I would like to begin by

acknowledging that we are

on the ancestral grounds of

the Beothuk people

Dr Alia Norman

Radiation Oncologist

Cannabinoid Medical Clinic

Churchill Square

Introduction to the

Cannabinoid System

And Medical Use

Disclosures:

Employed by and receive

speakers fees from

CANABO

THC vs CBD

Delivery Routes

Why it works

What it works for

Safer Use

Research Opportunities

Objectives:

2752 publications in 2017

The Endocannabinoid System

● Neural development● Immune function● Inflammation● Appetite● Metabolism and energy

homeostasis● Cardiovascular function● Digestion● Bone development and

bone density

● Synaptic plasticity and learning

● Pain● Psychiatric disease● Psychomotor behavior● Memory● Wake/sleep cycles● Regulation of stress

and emotional state● Cancer

Eat, Relax, Sleep, Forget, Repair

Local action, Short duration

3 Main Drugs

3 Main Routes

Nabilone

Synthetic THC mimic.

Indication: nausea with chemo

Most common use: chronic pain

Most common side effect: cognitive dulling

$ Covered, but not efficient

Research Idea: Cost comparison of Herbal

vs Meds Replaced including Nabilone

THC is the psychoactive

component

Side effects: impairment, racing heart, can

trigger anxiety and even psychosis.

Is more helpful for sleep and appetite

Best pain relief combines THC+CBD and

can reduce side effects from THC.

CBD (Cannabidiol)

CBD has very minimal impairment

Can reduce

Anxiety

Seizures

Inflammation

Pain

Cravings

Epidiolex

Oral very high CBD, very low THC

Seizure trials

Lennox-Gastaut trial: reduction

in monthly drop seizures

Herbal Cannabis Routes:

Sprayed: Sativex THC:CBD, Elixer THC or CBD

Inhaled: vapourized or smoked. Don’t smoke

salad oil.

Eaten: Edibles, Canadian oils, decarboxylated

Other: topical creams or patches, vaginal

Vapourizers: boil don’t bbq

½ a grain of rice is not a dose

It’s important for seniors to

understand the change in

THC/CBD levels since the 60s

Then:

10THC:5CBD

Now

24THC: 0 CBD

“Medical” can be

either.

“Strains” or Chemovar

Turpenes

-Smell and taste

-Strain Differences

-More reliable than

Indica or Sativa

Entourage Effect

Crowdsourcing Chemovar

Selection

Seen individuals benefit so far...

Inflammatory arthritis

Diffuse osteoarthritis

Interstitial cystitis

Parkinson’s

Nausea

IBS

Migraine

Nerve pain from disk disease,

chemo, diabetes

Appetite loss

Phantom Limb

Replacing opioids/benzos

Fibromyalgia

PTSD nightmares

Insomnia

Anxiety (also common side

effect)

Cancer pain

MS and spinal spasticity

Crohn’s and UC

Seizures

Autism behaviours

Trial Evidence

Inflammatory arthritis *S

Diffuse osteoarthritis

Interstitial cystitis

Parkinson’s bradykinesia

Nausea *N

IBS

Migraine

Nerve pain from disk disease,

chemo, diabetes

Appetite *cannabis in AIDS

Phantom Limb

Replacing opioids/benzos

Fibromyalgia *N

PTSD nightmares *N

Insomnia

Anxiety

Cancer pain*S (mixed results)

MS and spinal spasticity *S

Crohn’s and UC

Seizures *CBD

Autism Behaviours

Strong Trial Evidence

Seizure in refractory epilepsy syndromes.

Chemo nausea: similar efficacy to maxaran

Negative Trials

Sativex cancer pain: didn’t reach endpoint

Very low dose THC for appetite in cancer

patients.

Target Conditions

Fibromyalgia CBD + trial

Sleep

Anxiety and Mental Health

Opioid Replacement

Exploring Cancer Responses

Trial challengesHard to make THC placebo

USA: schedule 1

Unusual dose response pattern

It works better for some people than others with the same disease..

Try any treatment on thousands of patients, some will hit a home run.

5-10% Super

Responders

Cannabinoids and Pain

Mechanisms:

-reduce inflammation

-reduce muscle spasm

-block overactive nerve

firing

-central effects (mood,

sleep, sensory alteration)

Chemical Circuit Breaker

Is Cannabis a Solution to the

Opioid Epidemic?

• Can reduce the opioid dose

needed for pain relief or replace

opioids

• Doesn’t suppress breathing

• Even at high doses

Examples of default styles

Therapeutic Index

Ratio of physically harmful dose to Useful dose.

Fatal overdose for cannabis is >1000 lbs.

Cannabis 1000:1

Diazepam 100:1

Morphine 70:1

Cocaine 15:1

Alcohol 10:1

Digoxin 2:1

Can THC be addictive?

Cannabis use disorder: 9%-15%

Dopamine release

Slow clearance reduces withdrawal but makes it

harder to identify.

Insomnia, Irritability, Low Appetite

Polypharmacy

In medical practice,

cannabis offers the

opportunity to reduce

multiple medications.

Make a plan for which

drugs to taper and when.

Adjunctive nabilone in cancer pain and symptom management: a

prospective observational study using propensity scoring.

Maida 2008 J Supportive Oncology n=112

Cannabis and Cancer?

May be a balance

between PRO and

ANTI cancer effects.

Clinical trials needed.

My opinion:

Avoid in curative cases

and with

immunotherapy

Patients trust something natural more than pharmaceutical...

When a plant mimics something our body naturally produces, effects can be powerful. Many drugs are plant derived

but not all natural products are harmless or safe

-morphine

-cocaine

-tobacco

Cannabis Best Health Practices

• We don’t have good predictors for who

will respond to CBD.

• Lowest side effects

• Reduces side effects of THC

Try CBD

For

Several

Days

Cannabis Best Health Practices

• Joints have 5x the tar of cigarette

• Vapourizing offers rapid onset / tight

control over dosing.

• Orals offer long lasting relief.

Try

CBD

Don’t

Smoke!

Cannabis Best Health Practices

Wait 4 hrs for driving.

Mental health and development risks for

heavy teen users.

Rapid heart rate and blood pressure

changes

Try

CBDDon’t

Smoke!

THC is not for

everybody.

Use Responsibly

Cannabis Best Health Practices

Questions?

Cannabinoid Medical

Clinic

www.pharmacists.ca

Stout: Drug Metab Rev 2014