Cannabis Patient Navigator

A Primer for Using Cannabis as an Adjunct to Therapy
Roslyn Dauber medcannabisnavigator.com [email protected]

Medical Advice Disclaimer
DISCLAIMER: THIS PRESENTATION DOES NOT PROVIDE MEDICAL ADVICE
The information, including but not limited to, text, graphics, images and other material contained in this presentation are for informational purposes only. No material in this presentation is intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen. Do not disregard professional medical advice or delay in seeking it because of something you have read in this presentation.

IS CANNABIS MEDICALLY EFFECTIVE?
In addition to anecdotal evidence, 35,000 peer reviewed research studies have been published in the last 10 years that show ma*****na’s medical efficacy to relieve symptoms and side effects of a variety of medical problems.
Today, the largest group of new users are people over 55. Recreational and medical sales were close to 33 billion in 2022, led substantially by the CBD market. Additionally there was at least 55 billion in sales in the gray and black market. This makes cannabis one of the highest selling products in the US.

For the past 20 years plants have been bred for recreational use with very high THC levels. This is the opposite of the philosophy around medical use.
For medical use:
Go slow and start with the smallest amount possible per dose.
[This translates to one puff if smoking,.5mg or less if edible.]

U.S. Population Aging & Cannabis
Between 2010 and 2020 people over 55 in the US grew by 27%,
20 times larger than those under 55. In 2020 1 in 6 were age 65 or over.
By the 2030’s Americans over 65 are projected to outnumber all children under 18.
The fastest growing group of new cannabis users are people over 55, mostly medical cannabis consumers.
42% of US adults have used cannabis and say they will again.
74% of the US population lives in states where cannabis is legal for medical use. In 2023 medical cannabis is a 13 billion industry

Why People Use Cannabis
94% say their medical condition/symptom improved with cannabis use
Source: Reiman, Amanda. Editor. Cannabis Consumers in America 2023. New Frontier Data. 2023
83% for relaxation, unwinding stress, or anxiety 61% for sleep, improving quality or falling asleep. 64% pain management
41% depression
75% of medical users say they are treating a specific medical condition diagnosed by a medical doctor.

Working with your Client
Medical and recreational use
• Create an atmosphere where discussion is comfortable
• What pharmaceutical prescriptions are they on? With cannabis use they can be effected unknowingly
• Inform them about possible negative effects, especially if they are under 25 - possible emotional and cognitive impairment for daily users
• Encourage them to keep a log of their use
• Encourage them to use the smallest amount to get the effect they are looking for
• Warn of risk of impaired driving
• Memory - in what circumstances is some forgetfulness helpful (helps with ptsd)

The Endocannabinoid System (ECS)
A unique and widespread homeostatic physiological regulator
All you need to know about Endocannabinoids! - Alternative Medicine Magazine
The ECS is complicated but research shows it’s linked to the following processes:
▪ sleep, mood & stress
▪ skin & nerve function
▪ appetite & digestion
▪ memory
▪ reproduction and fertility
▪ pain
▪ inflammation & immunity
▪ bone remodeling & growth
▪ cardiovascular system
function

THE ENDOCANNABINOID SYSTEM
The body’s endocannabinoid system is composed of endogenous cannabinoids (endocannabinoids), which are neurotransmitters that bind to cannabinoid receptors located throughout the nervous system and regulate synaptic transmission in the nucleus accumbens and many other areas of the brain.
https://news.feinberg.northwestern.edu/2023/10/05/study- explores-how-endocannabinoids-regulate-brains-response-to- stress/
Image: https://budssmoke.com/the-endogenous-cannabinoid- system/

Psychiatric Conditions
Anxiety - Second only to pain management, people turn to cannabis to help
them relax, be less anxious in situations like social anxiety and panic attacks.
Insomnia - Insomnia is a common sleep disorder that can make it difficult to fall asleep, hard to stay asleep or cause you to wake up too early and not be able to get back to sleep. Chronic insomnia can be debilitating and can drastically impact a person’s quality of life, causing other related health issues and comobidities. Cannabis has been shown to help promote sleep and improve sleep quality and duration.

Cannabis for Post Traumatic Stress Disorder (PTSD)
PTSD
Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful or distressing
events. Symptoms often include nightmares and flashbacks and problems sleeping and
concentrating.
Research is ongoing, but PTSD is one condition which cannabis shows real promise in. While CBD
can help with the anxiety, patients with PTSD have lower levels of the neurotransmitter anandamide,
so the brain has to compensate and it expands the number of CB1 receptors, which THC binds to.
THC also reduces what’s called REM sleep. Within REM sleep, we have intense dreams, so people
with PTSD will often have nightmares, intrusive thoughts and flashbacks, but THC could help
reduce these.
Sinclair, S. https://cannabishealthnews.co.uk/2022/03/04/which-conditions-can-i-get-a-medical-cannabis-prescription-for-anxiety22/ March 4, 2022

Cannabis & Depression
https://www.webmd.com/depression/depression-ma*****na
• People who have depression are twice as likely to use cannabis as those who don’t
•
University of Buffalo's Research Institute on Addictions found that chemical
compounds in the brain known as endocannabinoids, which are linked to feelings of
overall well-being, activate the same receptors as many of the active compounds in
ma*****na. Chronic stress can deplete the endocannabinoid system. Researchers
share that possible benefits include the restoration of “normal” endocannabinoid
function and mood stabilization
A 2018 study found that smoking cannabis can significantly reduce self-reported levels of
depression in the short term. Yet the researchers also found that repeated use didn't lead to
any long-term reduction of symptoms.
•

Memory Disorders
Source: Pautex, et.al., Front. Aging Neurosci., 29 September 2022 Sec. Alzheimer's Disease and Related Dementias
Volume 14 - 2022 | https://doi.org/10.3389/fnagi.2022.957665
• Cannabinoids may have neuroprotective properties. This means it could protect nerve cells against damage and degeneration, reducing your risk of developing neurodegenerative diseases. Neurodegenerative diseases — like Alzheimer’s disease and Parkinson’s disease — often lead to dementia.
• More recently, a 2022 review says that there is “strong evidence” that certain chemicals in cannabis — including cannabinoids, terpenes, and flavonoids — have neuroprotective properties that could directly protect against amyloid β.Amyloid β is a protein that forms plaques in the brain. These plaques can disrupt communication between nerve cells and cause inflammation in the brain. Amyloid buildup is a hallmark of Alzheimer’s disease.some observational studies suggested that cannabinoids could improve the symptoms of dementia
• More recently, a 2022 observational study assessed 19 people with dementia who were given 12.4 mg THC and 24.8 mg CBD per day for up to 13 months. Their symptoms seemed to improve — so much that some
needed fewer medications and less assistance from caregivers. [Ther Adv Drug Saf. 2019; 10: 2042098619846993. Published online 2019 May 15. doi: 10.1177/2042098619846993 Safety and effectiveness of cannabinoids for the treatment of neuropsychiatric symptoms in dementia: a systematic review Jodie Belinda Hillen, Natalie
soulsbyhttps://www.healthline.com/health/medical-ma*****na/ma*****na-and-dementia ]

Obsessive Compulsive Disorder
Obsessive compulsive disorder (OCD) is a common mental health condition where a person has obsessive
thoughts and compulsive behaviours. As well as helping to regulate the anxiety caused by the condition, some
observational studies have shown that cannabis can help reduce compulsions, intrusions and unwanted thoughts.
Helps Reduce or Eliminate Opioid Dependency
Cannabis has been taken to successfully wean the need for opioids. From a survey of patients in 2016, of the 542
opioid users who added cannabis:
• 39% were able to completely stop opioid use
• 39% used cannabis to reduce their opioid dosage
• Adding cannabis reduced pain by more than 40% in nearly half the patients and improved function in 80% • In 87% of patients, it improved quality of life
• (https://www.leafly.com/news/health/using-cannabis-to-reduce-opioid-dependence)
• FREE GUIDE:
•https://healer.com/wp-content/uploads/2018/04/Healer-Medical-Cannabis-Opioid-Guide.pdf

Cannabis Improves Medical Conditions
It is not a cure.
• Reduces chronic pain
• Tourette’s Syndrome
• Sleep- improves ability to go to sleep
• Stabilizes moods
• Decreases anxiety
• Decreases seizures - epilepsy, Parkinson’s M.S. • Can be energizing
• Relaxing
• Calms aggressive self harming autistic behavior • Glaucoma

Possible Cannabis Side Effects
THC (especially true for children)
Possible physical effects include:
• impaired body movements, such as slow reaction times • fast or irregular heartbeat
• Drowsiness or sleepiness
• Dizziness
• Breathing problems
Mental and cognitive effects may involve:
• altered senses
• Mood swings
• increased anxiety
• trouble thinking clearly and problem-solving • memory problems
• altered sense of time

Curious Variations in Client Response to Cannabis
Are due to the state of the individual’s endocannabinoid system
• Endocannabinoids are naturally produced by the human body.
• The endocannabinoid system creates homeostasis in the body.
• If one’s body is producing insufficient amounts of endocannabinoids (which can occur for a number of reasons), imbibing cannabis can have a soothing and /or energizing effect.
• If the body is producing an oversupply of endocannabinoids, taking cannabis can create acute anxiety.
• Consuming frequent large amounts of cannabis can flood the Endocannabinoid system and create a tolerance for THC, leading to higher consumption. The solution to restoring sensitivity is complete cessation of use. Often 5 days of abstinence will be sufficient.

Potential Problems Using Cannnabis
Adolescents are the most vulnerable
• Drug drug interactions must be evaluated. Talk to your doctor about using THC if you are taking: Tricyclic antidepressants: MAO inhibitors; anti-epilepsy drugs; benzodiazepines; statins; proton pump inhibitors; beta blockers and anticoagulants.
• Be Aware THC causes significant additive sedation when combined with alcohol, barbiturates and other CNS depressants.
• Cannabis Use Disorder CUD. Effects 10% of the 193 million users. Symptoms: 1. Overuse - multiple times a day.
2. Craves cannabis constantly and can’t control use or cut down.
3. Develops a tolerance and has withdrawal problems when attempted.
DISCONTINUE USE! SAMHSA help line 800 662 5357. Teenagers are the most vulnerable.

Known THC Drug-to-Drug Interactions
Cannabis may not affect all the medications in these classes but when in doubt, offset cannabis administration 1.5 to 2 hours from tricyclic antidepressants, MAO inhibitors, anti-epilepsy drugs, benzodiazepines, statins, proton pump inhibitors, beta blockers, and anticoagulants.
THC activates the CYP1A2 enzyme. When activated, serum levels of the medications metabolized by this enzyme may be lower than expected. Some of the medications affected are chlorpromazine, clozapine, cyclobenzaprine, olanzapine, duloxetine, haloperidol and naproxen.
Delta-9 THC causes significant additive sedation when combined with alcohol, barbiturates and other CNS depressants.

Potential Problems from Cannabis use
Continued
•
dehydration and abdominal pain. It comes from years of heavy use and leads to
Hyperemesis - heavy users can experience frequent cause and severe vomiting, compulsive showering or bathing to relieve symptoms. Quitting is the only cure.
•
cannabis they find at home. Be sure to store edibles out of reach of children. The
Acute Cannabis Intoxication - most common with children who accidentally take younger and smaller the child the more an accidental dose can effect respiration,
heart rate and orientation.
Take a child to the emergency room IMMEDIATELY.
Cannabis is also toxic to dogs, take them to the vet immediately.

Signs of acute cannabis intoxication in the ED
Signs and symptoms:
▪ Tachycardia
▪ Somnolence
▪ Agitation and aggression
▪ Vomiting and/or cyclical
vomiting syndrome
▪ Psychosis
▪ Nausea
▪ Ataxia
Treatment:
▪ Comfort measures (reassurance, quiet room, soothing music)
▪ IV fluids
▪ Oral hydration with lemon water
▪ Benzodiazepines
▪ Low dose propranolol
▪ Anti-nausea medications
Tests:
▪ EKG
▪ CBC, Chemistry,
urine and blood tox screen

Does cannabis cause schizophrenia and/or psychosis?
● There is currently no conclusive scientific evidence that cannabis causes schizophrenia and/or psychosis. However, a genetic predisposition for psychosis combined with the use of cannabis can increase one’s risk of developing a psychotic disorder like schizophrenia, and/or manifesting at an earlier age than would otherwise occur.
● Patients with a family history of psychotic disorders are advised to proceed with caution before considering medical cannabis, and to consult up-to-date scientific literature.
● Israeli cannabis scientist Dr. Raphael Mechoulam conducted research showing 800mg of CBD was an excellent alternative to a traditional antipsychotic
(Amisulpride) which is effective but comes with significant side effects. In Mechoulam’s study, CBD had no appreciable adverse effects.
● More research is needed on this subject.

CBD
CBD is extracted from H**p Plants - in 46 states a cbd product can not have more than .03% total THC
• Regulation of H**p/CBD products vary from state to state.
• Permitting is no longer required from the DEA for industrial h**p grown as outlines in the 2014 Farm Bill.
• There is a lack of oversight and testing in the CBD industry, so when purchasing projects make sure the labeling is clear. It is regulated separately from ma*****na THC products, less stringently. Should what you buy have slightly more than .03%, it could show up in a urine test as THC -positive
• CBD is often characterized as non-psychoactive which is not exactly true. It will not create a high effect, but it is usually calming - helping with pain and sleep.
• If one feels higher than desired from taking something with THC, CBD tinctures or gummies can level the THC effect and calm the user down.

CBD: Cannabidiol
CBD has low affinity at CB receptors but seems to be active within other biological systems.
● Reduces anxiety
● Reduces seizures
● Antioxidant/Neuroprotective
● Anti-inflammatory
● Psychoactive – non intoxicating
● Mitigates intoxicating effects of THC
Batalla A and Postma A (2021)

CBD unlike THC
https://thecbdinsider.com/knowledge-center/how-cbd-works-cbd-cannabinoid-receptors/
•THC binds with CB1 and CB2 receptors producing psychological effects as well as the ‘high intoxicating sensation.’ while CBD doesn’t directly bind to CB1 and CB2 receptors, rather it acts as a negative modulator of CB1.
•
•
• • •
•
•CBD’s ability to interact with a wide range of receptors makes it a versatile treatment.
CBD does not only interact with cannabinoid receptors but also non-cannabinoid receptors. The interaction with these receptors suggests
CBD has the potential to treat several conditions by reducing inflammation, alleviating pain, and decreasing anxiety
CBD does not bind with CB1, but CBD can help activate CB1 by increasing anandamide (an endocannabinoid) levels. However, CBD can
also prevent molecules such as THC from binding with CB1 by changing the shape of the receptors, negating THC’s intoxicating effects.
CB2 receptors are most abundant in the immune system and are known to regulate the release of cytokines, a proinflammatory protein
released by the immune system. CB2 is not abundant in the brain, like CB1.
CBD reduces inflammation when it interacts with CB2 receptors by speeding up the natural death of inflammatory immune cells that
release cytokines.
CBD binds with a receptor in the serotonergic system called 5-HT1A. By binding with 5-HT1A, CBD boosts serotonin levels, making it
potentially useful for treating anxiety, sleep, and other disorders. Unlike some serotonin-boosting medications, CBD does not cause
addiction or other harmful side effects.
CBD has been shown to bind with the mu- and delta-opioid receptors, which are responsible for pain perception. This suggests
CBD could be useful as a pain reliever.

Known CBD Drug-to-Drug Interactions
Cannabidiol (CBD) does not cause intoxicating
effects, but high doses can cause sedation,
diarrhea, and decreased appetite. Medications that can interfere with CBD metabolism include:
clopidogrel (Plavix) cimetidine
citalopram (Celexa) delavirdine (Rescriptor) efavirenz (Sustiva) felbamate (Felbatol) fluconazole (Diflucan) fluoxetine (Prozac)
fluvastatin fluvoxamine (Luvox) indomethacin (Indocin)
isoniazid ketoconazole lansoprazole (Prevacid)
lovastatin (Mevacor) metronidazole (Flagyl)
modafinil (Provigil) omeprazole (Prilosec) oxcarbazepine (Trileptal)
paroxetine (Paxil) sertraline (Zoloft) sulfamethoxazole ticlopidine (Ticlid) topiramate (Topamax)

CBD & THC Together
CBD affects the metabolism of THC.
Taking a dose of CBD, or using a CBD:THC ratio product, increases THC blood serum levels because CBD is a competitive inhibitor of CYP450 and thus slows down the conversion of THC into its more potent metabolite, 11-OH-THC. THC remains active for a longer time in the body and and the high is not as intense. Starting with a 1:1 is broadly effective well tolerated and supported by a large body of nabiximols clinical trial data.
An example of this is Dr. Sulak's recommendation of 1-2 mg of THC with a corresponding dose of CBD if indicated. (Sulak 2021) healercbd.com

Minor Cannabinoids
Also being researched
CBG - Non-psychoactive precursor to all cannabinoids; non-intoxicating, antibacterial, anti-inflammatory, analgesic, muscle relaxant, anti-depressant, anti-hypertensive
CBN - Mildly psychoactive, sedative, anti-fungal, anti-inflammatory, anti-insomnia, anti- spasmodic
CBC - Non-Psychoactive, anti-inflammatory, anti-spasmodic, neuroprotective, anti-emetic THCV - Less psychoactive than THC, analgesic, appetite suppression (theorized), blood
sugar regulation, bone stimulant
CBDV - Non-psychoactive, anti-emetic, anti-convulsant

Mechanism of Action of Cannabis & Cannabinoids
The effect of cannabis can be explained on the basis of the function of the cannabinoid receptor system, which consists of CB receptors (CB1, CB2), endoligands to activate these receptors and an enzyme--fatty acid amide hydrolase (FAAH)--to metabolize the endoligands. The endoligands of the cannabinoid receptor system are arachidonic acid-like substances, and are called endocannabinoids.
Various cannabinoids have diverse effects on the receptors, functioning as agonists, antagonists or partial antagonists, as well as affecting the vanilloid receptor.
Many known effects of cannabis can be explained on the basis of this mechanism of action as can the use of cannabis in various conditions including multiple sclerosis, Parkinson's disease, glaucoma, nausea, vomiting and rheumatoid arthritis.
[a ligand is any molecule or atom which binds reversibly to a protein.]
Scholten WK (2006)

Presented by Masters in Medical Cannabis Science & Therapeutics Graduates
Clinician Education for Recommending Cannabis

• • • • • • •
Thank you for joining us today
For more information
Call 303 664 5011
Or email [email protected] Roslyn Dauber
Services: individual patient consulting Educational trainings for dispensaries Briefing medical professionals Answering your questions, finding resources

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