ECHO Discussion June 2015 - Healing, Teaching & … · ECHO Discussion June 2015 Joseph Bubalo...
Transcript of ECHO Discussion June 2015 - Healing, Teaching & … · ECHO Discussion June 2015 Joseph Bubalo...
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ECHO Discussion
June 2015
Joseph Bubalo PharmD, BCOP, BCPS
OHSU Hospital and Clinics
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Marijuana Use Topics
• Medical marijuana
• Recreational marijuana
• What does it mean for medical practitioners
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• Listed in U.S Pharmacopeia 1850-1941
– marijuana & hashish extracts were the 1st, 2nd, or 3rd most prescribed meds in the US from 1842-1890s
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Marijuana
• Cannabis sativa – herbal plant containing >
80 different cannabinoid compounds
• Primary cannabinoids are delta-9-
tetrahydrocannibinol (THC), cannabidiol
(CBD), and cannbinol.
DeVane CL Pharmacotherapy 2013;33(10):1009-1011
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Cannabinoid Receptors
• Cannabinoid -1 (CB1) – primarily located
throughout the brain and nervous system
• Cannabinoid -2 (CB2) – peripheral tissues
and immune system
• Body produces endocannabinoids ,
anandamide and 2-arachidonoylglycerol,
which natural stimulants of the CB
receptors
DeVane CL Pharmacotherapy 2013;33(10):1009-1011 Collins S Pharmacy Today 2014;Apeil:HSE6-7
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This is actually how it works
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Product Issues
• Purity – (herbicides, pesticides)
• Potency (THC content)
– Recent Oregonian project showed just 2 of 15
products within 10% of stated amount
• Dose per condition?
• All medical research marijuana grown on a
single plot in Mississippi –supplied via FDA
• >700 strains currently cultivated outside this
plot
– Dosing is dependent on strain and route
Collins S Pharmacy Today 2014;Apeil:HSE6-7 Crombie N Oregonian March 8, 2015 A1, A12-14
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Smoking
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Other methods of ingestion: include
tinctures, oils, etc.
• Tinctures, made with 90% alcohol and marijuana, crosses transdermally, or orally.
• Rapid high - won the award at the Cannabis Cup.
• Matched with peppermint, sage, or cinnamon as well.
Endless video
available on
YouTube.
Rarely discuss the
medical effects, vs the quality of the high
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Butane Honey oil (BHO) is different
than “essential oils”
• Extracted using butane
– Between 75% and 99% THC.
• Designer refiners using vodka to enhance
cache’.
– “Dabs”
– “Wax”
– Smoked much more like crack or meth. Gas
fumes are inhaled.
– May be sprinkled on or combined with other
forms of deliver e.g. oral consumables
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Available Routes of Administration
• Inhaled – onset 2-30 minutes with 2-3 hr.
duration (smoked or vaporized)
• Oral – 2-3 hour onset with 5-8 hr. duration
– Often in the forms of cookies, brownies, or
candy
• Topical – oils or tinctures (also used orally)
• Not the same as hemp lotions
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Bioavailability • Proposed potency categories (oral) based on THC
content (2-3 mg smoked for average “high”)
– Low - < 7 mg/dose
– Medium 7-18 mg/dose
– High >18 mg/dose
– Note: THC may not be the most prevalent cannabinoid in each
strain or the desired one
• Need 3-5 x the dose orally vs. inhaled dose due to
stomach acid effects on THC and hepatic first pass
effect
• Oral bioavailability - 4-12% THC, 13-19% CBD vs.
inhaled ~35% for both
Ashton CH et al J Psychopharmacology 2005;19(3):293-300 Hall W Addiction 2014;110:19-35
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Cannabinoid Metabolism
• Distribute into fatty tissues and released
slowly (tissue half-life 5-7 days)
• Hepatic metabolism
• Many different metabolites eliminated over
days to weeks via urine and feces
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Drug-Drug Interactions
• THC inhibits effects of cannabidiol
• Various cannabinoids inhibit P-glycoprotein
• Additive or opposing effects with sedating
agents, antidepressants, sympathomimetics,
alpha-adrenergic agonists, and lithium.
• Inhibit and induce CYP 450 enzymes
DeVane CL Pharmacotherapy 2013;33(10):1009-1011 Collins S Pharmacy Today 2014;Apeil:HSE6-7
Ashton CH et al J Psychopharmacology 2005;19(3):293-300
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Oral Product Examples
• Colorado: standard dose 10 mg THC
– Most products have multiple servings
• Recent survey or Oregon based products - rated dose (actual)
– Coma treats pizza 350 mg (52)
– Infinite Flower Cookie 197 mg (50 mg)
– Steve’s Root Beer 70 mg (62)
– Lunchbox Alchemy Squib Candy 106 mg(59)
– Happy Snaps Cookie 100 mg (58)
– BhombChellys Jelly Candy 79 mg (76)
– Cheeba Chews 77 mg (78)
– Leif Medicinals Chocolate truffle 75 mg (98)
– Sour Bhotz candy 75 mg (33)
– Drip ice cream 46 mg (70)
Crombie N Oregonian April 12, 2015 A1,A8-9 Crombie N Oregonian March 8, 2015 A1, A12-14
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Medical Marijuana
• 22 states and the District of Columbia have
medical marijuana laws
• Changing trend from illegal drug the
therapeutic botanical
• As it becomes increasingly legal and
prevalent
• …. public infers safe and effective
Wilkinson ST JAMA 2014;311:2377-2378
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Limited Scientific Studies • As the legal landscape evolves, the
medical one remains confusing – fewer than 20 randomized, controlled
clinical trials of smoked marijuana for all possible uses
• these involved relatively small numbers of people in all—well short of the evidence typically required for a pharmaceutical to be marketed in the U.S.
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Potential Medical Effects
• Sedative
• Hypnotic
• Anxiolytic
• Antidepressant
• Antipsychotic
• Anticonvulsant
• Antimania/Bipolar
• Appetite stimulant
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THC vs Cannabidiol (CBD)
Effect THC CBD
Agonist at CB1 + -
Anxiolytic +/- +
Psychotropic + -
Antipsychotic - +
Anticonvulsant - +
Antidepressant + -
Sedative/hypnotic + +
Antinociceptive + +
Neuroprotectant + +
Antiemetic + -
Appetite stimulant + No data
Cardiovascular effects + +
Ashton CH et al J Psychopharmacology 2005;19(3):293-300 THC = Delta 9 tetrahydrocannabinol
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Potential Medical Benefits for
Individuals • Analgesia
• Anorexia
• Nausea
• Glaucoma
• Multiple sclerosis
• Seizures, spasticity,
• Others – HIV/AIDs
California Medical Association White Paper 2011
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Cannabis Effects on Youth
• Neuropsychological decline over functional
domains
– Impaired concentration
– IQ loss
• Poorer educational outcomes
• Decreased employment/job attainment
California Medical Association White Paper 2011
Meier MH et al. PNAS early edition 2012; 1-8
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Oregon Impact of Marijuana
Legalization • Medical marijuana approved 1998
• Can be used in non-public places
• Use requires authorization by an MD to get
a card allowing use
• Patient can grow enough for themselves (7
plants, 3 mature, 4 immature and 1 oz..) or
can have a designated grower
• As of 6/2014 Oregon had > 60,500 card
holders
CD Summary June 17, 2014 [email protected]
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Oregon Impact of Marijuana
Legalization • 2005
– Increased marijuana possession to 24 oz. and grow limits to 6
mature, 18 immature plants.
– Created a grow registry
– Growers could be reimbursed for cost of supplies and utilities
but not labor
• 2012
– Dispensary system approved, reduced offenses for possession
of < 4 oz.
• 2013
– Moratorium on dispensaries to draw up rules around labeling
and packaging
Crombie N Oregonian 11/9/14 pp A2, A18, A19
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Oregon Impact of Marijuana
Legalization • 2014
• Voters approve measure 91
– State will create a taxed and regulated system for retail sales
– Can be smoked in non-public places
• As of 6/1/15
– Individuals > 21 years old can possess 1 oz. in public, 8 oz. at
home, 4 plants per household
– Edibles – 1 lb. solid, 72 oz. of infused liquids, and 1 oz. of extract
• As of 1/1/16
– Liquor commission will have rules for production, processing, and
sale of marijuana
– Licensing or outlets begins 1/4/16 with expectation that stores will
open in the first half of 2016
Crombie N Oregonian 11/9/14 pp A2, A18, A19
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Workplace Related Impairing Effects of Marijuana Include
• Inability to accurately gauge lengths of time and distance as well as impairment of hearing and vision and short term memory
• Inability to cope with sudden changes in surrounding and/or emergency situations
• Loss of balance
• Visual and/or auditory hallucinations
• Non-caring, uncommitted, unconcerned attitude
•Decreased cognitive
reasoning
•Decreased motor
coordination
•Inability to concentrate or
remain focused on a single
thought or idea
•Increased drowsiness,
fatigue and lethargy
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How Does This Affect
Employment and Work on the Job
• Employers may mandate drug testing
• Medical professionals often required to
report “impaired” individuals
• Expect clarification of job descriptions
• What roles in a healthcare facility or
institution are not “safety sensitive”?
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Summary
• Medical cannabinoids are here to stay
– Non-THC cannabinoids appear to be where medical
progress is likely
• Medical information is unclear but likely to
improve considerably in the next 5-10 years
• Current commercial products are not regulated in
a meaningful manner, production is non-
standardized, and dosage unknown
• Children appear to be at he most significant risk
for harm, currently 10% of Oregonian 8th graders
and 20% of 11th graders report current use
CD Summary June 17, 2014 [email protected]