therapeutic use of medical cannabis

Question 1

definition of hemp as in the farm bill

Answer 1

THC </= 0.3% on a dry weight basis

Question 2

what are the different cannabis markets

Answer 2

the pharmacy
medical programs
adult use (21+)
hemp market (farm bill)
illicit (dealer)

Question 3

what is the degree of regulation of each of the cannabis markets?

Answer 3

pharmacy most regulated
medical programs highly regulated but fewer lab testing requirements than pharmacy
adult use has less stringent regulations and lab testing
hemp market has regulations but lots of grey area
illicit has absolutely no regulation and you have to trust your dealer

Question 4

primary function of endocannabinoid system

Answer 4

regulatory/homeostasis
ex: memory, pain, sleep, mood, etc.

Question 5

what are the ligands in the endocannabinoid system

Answer 5

endocannabinoids: anandamide and 2-AG
phytocannabinoids: THC, CBD, CBG, CBN, etc
pharmaceutical cannabinoids: dronabinol, nabilone, cannabidiol, nabiximols

Question 6

what are the receptors in the endocannabinoid system

Answer 6

CB1, CB2

CB1 primarily in brain, nervous system
CB2 primarily in immune system

Question 7

role of the cannabinoid receptors CB1 and CB2

Answer 7

to modulate release of neurotransmitters like 5-HT, DA, NE
the most abundant G protein coupled receptor in brain

Question 8

how do the cannabinoids activate the receptors

Answer 8

RETROGRADE signaling: cannabinoids activate CB receptors pre-synaptically through feedback inhibition as opposed to post-synaptically

Question 9

what are the endocannabinoids

Answer 9

anandamide (AEA) which is selective for CB1
2-arachidonylglycerol (2-AG) which is more abundant, full agonist at CB1/CB2

Question 10

what are the pharmaceutical cannabinoids

Answer 10

dronabinol (marinol) for CINV
nabilone (cesamet) for CINV
epidiolex (cannabidiol) for seizures, undergoing trials for Huntington’s disease
nabiximols (sativex)– not in the US

Question 11

THC has enhanced activity for ___

Answer 11

CB1

Question 12

CBD also inhibits ____

Answer 12

FAAH enzyme

Question 13

different major roles of the phytocannabinoids

Answer 13

THC: psychotoxic
CBD: anticonvulsant
CBN: sedative
CBG: analgesic, anti-inflamm
THCV: appetite suppressnat

Question 14

what are some other MOAs of medical cannabis

Answer 14

there is also activity outside of the endocannabinoid system
such as COX1/COX2
and mu opioid receptors, alpha-2 adrenergic, G-protein coupled receptors, many more

Question 15

what is the difference between psychoactive and psychotoxic

Answer 15

psychoactive means affecting the mind, consciousness, mood, and thoughts
psychotoxic means intoxicating or causes significant mood change

Question 16

what is the precursor/mother cannabinoid

Answer 16

CBGa

Question 17

what is the role of the terpenes

Answer 17

odorous– scent and flavor profile in cannabis, protection & attraction

Question 18

what are the flavonoids and flavorants

Answer 18

flavnonoids: color, aroma
flavorants: flavor, aroma

Question 19

what is the entourage effect theory

Answer 19

cannabinoids, terpenes, flavonoids, flavorants, and other naturally occurring compounds in cannabis act synergistically to enhance the overall effects

Question 20

what are the trichomes

Answer 20

tiny little crystals that cover the leaves and buds– produce and store cannabinoids, terpenes, and flavonoids

Question 21

what are the different ways to classify cannabis

Answer 21

genotypes (Strain names– indicates possible characteristics)

phenotypes (Sativa, indica, hybrid)

chemotype (grouped by most abundant cannabinoid)

chemovar (defined by chemical variety)

Question 22

what are some differences between sativa and indica

Answer 22

sativa: tall, thin and lanky; leaves are thin; matures slower; effects are said to be uplifting and invigorating; daytime use

indica: short and stalky; leaves are broad/chunky; matures quicker; effects are said to be sedating and relaxing; nighttime use

Question 23

what are some different chemotypes?

Answer 23

type 1: THC
type 2: balanced 1:1
type 3: CBD
type 4: CBG

Question 24

what does isolate mean

Answer 24

contains one singular cannabinoid or terpene

Question 25

what does broad spectrum mean

Answer 25

contains one main cannabinoid and other naturally occurring plant compounds but excludes a specific cannabinoid

Question 26

what does full spectrum mean

Answer 26

contains all naturally occurring plant compounds

Question 27

what are some possible dosage forms for medical cannabis

Answer 27

inhalation (cartridge, concentrates, dry leaf) ingestion (capsules, oral liquid, tinctures and elixirs, rick simpson oil) topical transdermal suppository distillate syringe

Question 28

true/false: you should hold in after you inhale

Answer 28

false no evidence supports this

Question 29

bioavailability, onset, and duration of inhaled dosage form

Answer 29

<50% bioavailable onset in 5-10 mins duration 2-4 hours

Question 30

side effects from inhaled dosage form

Answer 30

throat irritation, coughing, bronchitis

Question 31

which of the inhaled dosage forms are free of other excipients

Answer 31

concentrates, dry leaf

Question 32

what was the cause of EVALI

Answer 32

additional excipients were used to thin out oil, leading to severe lung injury; toxic byproducts are formed (myrcene--methacrolein)

Question 33

considerations for temperature

Answer 33

boiling points vary from ~300-450 vaporizing at a temp too low will not express the cannabinoid or terpene; vaporizing at a temp too high will obliterate the cannabinoid or terpene providing little therapeutic benefit

Question 34

what are some factors that can alter the ingestion of cannabis

Answer 34

recent meals can delay the onset, prolong duration, and cushion the potency. dose stacking can lead to overmedication

Question 35

bioavailability, onset, and duration of ingested cannabis

Answer 35

bioavailability 10-20% onset 1-3 hours duration 6-8 hours, up to 24

Question 36

counseling/dosing of ingested cannabis

Answer 36

start with a low dose, on an empty stomach

Question 37

onset/duration of transdermal cannabis

Answer 37

onset is variable ~30 mins duration is variable ~8-12 hours

Question 38

onset/duration of suppository

Answer 38

onset 15-60 minutes duration 2-8 hours

Question 39

how are distillate syringes used

Answer 39

they can be either ingested or inhaled

Question 40

combustion as a consumption method?

Answer 40

this is not approved in most medical programs due to harmful effects of inhaling carbon monoxide & tar production an immediate loss of potency (30-60%) is noted upon incineration

Question 41

describe cannabis withdrawal symptoms/duration

Answer 41

insomnia, vivid dreams, anxiety may last for up to 45 days

Question 42

what is a significant drug interaction to look out for

Answer 42

clobazam

Question 43

pharmacokinetic vs pharmacodynamic drug interactions

Answer 43

PK: clobazam, phenytoin, beta blockers, CCBs, warfarin, buprenorphine, valproic acid, theophylline, antifungals, antiretrovirals, tacrolimus, tizanidine PD: additive effects -additive depressant: alcohol, barbiturates, benzodiazepines -additive tachycardia, hypertension with sympathomimetics -additive xerostomia and drowsiness with anticholinergics

Question 44

what are the cardiac side effects

Answer 44

increased risk MI, stroke, heart failure

Question 45

what is cannabis hyperemesis syndrome

Answer 45

cyclic episodes of nausea/vomiting with chronic cannabis use excessive bathing in hot water provides relief treatment is cannabis holiday, IV fluids, antiemetics, PPIs, topical capsaicin

Question 46

contraindications

Answer 46

allergy to active drug or excipients schizophrenia, psychosis, bipolar disorder pregnancy, lactation history of heart attack, stroke, angina COPD, asthma liver/kidney dysfunction

Question 47

what is the correct dose

Answer 47

the lowest dose that provides therapeutic benefit without adverse effects

Question 48

true/false: patient must experience psychoactivity to have effect

Answer 48

false

Question 49

which preparations should be used for chronic conditions vs prn

Answer 49

chronic: long acting oral preparation prn: vaporization

Question 50

dosing for inhalation vs PO

Answer 50

inhalation: start with one inhalation and wait 15 minutes, may increase by 1 inhalation q15-30 minutes oral: start with 2.5 mg at bedtime- increase to BID after 2 days- increase by 2.5 mg every 2 days