-During-Pregnancy-and-Lactation

Are the receptors for cannabinoids and/or THC specific only to cannabinoids and/or THC?
While there may be additional THC/CBD receptors of interest, CB1 and CB2 are the most prevalent. In general the agonists show little selectivity between the CB1 and CB2 receptors, while the antagonist compounds are highly selective (>1000 fold selective for CB1 vs. CB2). For an in depth discussion, I refer you to Console-Bram, et al. Prog Neuropsychopharmacol Biol Psychiatry. 2012 Jul 2; 38(1): 4–15.

As we see CBD products and marijuana usage increase among patients I worry about interactions with their meds. Are you aware of any known medication interactions with commonly prescribed medications?
I have not read about many well-controlled marijuana-drug interaction studies. With that said, marijuana is known to modulate a number of common isoenzymes employed for drug metabolism. CYP1A2, CYP3A4, CYP2C9, and CYP2C19 enzymes are known to be affected by marijuana use. With the impact of marijuana on so many diverse enzymes, suggests that the potential to interact with any number of medications is real. In the absence of solid data, it is prudent to be wary of drugs relying the cytochrome P450 system for metabolism, with a special emphasis on CYP3A4, CYP2C9 or CYP1A2.

Are there any associations between psychosis and Marijuana?
Such associations have been offered. As a starting point, I refer you to an article by the National Institutes of Drug Abuse: https://www.drugabuse.gov/publications/marijuana/there-link-between-marijuana-use-psychiatric-disorders.

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