Cannabis Use in Medicine: A Concise Handbook

Preface
Acknowledgments
Contents
Part I: Introduction and Background to Cannabis Use  in Medicine
1: Introduction to Cannabis for Medical Use
Introduction
Recreational Cannabis Use
The Use of Cannabis for Medical Conditions
Cannabis Products
The Use of Cannabis in Oncology: A Case Example
Summary
References
2: Legal Aspects of Cannabis
Introduction
The History of Medical Marijuana in Canada (See Fig. 2.1)
The Legal Framework of Medical Cannabis in Canada Today
Cannabis Products
Licenses Under the Cannabis Act
Access to Cannabis for Medical Purposes
The Medical Document
The Written Order
Holders of a License for Sale
Registration with Minister
Hospital Patients
Drugs Containing Cannabis
Research with Cannabis
Importation or Exportation of Cannabis for Medical or Scientific Purposes
Summary
Acts and Regulations Referenced in This Chapter
References
3: Pharmacology of Cannabis
Introduction
The Cannabis Plants
The Endocannabinoid System (See Fig. 3.1) [6–11]
Endocannabinoid Receptors
Pharmacokinetics of Phytocannabinoids [8, 9, 15]
Δ9-Tetrahydrocannabinol (THC)
Cannabidiol (CBD)
Terpenoids [6]
Synthetic Cannabinoids
Routes of Administration (See Table 3.4) [8–10, 17]
Inhalation [3]
Oral [3]
Topical
Special Populations
Summary
References
4: Patient Assessment and Dosing Recommendations for Cannabis
Introduction
Initial Clinical Assessment [4–7]
Dosing Recommendations [1, 3–6]
Administration
Follow Up Appointments [5, 6, 8, 9]
Summary
References
5: Analytical Testing of Cannabis
Introduction
Analytical Techniques
Immunoassay
Gas Chromatography-Mass Spectrometry (GC-MS)
Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)
Sample Types and Analytes Measured
Urine Sample
Blood
Oral Fluid (Saliva)
Hair
Sweat
New and Upcoming Chemical Detection Method Using Breath Sample
Challenges and Limitations
References
6: The Role of Genetics in the Use of Cannabis
Introduction
Cytochrome P450 Enzymes
Cytochrome P450 Enzyme: CYP2C9
CYP2C9 Polymorphisms
Clinical Significance
Practical Implications to CYP2C9 Genetic Testing
AKT1 Protein Kinase
AKT1 Polymorphisms
Clinical Significance
Practical Implications to AKT1 Genetic Testing
Catechol-O-Methyltransferase (COMT) Enzyme
COMT Polymorphisms
Clinical Significance
Practical Implications to COMT Genetic Testing
Cytochrome P450 Enzyme: CYP2C19
CYP2C19 Polymorphisms
Clinical Significance
Practical Implications to CYP2C19 Genetic Testing
Conclusion
References
7: Evidence Based Reviews on Cannabis Therapy
Introduction
Types of Study Designs in Health Research
Hierarchy of Evidence: The Traditional Model
The Revised Model
Critical Appraisal Tools (CATs)
Clinical Practice Guidelines
Grades of Recommendations
From Evidence to Practice
Patient Engagement in Cannabis Research
Conclusions
References
Part II: Use of Cannabis in the Management of Specific Medical Conditions
8: The Effects and Benefits of Cannabis on the Gastrointestinal Disorders
Introduction
The GI Tract and Endocannabinoid System (See Chap. 3 on Pharmacology of Cannabinoids)
Effects of Cannabis on Specific GI Conditions
Conclusion
References
9: Neurological Diseases and Cannabinoid Treatment
Introduction
Background: Cannabis Formulations and Products
Neuropharmacology (See Chap. 2 on the Pharmacology of Cannabis)
Epilepsy
The Effects of Seizure Control with Cannabis
Other Considerations
Adverse Effects
Summary Points
Multiple Sclerosis
Efficacy of Cannabis for Symptom Relief in Patients with MS
Other Outcomes and Adverse Effects
Summary Points
Sleep
Sleep Outcomes
Effect on Measures of Sleep
Effect on Sleep Architecture
REM Sleep Disorder
Summary Points
Important Cannabis Drug-Drug Interactions in Neurology
Summary
References
10: Cannabinoid Treatment for Rheumatic Disease
Introduction
Overview of Rheumatic Diseases
Inflammatory Arthritis (IA)
Osteoarthritis (OA)
Fibromyalgia (FM)
The Endocannabinoid System and Rheumatological Conditions
The Role of Cannabis in Rheumatological Conditions
Key Points for Medical Cannabis Use in Rheumatology Patients
Treatment Principles to Reduce Harm
Contraindications and Cautions for Medical Cannabis
The Adolescent and Young Adult with a Rheumatic Disease
The Adult with a Rheumatic Disease
The Elderly Person with a Rheumatic Disease
A Pragmatic Approach to Cannabis Recommendations
References
11: The Use of Cannabis for Pain Management
Introduction
Chronic Pain
Pathophysiology of Pain
The Endocannabinoid System and Pain
Chronic Pain Assessment and Management Strategies
Opioid Therapy for Chronic Pain
Cannabis Use for Opioid Detoxification
Use of Cannabis for Chronic Pain
Summary
References
12: Complications and Adverse Events from Cannabis Use
Introduction
Cannabis in the Emergency Department
Pharmacodynamics of Cannabis
Emergency Department (ED) Presentations
Acute Cannabis Intoxication [2, 5]
Intoxication Secondary to Synthetic Cannabinoid Receptor Agonists (SCRAs) [6–8]
Cannabis Use Disorder (Problematic Marijuana Users)
Cannabis Withdrawal
Cannabinoid Hyperemesis Syndrome (CHS) [10–14]
Pathophysiology of CHS [15]
Diagnosis of CHS [10, 16]
Management [17–19]
Accidental Pediatric Ingestions [2, 5, 22–24]
Medical Conditions Associated with Cannabis Use
References
Part III: Cannabis Use in Specific Populations
13: Occupational Considerations Related to Cannabis Use
Introduction
Medical Cannabis in the Workplace
CBD Use in the Workplace
Functional Impairment
Work Performance
Specific Cognitive, Psychomotor and Physical Functional Impairment
Testing for Impairing Drugs
Synergistic Effects of THC, Alcohol and Other Prescription Drugs
Urine Drug Testing—State Vs. Federal law
CBD and Positive Urine Drug Tests (UDTs)
Future
References
14: Pediatric Considerations when Prescribing Cannabis
Introduction
Clinically Useful Principles of Pharmacokinetics, and its Characteristics in Children
Pharmacological Properties of THC and CBD (See Chap. 3 on The Pharmacology of Cannabis)
Elimination Pathways of THC and CBD [1–3]
Known and Potentially Interacting Drug Elimination Pathways of Medical Cannabinoids
Pharmacokinetic Parameters of Oral Medical Cannabinoids in Adults [8–11]
Pharmacokinetic Parameters of Oral Medical Cannabinoids in Children
Pharmacogenetic Considerations (See Chap. 6 on The Role of Genetics in the Use of Cannabis)
Adverse Effects
Cannabis-drug Interactions [13]
Pearls for Pediatric Dosing of Medical Cannabis
References
15: Cannabis Use in the Pregnant Patient
Introduction
Effects of Cannabis in Pregnancy and Breastfeeding
Indications for Cannabis in Pregnancy
Cannabis Use for Pregnancy-Related Nausea and Emesis
The Impacts of Cannabis on Pregnancy and the Fetus (See Fig. 15.1)
On the Placenta
On Preterm Birth
On Birth Weight
On Neonatal Intensive Care Unit (NICU) Admission
On Stillbirth
On Congenital Anomalies
On Other Pregnancy Related Conditions
On the Child
On Breastfeeding
Recommendations from Professional Societies
American College of Obstetricians and Gynecologists (ACOG) (Committee on Obstetric Practice)
Society of Obstetricians and Gynecologists of Canada (SOGC) [34]
Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) (Women’s Health Committee)
American Academy of Breastfeeding Medicine (ABM) [35]
American Academy of Pediatrics [36]
Other Implications
References
Index