PROVIDER’S GUIDE TO MEDICAL MARIJUANA...PROVIDER’S GUIDE TO MEDICAL MARIJUANA GWEN LEVITT, DO,...

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4/16/2019 1 PROVIDER’S GUIDE TO MEDICAL MARIJUANA GWEN LEVITT, DO, DFAPA DISCLOSURE There are no disclosures related to this presentations.

Transcript of PROVIDER’S GUIDE TO MEDICAL MARIJUANA...PROVIDER’S GUIDE TO MEDICAL MARIJUANA GWEN LEVITT, DO,...

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PROVIDER’S GUIDE TO MEDICAL MARIJUANAGWEN LEVITT, DO, DFAPA

DISCLOSURE

• There are no disclosures related to this presentations.

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OBJECTIVES

• Familiarize yourself with types of cannabis products and their uses• Familiarize yourself with culture and language of medical and recreational

marijuana use• Learn about the legal aspects of medical marijuana• Familiarize yourself with the impact of medical marijuana on your practice

and patient health

• 19 yo male admitted involuntarily to the hospital with new onset psychosis. He is an ASU student in the electrical engineering program. He had very good grades in his first semester and behavior began slipping second semester.

• He was an excellent student in high school. • The past few months he had been acting oddly culminating in being found

naked in the bushes outside his apartment fearing someone was after him and stripping nude in front of his older sister and trying to sit on her lap.

• Told dad he was using CBD oil• He continually mentioned “animal crackers”

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THE PLANT

• There are over 100 cannabanoids in hemp and marijuana plants. • The two main cannabinoids are Cannabidiol (CBD) and

Tetrahydrocannabinol (THC). Both of these cannabinoids can be found in the seeds, stalks, and flowers of hemp and marijuana plants.

• THC is more concentrated in the marijuana plant while CBD is found in higher amounts in hemp. The average THC content found in green leafy marijuana (called flower or bud) is about 12% THC and CBD contains under 0.3% THC. (There are “high” content marijuana strains available now that have 19% to up to 35% THC.)

• THC is psychoactive, CBD is not. It is believed that combining CBD with THC will help potentiate the effects of THC.

ANIMAL CRACKERS AKA GIRL SCOUT COOKIES

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• The Top 8 Marijuana Strains in 2018• Blue Dream. As a hybrid between Blueberry and Purple Haze, Blue Dream has been

a popular favorite in California for years, but has quickly become one of the top sellers in recreational markets around the country.

• Jack Herer.• Green Crack. ...• Skywalker OG.• Gorilla Glue #4.• Girl Scout Cookies. ...• OG Kush.• Sour Girl.

• The cannabinoid, cannabichromene (CBC) is currently a compound of interest.

• It appears to be useful in treating pain, inflammation, depression, anxiety, and works as an antifungal agent.

• CBC is being combined with CBD to enhance the analgesic properties of both.

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STRAINS

• There are two plant species that are important to know about; Indica and Sativa. • Indica is the plant that contains mostly CBD. Its effect is described as a “full body

narcotic feel” or a “body high”. It is marketed as the product best for treating pain and sleep. (My memory tool: Indica indicates pain)

• Sativa is high in THC. It “uplifts the spirits” or gives a “head high”. Sativa would be recommended for depressive symptoms or fatigue. (My memory tool: Sativa satisfies)

• Hybrids of Sativa and Indica are also available; typically having a higher ratio of THC to CBD. This type would likely be suggested to decrease depression and stimulate the appetite.

• There are over 1000 unique strains of the plants being grown.

MARIJUANA VS. WINE

• Sweet grape and lime flavors, heavy, sweet funk• Aroma of burnt toffee• Earthy with sweet floral notes

• Precise, wet-stone and lemon zest• Peppery, funky, black raspberry• Lemon-lime, subtle yet complex, ebullient and youthful

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• Offers excellent pain relief as well as an uplifting, energetic, and euphoric feeling. Known for treating stress depression and lack of appetite

• Very relaxed and sleepy effect so good for pain relief and a marijuana “sleeping pill” to assist with insomnia

• Eases you into a peaceful mindset and releases stress and tension

SERVING SIZE

• The recommended dose of marijuana or “serving size” recommended by the Marijuana Enforcement Division, a department of the Colorado government that regulates the marijuana industry, is 10 mg.

• It is suggested that beginners use 10 to 20 mg initially. • “Microdosing” is a term usually used in relation to edible marijuana (edibles)

meaning small serving amounts; 2.5 to 5 mg at a time. (A dose of 2.5 mg is described as the effect of a glass of wine.)

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TERPENES

• Terpenes are the essential oils found in the plant that can be extracted. This is what gives marijuana that “skunky” smell and characteristic taste.

• Lavender, pine, clove and citrus oils are examples of terpenes. It is known that certain terpenes have chemical properties that are useful such as pine oil being antibacterial (think of Pinesol) and clove oil being an anesthetic.

• There are 10 common terpenes found in cannabis. The research about the effects of terpenes is in its infancy.

• Marijuana “experts” believe that terpenes have synergistic properties, called the entourage effect. Users now look for the amount of terpenes found in the products they purchase and feel the higher the terpene level, the better the quality of the product.

• Myrcene is the most common terpene found in marijuana (up to 60%). Myrcene is known as a muscle relaxant.

• Butane Hash Oil (BHO), an extract from the marijuana plant made through a process utilizing butane as a solvent, is very high in terpenes, about 40%.

• There is now a carbon dioxide extraction method for BHO that has been developed. This oil is less viscous, but more costly to produce. (less volatile)

• Products made just with terpenes are now available.

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PRODUCTS

• A person can buy bud or flower, oils, tinctures, and edibles. • Smoking bud or flower can be done with a joint. This is the “classic” delivery

device in which about a gram of marijuana is stuffed into rolling paper and made into a cigarette.

• A blunt, made with heavier tobacco (cigar) paper, holding two to three grams of marijuana, is another method of smoking.

• Bud or flower can be smoked with a simple glass pipe or a water pipe (bong). Bongs are preferred by some users because the water cools the smoke making it easier to take in a larger amount of cooled smoke and hold it in the lungs longer hence increasing the amount of THC absorbed.

• Spiffing is smoking marijuana and tobacco together.

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• Vaporizers use oils or the wax (BHO) products; this can be referred to as vaping. (Not to be confused with e-cigarettes.)

• Vaporizers are considered to be a healthier way to inhale product. The temperature used to vaporize the marijuana is lower so it is believed that fewer toxins are released into the body.

• Vaporizers can be akin to the electronic cigarette device or are more complex with metal screws to heat the product and glass bong-like smoking vessels called rigs.

• Using wax products is called dabbing. • Prefilled cartridges of carbon dioxide extracted oil are used with devices

called vaporizing pens. • Dipping wax in terpene oil is called terp dripping. Users may prefer these

methods because it uses less product and reportedly gives a “cleaner” high.

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• Edibles are comestible items infused with marijuana. • Cooking oil, butter, lollipops, biscuits, baked goods, drinks, chocolates, chips,

pizza, candy straws, gummies, syrups, and mints are just a few edibles one can find in the “grocery” aisle of a dispensary.

• Syrup is a great alternative because you can discreetly put it in a drink and “give your lungs a break”. (Also can use at work!)

• The candy bars are often scored to make them easy to split and take smaller doses of THC.

• Some are marketed as being pesticide-free, containing important minerals and antioxidants, and “all natural”.

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• Edibles can take one to three hours to be absorbed. Because of this, they are recommended more for chronic conditions and stomach ailments such as Crohn’s Disease.

• Metabolism can be impacted by certain medical medications. (Liver enzyme pathways)

• The amounts of THC in the edible is highly variable and hard to control. So far, edible products that have been tested have not been able to show an exact amount of THC in the product.

• Between the slower onset of action, leading people to eat more to feel the effects, and the dose variability, overdosing is more common with edibles.

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• These products also are marketed with catchy phrases. For example, the chips are “potent and savory” and come in many flavors.

• Chips are the products that seem to have the most variability of THC per chip. (It is estimated that a serving contains 100 mg of THC.)

• The scored candy bars, individually wrapped chews and gummies offer more consistent dosing.

• Some of the candy-like products and baked goods are very high in calories. • Product information on the packaging varies from basic to actual nutritional

labels. • The amount of THC in the product must be listed on the package. In

Colorado, the size of this label is regulated to insure it is readily visible.

• One serious problem with edibles is their consumption by children. • These products do not look drastically different from similar non-THC

products. • Some states have regulated the edible gummies by requiring them to be in

square shapes and not animal shaped which is more interesting to children. • One product, Zen Voodoo Sour Straws, is a sour-candy strip coated with a

sugar like substance that contains 375 mg of “top shelf” THC. It is marketed as tasty, potent, inexpensive, and very sweet.

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• Ingesting edibles delivers about five times more THC to the body as the primary metabolite is more potent than the metabolite produced from smoking.

• In Colorado, ER related incidences are much more common in those using edibles than other forms of marijuana.

• Despite this, edibles are seen as a more healthy option because you are not smoking or vaporizing the product into the lung.

• Edibles are a more discreet method of taking in marijuana so may be viewed as less stigmatizing.

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• Hashish is cannabis resin and is considered an extract and contains terpenes that have undergone various changes due to the manufacturing process.

• In the traditional method of making hashish, the stalks of the marijuana plant are pressed or rubbed together to create a sticky brownish ball or paste. This is dried and then can be compressed into small cakes or made into powders. Today there are methods of making hashish using ice water and/or chemical processes.

• Due to its gooey texture, hashish usually is smoked in a pipe or mixed with flower or bud to be smoked.

• It contains about 4% to 15% THC.

CHARLOTTE’S WEBB

• This is an oil made from a hybrid of hemp and marijuana. • The growers found that this variety had a “boring” and a disappointing

effect because it did not produce a “high”. • Parents and physicians of a young 11 year old, named Charlotte, tried the oil

from this hybrid and found that it reduced her seizures. • In 2014 the American Academy of Neurology stated that there was

insufficient evidence to support the use of cannabinoids for reducing seizure activity.

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SCIENCE• Cannabis interacts with the endocannabinoid system in the body. This

system helps regulate pain, appetite, mood, memory, immune response, sleep, and cellular life cycle.

• There are two important cannabinoid receptors; cannabinoid 1 (CB1) and cannabinoid 2 (CB2).

• CB1 is found in highest concentration in the brain and central nervous system and confers the psychoactive effects.

• CB2 receptors are found in immune system tissues and has no psychoactive properties.

• THC has a high affinity for CB1 receptors; hence it makes you “high”. • CBD products have a high affinity for CB2 AND 5HT1A.• Terpenes have an affinity for CB2 receptors. • It is also known that THC acts on several opioid receptors in the brain as well.

• Smoked or vaporized THC goes into the lungs and is absorbed into the blood stream.

• Ingested products are broken down by saliva and stomach acids which make them more water soluble.

• THC (Delta-9 THC) goes through the liver and is metabolized into Delta-11 THC, along with many other metabolites.

• Delta 11-THC is ten times more potent than Delta-9 THC. • Medications that impact important liver enzyme pathways (P450, CYP2C9,

CYP2C19, and CYP3A4) can impair or potentiate the metabolism of THC. Likewise, liver diseases can impair metabolism of the compound as well.

• The bioavailability of inhaled products is about 11% to 45% and 13-19% for edibles.

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• Myrcene, the most common terpene in marijuana is metabolized into two toxic products; benzene and metacrotein (MC).

• MC is a known noxious irritant. • MC is a very similar compound to acrolein, an air pollutant that is monitored

as a substance of great concern. • Benzene is a potent carcinogen and is known as the largest single known

cancer risk compound found in air pollution. • The average air quality in the United States is about 0.313 parts per billion

(ppb). One lung full of a dab of BHO is estimated to contain 15 ppb of noxious substances. (This translates into a 50 fold increase compared to daily air pollution rates.)

• There is some evidence to suggest that cannabis use can cause inflammation of the arteries.

• Delta-8 and Delta-9 THC are known vasoconstrictors. • Cannabis also increases triglycerides in the blood. • In 2011, United States Department of Health and Human Services reported

455,000 emergency room visits related to marijuana. • Overdosing on marijuana presents as with elevated heart rate and blood

pressure, shakes or seizure-like activity, headache, pale skin, paranoia, extreme anxiety or hallucinations, and odd behaviors. Decreased judgment, perception, and coordination that can lead to injuries or even death.

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THE LAW• Since 1996, 31 states and the District of Columbia have legalized the

production and sales of medical marijuana (as of June 2018). • Fifteen states have approved laws for production and sales of CBD • Eight states have recreational marijuana use laws. • Hemp products are legal in all 50 states. • Forty eight states have made CBD products legal for medical usage• Seventeen states regulate the levels of THC in CBD products.

• It is still against federal law to use marijuana. It remains illegal to transport cannabis from any state to any other state (even if it has been legalized), by any mode; plane, train, automobile or the United States mail. (Drug paraphernalia is also illegal to transport.)

• Dispensaries sell products that help plane travelers evade detection such as “TSA compliant” CBD oil vials and plastic bags that hide the scent of marijuana from drug-sniffing dogs.

• Marijuana growers and distributers obtain a license to transport products within their state of operation.

• CBD with a THC concentration less than 0.3% can be sent through the mail.

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• Most states that have legalized cannabis have created laws so that a person caught with an ounce or less of cannabis and a legitimate medical marijuana card will not be prosecuted. In 2014 the Rohrabacher-Farr amendment bars the United States Department of Justice from prosecuting individuals in states that have medical marijuana laws.

• Canada was the first large international country to legalize marijuana starting in October 2018. (The manufacture, sales and production will be government run.)

• Uruguay also has legalized the substance.• It still remains illegal to cross the US- Canada border with marijuana.

HOT OFF THE PRESS

• February 2019: Agriculture Improvement Act 2018- legalizes hemp production and use but FDA regulations of cannabis and cannabis-products remain unchanged.

• The new law removes hemp from the Controlled Substance Act – so no longer an illegal substance (<.03% THC)

• Regulations for cannabis products regardless of the source, including plants classified as hemp

• All cannabis products claiming intended use for medical purposes- cure, mitigation, treatment or prevention of a disease will be tested by the FDA

• Selling unapproved products with unsubstantiated claims is illegal

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CANADA

• Must be 19 yo to purchase (Quebec may vote for 21 years, now 18 years)• Currently just over a dozen stores open, can be purchased on-line with

Canadian credit card. US visitors must find store and buy with cash• $7-12 per gram (US dollars)• Can buy, carry and share up to 30 gram = 60 joints• Public consumption varies by local jurisdiction, typically where cigarettes

can be smoked except in cars or near children (66 foot rule)• DUI illegal, if cannabis in the car must be in sealed container and out of

reach of the driver• Two hour tour packages offered for visitors for $50 (Canadian dollars)

FINES: ZERO TOLERANCE-$500 TO 5,000

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• A 1986 federal law prohibits a person from possessing a firearm or ammunition if using marijuana.

• In 2011 the Bureau of Alcohol, Tobacco and Firearms produced a directive that stated that guns should not be sold to those who hold a medical marijuana card. However, states such as Arizona, do not actually prohibit the sale of weapons to card holders.

• The amount of THC in a product determines its legal status. “Industrial hemp” has less than 0.3% THC and is utilized to make biodegradable plastic, paper, textiles and fuel. These products are legal.

• In Arizona medical marijuana is banned on state campuses, school buses, on the grounds of a school or correctional facility.

• A person cannot use marijuana at a dispensary, on a bus or in public spaces. • In 2015, Arizona determined that a person on probation cannot be banned

from utilizing medical marijuana if he/she has a valid card. • In June 2018, the Arizona Court of Appeals made cannabis extracts illegal,

which includes edibles. • It is illegal to drive under the influence of marijuana. • One cannot utilize a medical marijuana card form another state to buy

product. • In Arizona one has to show the medical marijuana card upon entering a

dispensary.

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OBTAINING A LICENSE• In Arizona you must be a legal resident and obtain a two physician approval

(licensed MD, DO, naturopathic or homeopathic physician) and have a completed Physician Written Certification form to obtain a medical marijuana license. ($300 a visit)

• The only approved conditions are cachexia or severe wasting, chronic pain, severe nausea, seizures, and muscle spasms.

• The patient pays $150 for the card. (If a person has Supplemental Nutrition Assistance Program SNAP for low income individuals it costs $75.) The card is valid for one year. A similar process for obtaining a certification must occur with each renewal.

• A person creates a profile with a password protected account and designates a dispensary.

• An individual can have 2.5 ounces of cannabis in a 14 day period. (Although not legal in Arizona, the amount of edibles that can be purchased at one time is regulated.)

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• As of 2016 there were 80,000 card holders and in 2017 there were 157,000 medical cards approved.

• That translates into 43 tons of medical marijuana being consumed. • This is a 50% increase over 2016.

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COSTS• A gram of bud or flower marijuana costs about $5 to $20; an ounce $200 to

$400. (An “eighth” is 3.5 grams.) (Dispensaries in Arizona advertise $110/ounce)

• Concentrates cost about $20 to $60 per gram. • Edibles are $2 to $5 dollars per dose. • Tinctures, are sold by the bottle and are priced by strength and can cost $15

to $50 per bottle. • A consult with a dispensary retail “expert” can cost the patient $80 to $200. • Patient supplies also must be factored into the equation. Rolling papers are

about $2 a packet. A simple glass pipe can cost $20 and a water pipe or bong can be $50 to $300. Vaporizers are $100 to $700.

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• A Tempe, Arizona based firm called American Green invented the ZaZZZ, a marijuana vending machine. Not approved for use in Arizona, these machines have been available in Colorado since 2014 to sell edibles and in Washington since 2015. Driver’s license and medical card must be loaded into the machine and payment can be in cash or Bitcoin. The US government has banned use of credit or debit cards to purchase marijuana. There is a website one can use to locate the nearest machine.

• In 2014 a group of California marijuana enthusiasts started an on-line directory, using Google, to locate dispensaries throughout the state. In 2016, this group created an “App” called Meadows that allows card holders to order cannabis products on-line and have them delivered to any location in the state. One can pay extra fees to track the status of the delivery and to create and digital signature too!

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TAKE HOME MESSAGES

• Ask the patient what type, variety and route of marijuana are they using: This will give you an idea of impact on the patient:• Indica vs. sativa…CBD vs. THC• Higher content THC products will be more psychoactive• How the product might interact with prescription medications• Is the “oil” the patient is using CBD vs. terpene- CBD not psychoactive, but

terpenes are psychoactive• Smoking may have more adverse medical impact than ingesting (ie. lung)

The only approved conditions for a card in Arizona are cachexia or severe wasting, chronic pain, severe nausea, seizures, and muscle spasms.

How do our patients obtain cards for PTSD, panic, migraines, insomnia?

Question the validity of your patient claiming they have a card

It costs about $300 to obtain a physician’s approval form, $75-100 for application, and $110-200 an ounce

How does your patient afford this habit?Diversion of marijuana by those with cards.How do they get to and from dispensary?Because of legalization more people looking at is as a safe product.