Course Content

What is Medical Marijuana?

The term medical marijuana refers to using the unprocessed marijuana plant or its basic extracts to treat symptoms of illness and other conditions. The U.S. Food and Drug Administration (FDA) has not recognized or approved the marijuana plant as medicine.

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Our society is at a tipping point of changing our relationship with our country’s most widely abused illegal drug.  There are so many things moving so fast and if you are not educated on the issue it will be easy to get left behind. More than a debate exercise, marijuana’s ever-changing state is a real situation with real implications in our workplaces, our communities, and our homes. It is critical for a pharmacist to be educated on all of the issues surrounding marijuana in order to best educate the public and the patients we serve.

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Since 1991 when the first state made it available for medical use, the degree of conflicting information and opinions has compounded. You will be faced with the following questions as a health care professional: Is it addictive? Does it lead to other drug use? Is it safer than other addictive drugs? Does it have medical value? Mix in any personal experience with the drug and society in general is left looking at today’s marijuana through a confused and possibly outdated lens.

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Background information

Cannabis also known as marijuana, originated in Central Asia but is grown worldwide today.  The Cannabis plant produces a resin containing psychoactive compounds called cannabinoids, in addition to other compounds found in these plants, such as terpenes and flavonoids. Terpenes are a type of strong-smelling chemical substance found in some plants. Terpenes are also found in essential oils (scented liquid taken from plants). Flavonoids are a member of a group of substances found in many plants and plant-based foods. Flavonoids have been shown to have antioxidant effects.

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We have very little research on using marijuana for medical indications. In order to conduct clinical drug research with cannabis in the United States, researchers must file an Investigational New Drug (IND) application with the FDA, obtain a Schedule I license from the U.S. Drug Enforcement Administration and obtain approval from the National Institute on Drug Abuse. Such strict requirements make it difficult for researchers to originate a clinical trial in the United States. This leaves many questions in the minds of health care professionals as to the safety and effectiveness of medical marijuana.

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Definitions

It is important to understand the terminology when discussing medical marijuana. The following are a few key definitions:

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Cannabis is a plant genus that produces three species of flowering plants: Cannabis sativa, Cannabis indica, and Cannabis ruderalis. Cannabis sativa and Cannabis indica are used to produce both recreational and medical marijuana. Cannabis ruderalis is rarely farmed due to its natural lower THC content. 

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Cannabinoids are the chemical compounds unique to cannabis that act upon the human body’s cannabinoid receptors. Marijuana’s most well-known cannabanoids are Tetrahydrocannabinol (THC) and cannabidiol (CBD).

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Marijuana is the general term for female cannabis plants or their dried flowers. Females are distinct from male plants in that they are the ones that produce flowers which contain the high percentage of cannabinoids that hold both their medicinal and psychoactive properties.

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Hemp is a fibrous product that can be produced from the male cannabis plant and can be used to manufacture of rope, paper, beauty products, and a vast array of other products. Marijuana derived CBD can contain up to 30% THC, while CBD derived from hemp contains less then 0.3% THC. 

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THC Versus CBD

The marijuana plant contains more than 100 cannabinoids. Currently, the two main cannabinoids from the marijuana plant that are of medical interest are THC (the component of marijuana that makes people “high”) and CBD (the non-psychoactive component in the marijuana plant). 

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Since CBD doesn’t make people “high”, these drugs aren’t popular for recreational use because they aren’t intoxicating. It is most useful in producing medical marijuana and has been indicated to be useful in reducing pain and inflammation, controlling epileptic seizures, and possibly even treating mental illness and addictions.

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The Historical Perspective

Cannabis use for medicinal purposes dates back at least 3,000 years. It was introduced into Western medicine in 1839 by W.B. O’Shaughnessy, a surgeon who learned of its medicinal properties while working in India for the British East India Company. Its use was promoted for reported analgesic, sedative, anti-inflammatory, antispasmodic and anticonvulsant effect.

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In 1937, the U.S. Treasury Department introduced the Marihuana Tax Act. This Act imposed a levy of $1 per ounce for medicinal use of cannabis and $100 per ounce for non-medical use. The American Medical Association (AMA) opposed the Act because physicians were required to pay a special tax for prescribing cannabis, use special order forms to procure it, and keep special records concerning its professional use. In addition, the AMA believed that objective evidence that cannabis was harmful was lacking and that passage of the Act would impede further research into its medicinal worth. In 1942, cannabis was removed from the U.S. Pharmacopeia because of persistent concerns about its potential to cause harm.

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In 1951, Congress passed the Boggs Act. This was the first time cannabis was included with other narcotic drugs.  In 1970, with the passage of the Controlled Substances Act, marijuana was classified by Congress as a Schedule I drug.

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State Versus Federal Perspective

Despite its designation as having no medicinal use, Cannabis was distributed by the U.S. government to patients on a case-by-case basis under the Compassionate Use Investigational New Drug program established in 1978. Distribution of cannabis through this program was closed to new patients in 1992.

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At the federal level, marijuana remains classified as a Schedule I substance under the Controlled Substances Act, where Schedule I substances are considered to have a high potential for dependency and no accepted medical use, making distribution of marijuana a federal offense. In October of 2009, the Obama Administration sent a memo to federal prosecutors encouraging them not to prosecute people who distribute marijuana for medical purposes in accordance with state law.

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In late August 2013, the US Department of Justice announced an update to their medical marijuana enforcement policy. The statement read that while marijuana remains illegal federally, the US Department of Justice expects states to create “strong, state-based enforcement efforts…. and will defer the right to challenge their legalization laws at this time.” The department also reserves the right to challenge the states at any time they feel it’s necessary.

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Since marijuana is still a Schedule I substance, federal law prohibits its prescription (unless it is an FDA approved product). Medical marijuana “prescriptions” are more often called “recommendations” or “referrals” because of the federal prescription prohibition.

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Recognizing that the marijuana plant does have legitimate medical uses, the FDA has worked with drug manufacturers to approve a CBD-based liquid medication called Epidiolex® for the treatment of two forms of severe childhood epilepsy, Dravet syndrome and Lennox-Gastaut syndrome. The FDA has also approved several THC-based medications, dronabinol (Marinol®) and nabilone (Cesamet®), prescribed orally for the treatment of nausea in patients undergoing cancer chemotherapy and to stimulate appetite in patients with wasting syndrome due to AIDS.

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Use of these drugs for the approved indications is permissible under federal law and can be obtained by patients with a prescription.

States with medical marijuana laws generally have some form of a patient registry, which may provide some protection against arrest for possession up to a certain amount of marijuana for personal medicinal use. 

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Some of the most common policy questions regarding medical marijuana include how to regulate its recommendation, dispensing, and registration of approved patients. Medical marijuana growers or dispensaries are often called “caregivers” and may be limited to a certain number of plants or products per patient. This issue may also be regulated on a local level, in addition to any state regulation. 

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Pharmacists must know the laws in their states in order to be in conjunction with all the legal requirements. As with all areas of health care, laws and initiatives are constantly in flux so it is critical for a pharmacist to remain up-to-date with current policy and procedures regarding both federal and state legislation. 

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There are many ways to remain current for recommendations on state legalities. A good website to refer to is sponsored by the National Conference of State Legislatures at

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https://www.ncsl.org/ for a list of specific state cannabis programs and the various regulations that one must follow.

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Recreational Versus Medical Marijuana

Medical marijuana typical has a higher percentage of CBD when compared to recreational marijuana.​This means that patients won’t experience as intense of a high from ingesting medical marijuana. This all depends on the strain, but medical marijuana is geared toward helping patients alleviate symptoms of their respective illnesses. As CBD is the component of marijuana that has most of the medicinal benefits, medicinal marijuana contains a higher percentage of it compared to recreational marijuana.

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Recreational marijuana usually has higher percentage of THC when compared to medical marijuana.​Recreational marijuana is more for an individuals own enjoyment of being high. THC is used less to alleviate symptoms of illnesses, and more for enjoyment and relaxation. As a result the strains sold at Recreational Dispensaries tend to have less CBD than those from Medical Dispensaries.

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You need a doctors recommendation to purchase medical marijuana. In order to enter a dispensary that sells medical marijuana, you need to first see a doctor and obtain a recommendation.  There are a variety of different illnesses that are required to obtain a recommendation.

There is no need for a recommendation to purchase recreational marijuana. Anyone over the minimum age can enter a Recreational Dispensary and purchase marijuana. There is no need for any other verification.

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You must be 18 years or older to purchase medical marijuana.​In general, one must be at least 18 years old to obtain a medical marijuana recommendation and purchase marijuana. There are some special circumstances where children, especially those with epilepsy, are granted a recommendation even though they aren’t of age. These cases are rare, and the majority of people need to wait until they are at least 18.

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In order to purchase recreational marijuana you need to be at least 21 years of age. In order to enter a recreational dispensary and purchase marijuana, you need to be at least 21 years or older. This is the minimum age in all states that allow recreational marijuana.

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Hemp Versus Marijuana

CBD laws differ  between hemp derived CBD and marijuana derived CBD. Even though the chemical component of CBD is identical in both hemp and marijuana, the marijuana derived CBD can contain up to 30% THC, while CBD derived hemp contains less then 0.3% THC. 

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In 2018, The Farm Bill made hemp legal in the United States but with serious restrictions:

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• First, hemp cannot contain more than 0.3% THC. Any cannabis plant that contains more than 0.3% THC would be considered non-hemp cannabis—in other words, marijuana—under federal law and would thus face no legal protection under this new legislation and would be subjected to all the restrictions for marijuana.

• Second, hemp cultivators must apply for licenses and comply with a federally run program.

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As a side note:  Marijuana can produce up to 400% more CBD than hemp, making it the go to option for any business trying to make a profit. These growers would not profit very much by growing hemp for use in its manufacturing process.

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Knowing the laws behind both sourced of CBD is essential for anyone looking to be involved in using or recommending the substance.

So Is CBD Legal Now?

One big myth that exists about The Farm Bill is that CBD was legalized. It is true that The Farm Bill removed hemp derived products from Schedule I status, but the legislations  does not legalize all forms of CBD.

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CBD “generally” remains a Schedule I substance  under federal law.

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The Farm Bill ensures that any cannabinoid that is derived from hemp will be legal, if and only if that hemp is produced in a manner consistent with The Farm Bill, associated federal regulations, associated state regulations and by a licensed grower. All other cannabinoids, produced in any other setting, remain a Schedule I substance under federal law and are thus illegal. 

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Synthetic Cannabinoids

Synthetic cannabinoids are part of a group of drugs called new psychoactive substances (NPS). Synthetic cannabinoids are human-made mind-altering chemicals that are either sprayed or dried, shredded plant material so they can be smoked or sold as liquids. Once purchased by the consumer these liquids are either vaporized or inhaled in e-cigarettes or used in other devices. These products are sometimes referred to as herbal or liquid incense.

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These chemicals are called cannabinoids because they are similar to chemicals found in the marijuana plant. Because of this similarity, synthetic cannabinoids are sometimes misleadingly called “synthetic marijuana” (or “fake weed”), and they are often marketed as safe, legal alternatives to marijuana. In fact, they are not safe and may affect the brain much more powerfully than marijuana. Their actual effects can be unpredictable and, in some cases, more dangerous or even life-threatening.

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Some of these synthetic cannabinoids may have been around for years but have reentered the market in altered chemical forms and are finding a renewed popularity.

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So far, there have been few scientific studies of the effects of synthetic cannabinoids on the human brain, but researchers do know that some of them bind more strongly than marijuana to the cell receptors affected by THC and can produce much stronger effects. The resulting health effects can be unpredictable and dangerous. Because the chemical composition of many synthetic cannabinoid products is unknown and may change from batch to batch, these products are likely to contain substances that cause dramatically different effects than the user might expect.

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The pharmacist should be aware and able to advise/warn on the use of such products. Labels on these products often claim that they contain “natural” material taken from a variety of plants. However, chemical tests show that the active, mind-altering ingredients are cannabinoid compounds made in laboratories. They market these products under a wide variety of specific brand names. Hundreds of brands now exist, including K2, Spice, Joker, Black Mamba, Kush and Kronic.

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Synthetic cannabinoid users report some effects similar to those produced by marijuana:

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• Elevated mood

• Relaxation

• Altered perception—awareness of surrounding objects and conditions

• Symptoms of psychosis—delusional or disordered thinking detached from reality

• Extreme anxiety

• Confusion

• Paranoia

• Hallucinations

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Although most synthetic cannabinoids are analogs of THC, they are structurally different enough that they can go undetected by most standard drug tests. Also, due to their high potency, a very small dose of synthetic cannabinoids is used making it even more likely to go undetected. They are also highly metabolized by the body, so the window to detect drug in blood and oral fluid is very small. However, now there are commercially available kits that specifically test for synthetic cannabinoids.

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Marijuana Test Kits

In the past, if someone wanted to test their cannabis for various chemicals and compounds, they had to have access to a laboratory full of specialized equipment. With the development of marijuana test kits, all of that changed. Today’s marijuana test kits are more than just THC test kits, they will show the entire chemical makeup of what is in the product to be tested.

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There are several different types of marijuana test kits available. Cannabis potency test kits offer more than a simple yes or no test to the detection of the presence of THC or CBD. Cannabinoid test kits provide a bigger picture of the potency by showing  each type of cannabinoid and the level at which it’s present. Most kits contain all of the essential equipment necessary to test a sample of material and decipher the results. This includes calibration charts for cannabis potency testing, test plates, dyes and test fluids, as well as all of the vials, jars, trays, pipettes, syringes and gloves needed to complete the tests. Kits also include an easy-to-use manual to guide the user through the process. In addition to the included equipment, an individual may need a digital weighing scale and a well-ventilated area to work depending on how big the sample size is that is to be analyzed.

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THC test kits (THC testers) are a different breed of marijuana testing equipment. While still useful, they don’t offer results on a variety of cannabinoids and their concentrations. Instead, they simply offer a straightforward yes or no result on the presence of THC.

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Because addiction, bad trips, and death due to synthetic cannabinoid ingestion is such a real threat, drug testing companies have created portable synthetic cannabis testing kits that make it easy to know if the product to be tested is all natural or a chemical-laced concoction that would render danger if ingested. The kits will test for a wide range of synthetic substances and will produce a color change that can identify the included substrates found on an enclosed color chart.

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While the line of thinking years ago was that all marijuana products were created equal, consumers know differently today. Black-market cannabis can contain various substances, including dangerous synthetics. While marijuana purchased from dispensaries is a safer bet in terms of not ingesting synthetics, it’s still impossible to verify the cannabinoid content of specific strains without testing them first. This is particularly important for medical marijuana patients who rely on certain cannabinoid profiles for their treatment and need to have a safe and consistent effect.

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Cannabinoid potency test kits are also used by growers working to perfect a strain for a specific purpose. Rather than guessing what the effects of that strain will be, this type of marijuana test kit gives growers the ability to understand the exact chemical makeup of the plant they’ve produced.

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The Need for Pharmacists in the Medical Marijuana Industry

Often, in the medical marijuana industry, the focus is on physicians who must recommend the medicine in order for patients to receive it at a dispensary.  But such a limited focus ignores the essential role of pharmacists in the process.  The pharmacist is on the critical front line of insuring that the right dosage forms and quantities are received by the patients.  However, many states overlook this critical role and do so at their own peril.

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There are many different ways a pharmacist can be involved and it seems to vary by state laws that are in effect. Some states require that a pharmacist be on site to dispense medical marijuana at a dispensary.  There are other states that give the dispensary a choice of having either a full-time physician or pharmacist at the main dispensary with physician assistants or certified nurse practitioners for satellite dispensaries. There are some states who designate the state’s pharmacy board to oversee the dispensary operations.  In most states, both physicians and pharmacists need to attend a course prior to being authorized to recommend or administer medical marijuana.

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Pharmacists offer a unique prospective in the administration of medical marijuana for many different reasons: 

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• Pharmacists are very familiar with the security procedures and protocols that need to be in place in order to prevent diversion of an array of potent and controlled drugs. 

• Pharmacists live in an atmosphere where leaving a cabinet door unlocked can lead to devastating effects such as theft. 

• Pharmacists can create and implement specific safety procedures to accept frequent deliveries of various forms of pharmaceuticals such as controlled substances. 

• Pharmacists are the last defense to protect patients from dangerous drug interactions that can occur between different pharmaceutical products or the negative consequences of using drugs with certain disease states.

• A medical marijuana dispensary may be more akin to a pharmacy and all the checks and balances of safety procedures that are in place to ensure correct and safe dispensing of medications to patients.

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Pharmacists are regularly approached by patients and prescribers about the use of cannabis for a variety of indications. 

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Prescribers often initiate cannabis as third- or fourth-line adjunctive therapy in addition to other medications, compounding the potential for drug interactions and adverse effects. Determining a safe and effective cannabis dosage requires appropriate and informed knowledge with the patients’ overall medication regimen. This is a role uniquely suited to pharmacists, supported by their ongoing relationships and frequent touchpoints with their patients and primary care providers.

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In the current medical stream, patients have latitude in selecting the potency of the cannabis authorized to them by their prescriber. Cannabis effects are individualized in patients, so the current approach to dosing and titration is highly patient specific, involving a “start low go slow” dosing strategy, including patient self-titration. Pharmacists can provide support and guidance to patients and prescribers with respect to these individualized dosing strategies.

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Pharmacists at the dispensary level

For many patients, particularly older ones or those who have been in the traditional health care setting for a while, it can be reassuring that a board licensed pharmacist is on hand to guide their cannabis decisions. While medical marijuana has been legal in a variety of states for several years, there is still a negative stigma and stereotype surrounding the plant that can be difficult for some new patients to shake, and having a pharmacist — that is, a health care professional they’ve had previous experience interacting with — can help ease any concerns or uncertainties.

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Many patients have already dealt with pharmacists for their conditions, using traditional pharmacies for their various prescriptions, so they feel comfortable with the same type of health care professional at the dispensary, providing for a smooth continuum of care. This is especially important for individuals with a lot of health and medication needs.

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While it’s clear pharmacists can be an important and integral part of medical cannabis, this system is not without its challenges. When it comes to having a pharmacist on staff, one problem is that it can be difficult to stay current with cannabis information. Because the plant is still illegal at the federal level, it’s not as easy to look up peer reviewed information on cannabis as it is for prescribed medications. The same is true for pharmacists who want to take continuing education courses regarding the plant.  With limited studies and data accessible, it can be difficult for pharmacists to do their job to the fullest.

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The pharmacist can serve as the medication expert by dispensing and counseling on medical marijuana use.

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What does the pharmacists do in a dispensary?

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• Pharmacists are responsible for treating marijuana like any other drug.

• They need to review patients’ medication and medical history, check for drug interactions, and counsel patients on use and adverse effects.

• Pharmacists should continue to serve patients as medication experts regardless of the dispensed medication.

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Minnesota and Connecticut are two states that use pharmacists at dispensaries where medicinal marijuana is distributed.

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These two states have designed a plan with their local pharmacists for medicinal marijuana patients to be treated in a professional atmosphere very similar to being seen in their physician’s office. This type of practice includes a pharmacist having regular business hours established for the patients to schedule appointments. These appointments will consist of the pharmacist reviewing the patient’s medical history and moving forward to make a plan surrounding the use of medical marijuana to the best advantage of the patient making sure all treatment goals are met.

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The pharmacists must certify that a patient has been diagnosed with one of the major qualifying medical conditions. These conditions consist of glaucoma, Tourette syndrome, cancer, ALS, muscle spasms, HIV or AIDS, epilepsy or seizures, another terminal illness or Chron’s disease. Most of these conditions will have a life expectancy of under a year and can produce nausea, severe wasting, and severe pain. These states have created a practice model for other states and pharmacists to follow to address the future of the pharmacist’s involvement in dispensing medicinal marijuana.

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Marijuana Pharmacology

In recent decades, the neurobiology of cannabinoids has been analyzed. The first cannabinoid receptor, CB1, was identified in the brain in 1988. A second cannabinoid receptor, CB2, was identified in 1993. Endogenous cannabinoids (endocannabinoids) have been identified and appear to have a role in pain modulation, control of movement, feeding behavior, mood, bone growth, inflammation, neuroprotection, and memory. THC acts primarily on CB1 receptors, and CBD acts primarily on CB2 receptors.

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CB1 receptors exist primarily in areas of the brain that regulate appetite, memory, fear, and motor responses. Stimulation of CB1 receptors in the brain lead to psychotropic effects from cannabis. CB1 receptors are also found outside of the brain in the gastrointestinal tract, adipocytes, liver, and skeletal muscle. CB2 is primarily expressed in macrophages and other macrophage-derived cells that are part of the immune system. The highest expression of CB2 receptors is located on B lymphocytes and natural killer cells suggesting a role in immunity.

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Cannabis Pharmacology

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Medical cannabis can be delivered by several routes of administration, including smoking, vaping, oromucosal, ingestion and topical. Route of administration affects the rate of absorption of THC and CBD, and thus influences the onset, intensity, and duration of the clinical effect of cannabis.

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Case

DJ is a 62-year-old male with a 10-year history of chronic back pain after a skiing injury. She has tried pharmacologic management for her pain with OTC remedies as well as physical therapy and trigger point injections. She has recently tried duloxetine with no relief. The use of opioids for her pain has been discouraged due to the chronic nature of her symptoms and she had negative side effects from gabapentin and amitriptyline. In addition, she complains of insomnia and irritability due to poor sleep likely due to her back pain complicating her sleeping pattern.

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At her next time in the pharmacy,  DJ tells the pharmacist that given her continued pain, she visited a medical cannabis provider, acquired certification for cannabis to manage the pain, and visited a dispensary where she encountered many different options for modes of consumption and many differing types of products, She has the following questions for the pharmacist:

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Should I start the medial cannabis for the management of my pain symptoms?

Is one type of medical cannabis better than another?

What side effects or complications should I be worried about? 

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As the educated pharmacist you are, you continue to ask more questions and you discover that the products at the dispensary DJ visited include a range of options that contain THC alone, CBD alone, and several different THC/CBD ratios, and they can be administered by several different modes of consumption.

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Based on what you know about the pharmacology, the potential medical effects and side effects could thus vary by the relative amounts of THC and CBD, and the timing and duration of the effects will vary according to the mode of consumption.

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When counseling DJ on how medical cannabis may affect her symptoms, interpreting the cannabis literature can be challenging for several reasons. First, formulations vary by state due to differing state-based legislation. Therefore, products used in clinical studies may not be representative of what is available to medical cannabis patients at a local level. In practice, patients self-titrate to symptom relief and are encouraged to do so. This makes it extremely difficult to recommend standardized dosing schedules. Many patients will need to be followed much more closely and work with a health professional on a continued bases to adjust the dosage based on symptomatic control. Furthermore, medical cannabis has largely been sought for the management of symptoms, rather than conditions.

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Indications

Chronic Pain

Chronic pain is the most commonly cited reason for seeking out medical cannabis. Medical cannabis is used to treat chronic pain related to neuropathy, cancer, multiple sclerosis, rheumatoid arthritis, musculoskeletal issues, drug toxicity and HIV/AIDS.

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The mechanism of cannabis’ analgesia is not completely understood. One potential mechanism is the interaction of cannabinoids with the human endocannabinoid system, thus leading to a reduction in pain stimuli or inflammation. Cannabis may also reduce emotional stress related to chronic pain  which may possibly shift perceptions of pain.

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A systematic review of over 28 randomized controlled trials found that cannabinoids have shown an average of ≥30% reduction in pain scores compared with placebo. Cannabis has been shown to reduce neuropathic pain in a dose-dependent fashion in some analyses. ​In these analyses, oral cannabinoids were found to have a smaller beneficial effect than inhaled cannabinoids. Though these findings are promising, the sample sizes are very small, many of the studies focused on specific products, including synthetic cannabinoids, and confidence intervals span close to the level of non-significance. Thus, there is very limited solid clinical evidence regarding the efficacy of products available to patients with chronic pain including the relative benefits of THC, CBD, or various THC/CBD ratios for pain.

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On a positive note, studies have shown that overall patients using medical cannabis were able to reduce or stop other pain medications such as opioids. This seems to be a very beneficial effect when considering the safety profile and addictive nature of opioids.

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Cancer Pain

When cancer pain is severe and persistent, it is often resistant to treatment with opioids making marijuana a viable alternative.

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Numerous studies have investigated the effect of marijuana for use as an analgesic in association with cancer pain:

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• Studies have shown that 15 mg and 20 mg doses of the cannabinoid delta-9-THC were associated with substantial analgesic effects, antiemetic effects, and appetite stimulation.

• An observational study assessed the effectiveness of nabilone in advanced cancer patients who were experiencing pain and other symptoms including anorexia, depression, and anxiety. The researchers reported that patients who used nabilone experienced improved management of pain, nausea, anxiety, and distress when compared with untreated patients. Nabilone was also associated with a decreased use of opioids, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, gabapentin, dexamethasone, metoclopramide, and ondansetron.  

• Some studies have supported the use of medical marijuana in neuropathic pain associated with the adverse effects of chemotherapy.

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Anxiety and Posttraumatic Stress Disorder

Anxiety and posttraumatic stress disorder (PTSD) are common reasons for seeking out medical cannabis. Among individuals engaged in care there is a growing desire to reduce the use of prescription anxiolytics, such as benzodiazepines, due to medication safety concerns. The benzodiazepines are associated with a high rate of addiction, physical tolerance and severe withdrawal symptoms making it a very legitimate concern to their use in treating anxiety and PTSD.

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The mechanism by which cannabis addresses anxiety is not completely understood. Preclinical data shows a relationship between anxiety and decreased endocannabinoids. There are few studies testing the efficacy of cannabis for the treatment of anxiety. In small randomized controlled trials cannabis has been found to be effective for the short-term treatment of anxiety symptoms.

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In surveys among combat veterans who use cannabis at least once per week, its use was associated with improvement in some symptoms of PTSD, such as disturbing thoughts and dreams. Preclinical studies suggested that THC can reduce signals of fear and threat as directed by the amygdala and that CBD can modulate emotional and social processes. Several small studies have been performed in people with PTSD, primarily among veterans. Unfortunately, most of these studies were poor quality, due to short follow-up, small sample size, and lack of a comparison group. Despite the lack of clinical data, self-management of PTSD with cannabis is common and PTSD is a commonly listed indication for certification.

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Antiemetic effects

Dronabinol, a synthetically produced delta-9-THC, was approved in the United States in 1986 as an antiemetic to be used in treating chemotherapy induced nausea and vomiting. Nabilone, a synthetic derivative of delta-9-THC, was first approved in Canada in 1982 and is now also available in the United States. Both dronabinol and nabilone have been approved by the FDA for the treatment of nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond to conventional antiemetic therapy.

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Numerous clinical trials have shown that dronabinol and nabilone are effective in the treatment of nausea and vomiting induced by chemotherapy.

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The National Comprehensive Cancer Network Guidelines recommend cannabinoids as breakthrough treatment for chemotherapy-related nausea and vomiting. The American Society for Clinical Oncology (ASCO) Antiemetic Guidelines recommends that the FDA-approved cannabinoids, dronabinol or nabilone, be used to treat the nausea and vomiting that is resistant to standard antiemetic therapies.

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Appetite Stimulation

Anorexia, early satiety, weight loss, and cachexia are problems experienced by many patients with terminal diseases. These patients are faced not only with the disfigurement associated with wasting but also with an inability to engage in the social interaction of meals. This makes any appetite stimulant very valuable to these patients.

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Several controlled trials demonstrated that oral THC has variable effects on appetite stimulation and weight loss in patients with advanced malignancies and HIV infection. Results have varied depending on the formulation and the type of study.

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• One study evaluated three different therapeutic approaches for appetite stimulation: the efficacy of dronabinol alone, dronabinol in combination with megestrol acetate and megestrol acetate alone for managing cancer-associated anorexia. The authors concluded that dronabinol did little to promote appetite or weight gain in advanced cancer patients compared with megestrol acetate. 

• A smaller, placebo-controlled trial of dronabinol in cancer patients demonstrated improved and enhanced chemosensory perception in the cannabinoid group—food tasted better, appetite increased, and the proportion of calories consumed as protein was greater than in the placebo recipients.

• Results remain conflicting and difficult to interpret. Studies have continued to show an increase in caloric intake, appetite stimulation, improved quality of life and yet the patients have failed to gain weight.

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Insomnia

Though insomnia is not a commonly listed indication for certification of medical cannabis, many patients self-manage insomnia with cannabis.

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Early research on cannabis and sleep shows that cannabis improves sleep onset and reduces the occurrences of awakening during sleep. Other research has found a reduction in rapid eye movement (REM) sleep with cannabis use. People enter REM sleep within the first 90 minutes of falling asleep and, as the sleep cycle repeats throughout the night, REM sleep occurs several times nightly. It accounts for approximately 20 to 25 percent of an adult’s sleep cycle, most dreams occur during REM sleep, and it is thought to play a role in learning, memory, and mood.

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Studies have raised concerns that cannabis used for sleep could lead to negative consequences. These concerns include developing tolerance to cannabis and thus increasing the dose of THC required in order to achieve the desired effect. Another concern is that sleep disturbances can develop when stopping cannabis use, therefore encouraging continued use of the drug.

Cannabis During Opiate Withdraw

According to a recent study, cannabis use may help relieve withdrawal symptoms during methadone treatment.  The study was designed to examine patterns of cannabis use prior to and during methadone maintenance treatment (MMT). Investigators examined cannabis-related effects on MMT, particularly during methadone stabilization. Retrospective chart analysis was used to examine outpatient records of patients undergoing MMT (n = 91), focusing specifically on past and present cannabis use and its association with opiate abstinence, methadone dose stabilization, and treatment compliance.  The current study showed that increased cannabis use was found to be associated with lower severity of withdrawal during MMT. These results suggest a potential role for cannabis in the reduction of withdrawal severity during methadone induction, however prospective studies will be required to verify these initial findings.

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This study suggests that cannabis may play a role in increasing the success of Methadone treatment by lowering the amount of withdrawal symptoms patients experience. The present findings may point to novel interventions to be employed during treatment for opiate dependence that specifically target cannabinoid-opioid system interactions.

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Dosage Forms

Dry Herb – Smoking Versus Vaping

Before we get to the dosing, we must first examine the difference between smoking and vaping. In recent years, vaporizing (vaping) has become very popular. Although research on vaping and its long-term health effects is ongoing, vaping is generally believed to be a safer and healthier alternative to smoking. As many people have already made the switch from cigarettes to vaping e-liquids, vaping is now also becoming popular among cannabis users. 

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The big difference between vaporizing and smoking is that vaporizing doesn’t burn your weed, but merely heats it to a certain temperature. The heat ultimately activates the cannabinoids and terpenes in cannabis, releasing them into a vapor that can then be inhaled.

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While the word is still out on whether vaping is really 100% safe, it is widely thought to be much safer than smoking. The reason for this is that almost all of the harmful substances that you get from smoking are produced by the combustion process, no matter if you’re burning weed or tobacco. As vaping doesn’t combust your weed, there is no smoke, and therefore far fewer toxins and free radicals.

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Tobacco smoke certainly contains high levels of carcinogens which is why it has amassed such infamy over the years. But unfortunately, it’s likely that the smoke from cannabis might also contain these compounds, albeit potentially in smaller amounts. Moreover, smoke is known to contain tar and cause issues in the lungs, making this method of cannabis intake extremely unsuitable for those with conditions related to lung health. In a study performed on marijuana smoking, the American Lung Association found that weed smoke may release even more tar into the body as compared to tobacco smoking. This primarily comes down to the fact that cannabis smokers normally inhale deeper and longer than cigarette smokers.

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The active compounds in cannabis are very sensitive. By administering cannabinoids, terpenes, etc. into the body via smoke, you burn off more than half of these compounds before you even take a full puff from the joint. You lose another 15–20% of the good stuff as the bud burns between draws. This makes smoking cannabis extremely inefficient.

Since the temperatures involved with vaporizing are much lower, and often much more specific, the active compounds are not only preserved, but utilized to their full potential. As a result, cannabis vapor will be purer and more potent—and the user will not be wasting as much of the bud. This also translates into cost savings for the user. 

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Vaping Increased Bioavailability

Since the cannabis vapor is purer and more potent as compared to smoking the bud there are special considerations for the user who is switching from smoking to vaping.

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The pharmacist can play a unique role in helping the patient determine the appropriate dose of the new vaping product. Patients who are switching to vaping from smoking should be counseled about the increased bioavailability that is likely and perhaps a need to reduce the dose.

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Customizing Your Vaping

More of the cannabinoids in your weed are released when you vape at higher temperatures, making for a more potent and faster-hitting effect.

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There are specific temperatures that coincide with the type of high the user desires. For a mellow high, set the vaporizer to a low temperature of about 150°C. For a somewhat stronger effect, adjust the temperature to a medium temperature of 166–187°C. For maximum potency out of the marijuana product, set the vape to the highest temperature setting. However, the user should be warned not to exceed 229°C since this is already near the combustion temperature, where the potency and flavor of the product will diminish.

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To get the most flavor or is the user prefers a very mild high, the user should be counselled to vape at lower temperatures. Refer to the next slide for a table that list the vaping temperatures with appropriate conversions for temperature reading in Celsius and Fahrenheit.

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Customizing Your Vaping Reference Table

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Dry Herb

The most common dose for smoking or vaping dried flowers (buds) is between 0.25–0.5 grams. A half gram of dry buds is a common amount found in most pre-rolled joints. Starting out with 0.25 grams of bud can be a good amount to gauge its potency and effects if the user is a beginner and naïve to the effects of marijuana. The dose can always be adjusted according to user preferences.

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Smoking or vaping dried buds has the advantage of near-immediate effects. Time to peak concentration is 5-10 minutes. For novice users, taking a couple of hits from a joint or two inhalations from a vaporizer may be all that’s needed to get sufficiently high. More experienced users may require more to achieve the same effect.

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Typical Dosage: 0.25–0.5g of dried bud

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Edibles

With most cannabis edibles, a single dose consists of 10mg of either THC or CBD. There are medicinal cannabis products that contain 100mg or more of THC, although these are normally for patients with severe medical conditions and are not meant as a single dose.

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When consuming edibles, it is important to remind the user that it can take some time for their body to metabolize to the active compound. This is a great counseling point for pharmacists to educate the users that the liver metabolizes the active drug into a potent psychoactive metabolite.  Edibles can take up to two hours before their effects start to be felt. It is very important to warn the user that because of this, it is not recommended to increase the dosage until a full two hours has passed. While it’s not possible to fatally overdose on cannabis, it can be very easy to overdo it with edibles and experience an unpleasant “trip”. Taking it slow is the way to go, for both novice and experienced users alike.

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Typical Dosage: 10mg of THC or CBD

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Hemp CBD Oil Extracts

A typical dose for an oral CBD extract made from hemp starts at 10mg, but this will vary depending on the naivety of the user and the condition being treated. Some health conditions may require a much higher dosage.

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CBD oil products available on the market today vary widely. They are available in various concentrations of CBD, and differ in regards to purity. Becoming familiar with the particular product and the recommended dosage individualized to each product is key to appropriate dosing. The pharmacist can aid the patient into understanding the unique characteristics of each product.

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CBD oils are well-suited for micro-dosing. The user can take 2.5–5mg of CBD with each dose, several times throughout an entire day.

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Typical Dosage: 10mg of CBD

Full Extract Cannabis Oil

Full-extract cannabis oils are sometimes used by patients with severe health conditions such as cancer or epilepsy. These highly concentrated cannabis oils are among the most potent forms of medicinal cannabis, with powerful effects even when taken in small doses.

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Many medicinal users take up to 1 gram of full-extract cannabis oil per day, divided into multiple doses. For a single dose, it is recommended to use one small droplet of concentrated oil. This can be repeated 3–4 times per day. The pharmacist should warn the user that one gram of concentrated full-extract cannabis oil is already a very high dose.

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Typical Dosage: Up to 1 gram, divided into multiple doses

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Topicals (Creams, Ointments, Sprays)

Cannabis exerts many of its medicinal effects by interfacing with the endocannabinoid system. This system has been found to exist within the skin, allowing cannabinoids such as THC and CBD to achieve anti-inflammatory, antibiotic, and analgesic effects on burns and wounds.

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Cannabis is now showing promise for the treatment of burns and wounds when applied topically. Cannabinoids exhibit anti-inflammatory properties, potentially assisting in the healing process and pain management of these conditions. Some cannabinoids have also been found to possess antibacterial properties, making them a potential first aid treatment when such injuries arise.

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Typical Dosage: Depends on product

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Transdermal Patch

Transdermal patches are available in varying strengths, with most of them ranging from 10–20mg of cannabinoids per patch.

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The transdermal patch option offer patients a variety of medicating advantages that other ingestion methods can’t provide, including:

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• Release of the active drug directly into the bloodstream.

• Quick absorption rate (the effect can normally be felt within 20 to 60 minutes).

• Slow-timed release method – Depending on the brand of cannabis transdermal patch, the effects can last for varying amounts of time. This can range for up to eight hours, while others deliver relief for as long as 96 hours. 

• A more benign way of administering cannabis medication that allows the user to apply a non-descript patch and go on with the activities of daily living and have the drug use go undetected while in public. This is not as easily achievable with other dosage forms.

• Bypasses the liver, preventing the production of THC metabolites that have a different pharmacology leading to a more predictable effect.

• No spike in THC, as with smoking or edibles, which can cause some of marijuana’s adverse side effects.

• Less euphoria is experienced due to the slower time release method of drug distribution.

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There are several different types of patches available with different ingredients included in each patch. The most common options are as follows:

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• THC Patches: Commonly used to treat appetite loss, pain and muscle spasms

• CBD Patches: Commonly used to treat inflammation, joint issues, muscle spasms, pain and anxiety

• THC-A Patches: Commonly used to treat pain relief without the THC-related high

• CBN Patches: Commonly used as a sleep aid

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Certain brands of patches include other soothing ingredients alongside cannabis medications, such as coconut, lidocaine, menthol and more.

Typical Dosage: 10–20mg of cannabinoids per patch

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What Is CBN?

Is CBN psychoactive?  

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There is currently no definitive answer to this question. Some research indicates that CBN is a non-psychoactive compound while still other research shows it might be a very mild psychoactive agent.  It does in fact appear to have very powerful sedative effects which may explain at least in part why it appears to have a very mild psychoactive profile.

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What indications have potential for CBN use?

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Insomnia- CBN has mainly been used as an agent to induce sleep. Research in mice has shown that CBN can prolong sleep time.  Some research indicates that the sedative effects of CBN are amplified when combined with THC. At this point in time there is still a lack of scientific research into the sleep-inducing properties of CBN.

Analgesic- Research indicates that CBN has analgesic capabilities in the body. CBN appears to influence the activity of neurons that are sensitive to capsaicin. 

A few CBN supplement products are available now, but this cannabinoid has yet to show up widely in supplement forms. There’s a lot more research to be done to understand how CBN affects the body, and ways it might be a safe, effective therapy for sleep problems and other health conditions. It is currently being investigated to treat osteoporosis, glaucoma, and as an anti-convulsant and appetite stimulant.

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BHO Cannabis Extracts (Dabbing, Vaping)

Dabbing is a form of combined vaporization and combustion where an extract from cannabis such as butane hash oil (BHO) is dropped onto the heated nail of a “dab rig” and inhaled.

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BHO and other cannabis extractions are very concentrated and extremely potent. They are typically available in 0.5 grams and full-gram quantities, but a single dose for dabbing is normally a mere fraction of that. A half-gram of BHO is normally good for about 20 dabs or servings.

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It is best to start out with a small dab about the size of a grain of rice. The pharmacist should counsel the patient that it may take several minutes until the full effect is felt.

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Typical Dosage: 25mg per dab

Micro-dosing

Micro-dosing cannabis is a new rising trend among medicinal cannabis consumers. When micro-dosing, the users takes minimal doses of THC, about 5–10mg per dose, once or several times throughout the day. The idea behind micro-dosing is that you take minimum effective dose of THC so that the desired effect can be felt, but the user can still function and go about their daily routine.

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Micro-dosing can be done with most forms of cannabis, although it is most common with oils since they are easier and more accurate to dose. However, micro-dosing is possible by means of smoking or vaping. To achieve this effect, it is recommended that the user just take a small puff or two each time. Micro-dosing is a great alternative consumption method for users with a low tolerance for THC.

Typical Dosage: 5-10 mg per dose several times per day

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Case

DJ decides to start using medical cannabis. She purchases two products that include 10-mg CBD tablets to be taken twice daily, and a vape pen that contains THC with 2-second inhalations as needed for pain. She experiences improvement in her chronic pain, but she also reports feeling somewhat dizzy and confused, particularly immediately after using vaped THC. Her family members say that she is more active and sleeping better but they have the following questions:

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Is DJ supposed to be drinking alcohol?

Is she at risk for lung disease due to vaping?

What is the risk of cannabis addiction?

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Is DJ supposed to be drinking alcohol?

The pharmacist should recommend that DJ avoid other sedating substances like alcohol while using the medical cannabis. The pharmacist also recommends that she reduce her THC consumption by using a vaped pen with a lower THC/CBD ratio.

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Is DJ at risk for lung disease? ​

To answer this question let’s take a look at the adverse effects of marijuana usage.

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Adverse Effects

Since legalization of medical cannabis, observational data have emerged describing cannabis-related adverse events.

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Because cannabinoid receptors, unlike opioid receptors, are not located in the brainstem areas controlling respiration, lethal overdoses from cannabinoids do not occur. However, cannabinoid receptors are present in other areas throughout the body, not just in the central nervous system and this leads to adverse effects which include tachycardia, hypotension, bronchodilation, muscle relaxation and gastrointestinal motility.

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Withdrawal symptoms such as irritability, insomnia, restlessness, hot flashes and sometimes nausea and cramping have been observed. However, these symptoms are mild compared with opiate or benzodiazepine withdraw and the symptoms are likely to dissipate after a few days.

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Pulmonary Adverse Effects

Chronic cannabis use can lead to symptoms of chronic bronchitis, including cough, sputum production and wheezing. Cannabis use may result in some changes to pulmonary function tests, but unlike tobacco, it does not seem to result in chronic obstructive pulmonary disease in observational studies.

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A longitudinal study evaluated repeated measurements of pulmonary function for a time period of over 20 years in 5,115 men and women whose smoking histories were known. While tobacco exposure was associated with decreased pulmonary function, the investigators concluded that occasional and low-cumulative cannabis use was not associated with adverse effects on pulmonary function. Similar studies need to be done in order to come to a definitive conclusion about the adverse effects of cannabis on pulmonary function.

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Other Adverse Effects

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Secondhand Smoke

People often ask about the possible psychoactive effect of exposure to secondhand marijuana smoke and whether a person who has inhaled secondhand marijuana smoke could fail a drug test.

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Researchers measured the amount of THC in the blood of people who did not smoke marijuana and had spent 3 hours in a well-ventilated space with people who were smoking marijuana. THC was present in the blood of the non-smoking participants, but the amount was well below the level needed to fail a drug test.

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Another study that varied the levels of ventilation and the potency of the marijuana found that some non-smoking participants exposed for an hour to high-THC marijuana (11.3% THC concentration) in an unventilated room showed positive urine assays in the hours directly following exposure. A follow-up study showed that non-smoking people in a confined space with people smoking high-THC marijuana reported mild subjective effects of the drug—a “contact high”—and displayed mild impairment on performance of motor tasks.

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So what is the answer? It depends on many factors including concentration of THC and ventilation to name a few.

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The known health risks of secondhand exposure of cigarette smoke to the heart or lungs raise questions about whether secondhand exposure to marijuana smoke poses similar health risks. At this point, very little research on this question has been conducted.

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A 2016 study in rats found that secondhand exposure to marijuana smoke affected a measure of blood vessel function as much as secondhand tobacco smoke, and the effects lasted longer. One minute of exposure to secondhand marijuana smoke impaired flow-mediated of the femoral artery that lasted for at least 90 minutes. The effects of marijuana smoke were independent of THC concentration, i.e., when THC was removed, the impairment was still present. This research has not yet been conducted with human subjects, but the toxins and tar levels known to be present in marijuana smoke raise concerns about exposure among vulnerable populations, such as children and people with asthma.

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Cure or Cause Cancer?

Highly concentrated THC or CBD oral extracts are being illegally promoted as a potential cancer cure. These oils have not been evaluated in any clinical trials for anti-cancer activity or safety. Another concern that needs to be monitored for is that CBD is a potential inhibitor of certain cytochrome P450 enzymes, highly concentrated CBD oils used concurrently with conventional chemotherapy regimens that are metabolized by these enzymes could potentially increase toxicity or decrease the effectiveness of these therapies. A number of studies have yielded conflicting evidence regarding the risks of various cancers associated with cannabis smoking:

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• A systematic review that included 19 studies evaluated premalignant or malignant lung lesions in persons 18 years or older who inhaled cannabis. The authors concluded that observational studies failed to demonstrate statistically significant associations between cannabis inhalation and lung cancer after adjusting for tobacco use.

• In a review of a published meta-analysis, the National Academies of Sciences, Engineering, and Medicine (NASEM) report concluded that there was moderate evidence of no statistical association between cannabis smoking and the incidence of lung cancer.

• Other studies have found similar results with other types of cancer including head, neck, and testicular cancer.

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Despite these few studies, more evidence is needed to determine if there is a link between marijuana use and the likelihood of developing cancer. To date there is no evidence that marijuana can actually cure cancer.

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Cannabis Use Disorder

All patients using medical cannabis should be screened for cannabis use disorder (CUD). CUD is defined as use leading to negative social, occupational, psychological and physical consequences.

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Providers should monitor for symptoms and recommend tapering off of cannabis if the user develops signs and symptoms associated with CUD. The Cannabis Use Disorder Identification Test (CUDIT) is a 10-item screening tool that is 73% sensitive and 95% specific. However, its length makes it difficult to use in a clinical setting. Modifications of the CUDIT, including the CUDIT-R and the CUDIT-Short Form, attempt to make more brief screening tools appropriate for busy clinical settings.

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The CUDIT-R is available on-line and free to use as long as appropriate citation has been used. It is an eight-item questionnaire intended for self-use and scoring. The item is designed to capture cannabis use/habits over the past six months. The form can be found at the following site:

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http://mycannabisiq.ca/wp-content/uploads/2018/07/2010_CUDIT-R-revised-with-scoring-EN.pdf

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This form may be administered in a clinical setting and may signal a further recommendation by the pharmacist for the patient to contact their physician or other health care provider.

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Case

The pharmacist recommended that DJ reduce her THC consumption by using a vaped pen with a lower THC/CBD ratio. With this changes, DJ reported back to the pharmacist a week later and noted her pain control improved and side effects seemed to be alleviated.

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Is DJ at risk for lung disease?

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You relay to her family that  cannabis may have some negative impact on her lung function tests and lead to symptoms of chronic bronchitis, including cough, sputum production and wheezing, but ​people who use cannabis as inhalants do not seem to go on to develop COPD. While more studies need to be done, inhaling cannabis does not appear to prove as dangerous to your lungs as compared to cigarette smoking. Although not entirely safe the benefits of its use need to be evaluated against the risks in each particular patient and their unique set of circumstances.

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What is the risk of cannabis addiction?

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It’s Not Just “Weed”

We are, indeed, in the midst of an opiate crisis. Heroin and painkillers are quickly addicting and become lethal fast. We can’t compare drugs and conclude that because we don’t see similar devastation with marijuana as we do with opiates, that it’s harmless. Complicating the comparison, some consumers are often thinking about marijuana from years ago. Things have changed however and  today’s marijuana is much more potent and is used in many other forms than merely “smoking a joint”.

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In the 1970s, the average THC content, was less than 1%. By the 1990s, it increased to 3 – 4%, and by 2014 it was nearly 12%. Today, in states with legal marijuana, THC levels are about 20 – 30% and range from 40 – 90% in newer forms of marijuana such as edibles and marijuana concentrates (etc. dabs, budder, wax, shatter). In some states, medical marijuana dispensaries have  a cap for the amount of THC that is allowed in any certain product and caps may differ depending on the specific dosage form.

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Increased potency has led to increased problems, including increased hospital and emergency room admissions and even higher rates of mental health problems. In addition, the steep increase in marijuana addiction treatment admissions has tracked very closely with the steep rise in potency. So in essence it’s not JUST WEED.

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Many people think that marijuana is not addictive. This could be because they know people who have used it for a long time who don’t seem to experience withdrawal when they stop using. Often people think of withdrawal as having the extreme signs such as tremors, hallucinating, or physical illness. Studies show the intensity of withdrawal symptoms varies across drugs and depends on how progressed the disease is. Marijuana’s half-life confuses the issue even more by creating a natural weaning effect when an individual stops using, thereby offsetting some of the withdrawal symptoms. Some THC metabolites have an elimination half-life of 20 hours whereas others are stored in body fat and have an elimination half-life of 10 to 13 days.

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When we take a look more closely at withdrawal symptoms, people trying to quit report irritability, sleeping difficulties, craving and anxiety. They also show increased aggression on psychological tests, peaking approximately one week after they last used the drug. These are the withdrawal symptoms we see in many other addictive drugs including nicotine and alcohol.

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The research is clear: marijuana is addictive. Lab studies and real-life experiences have long confirmed the addictive nature of marijuana that contains THC.

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Here are some basic numbers:

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• About 10% of users will go on to daily users

• Almost 7% – 10% of regular users become dependent

• Marijuana addiction rate is similar to alcohol and when use starts in adolescence the addiction rates are similar to cocaine use.

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Case Conclusion

What is the risk of cannabis addiction in DJ?

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Since DJ is taking a form of marijuana that contains both THC and CBD the information provided on the past few slides may apply to this patient. There is a potential for DJ to become addicted to marijuana. If DJ were using CBD alone the addiction question is less relevant.

Studying the connection of opiate deaths

Early research suggested that there may be a relationship between the availability of medical marijuana and opioid analgesic overdose mortality. In particular, a National Institute on Drug Abuse (NIDA) funded study published in 2014 found that from 1999 to 2010, states with medical cannabis laws experienced slower rates of increase in opioid analgesic overdose death rates compared to states without such laws.

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A 2019 analysis, also funded by NIDA, re-examined this relationship using data through 2017 (in other words the research was extended with an additional three years of data). Similar to the findings reported previously, this research team found that opioid overdose mortality rates between 1999-2010 in states allowing medical marijuana use were 21% lower than expected.

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When the analysis was extended through 2017, however, the researchers found that the trend reversed, such that states with medical cannabis laws experienced an overdose death rate 22.7% higher than expected. The investigators uncovered no evidence that either broader cannabis laws (those allowing recreational use) or more restrictive laws (those only permitting the use of marijuana with low THC concentrations) were associated with changes in opioid overdose mortality rates.

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Casual relationship?

Based on this study, the data did not support the interpretation that access to cannabis reduces opioid overdose. Indeed, the authors note that neither study provides evidence of a causal relationship between marijuana access and opioid overdose deaths. Rather, they suggest that the associations are likely due to factors the researchers did not measure, and they caution against drawing conclusions on an individual level from ecological (population-level) data.

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Buying On-Line CBD

A study published in the Journal of American Medicine in 2017 evaluated 84 CBD products that were available for purchase online, using high-performance liquid chromatography (HPLC). Only 30% of the evaluated products were accurately labeled in terms of CBD content, while 43% contained more CBD than indicated on the label and 26% contained less CBD than the label indicated. In addition, THC was detected in 18 of 84 products, which could not only lead to adverse effects, but could also lead to legal consequences depending on the quantity of THC, as products containing more than 0.3% THC are still illegal under federal law.

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The over labeling of CBD products in this study is similar in magnitude to levels that triggered warning letters to 14 businesses in 2015-2016 from the US Food and Drug Administration suggesting that there is a continued need for federal and state regulatory agencies to take steps to ensure label accuracy of these consumer products.

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Online products represent the most readily available source of marijuana to US consumers. Additional monitoring should be conducted to determine changes in this marketplace over time and to compare internet products with those sold in dispensaries. These findings highlight the need for manufacturing and testing standards, and oversight of medicinal cannabis products. In addition, a pharmacist must be certain to know where the cannabis products are being sourced when they are counseling their patients.

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DEA and Legal Issues

The legality surrounding marijuana can be confusing for both the users and the health care professional. While still a schedule 1 substance at the federal level, a number of marijuana products are legal at the state level. How does one interpret these conflicting policies? The current position of the Drug Enforcement Administration (DEA) is that it has enforcement priorities for marijuana, including:

• Preventing distribution to minors

• Preventing revenue from the sale of marijuana from going to criminal enterprises

• Preventing diversion from states where it is legal under state law to those states where it is not legal

• Preventing state-authorized marijuana activity from being used as a pretext for trafficking other illegal drugs or other illegal activity

• Preventing violence and the use of firearms in the cultivation and distribution of marijuana

• Preventing drugged driving and the exacerbation of other adverse public health effects

• Preventing the growth of marijuana on public lands

• Preventing possession or use of marijuana on federal property

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The DEA and the Pharmacist

Conflicting federal and state law creates a scenario in which pharmacists can be acting lawfully under state law while simultaneously being at risk of federal prosecution.

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Currently, the DEA will not take any action in states that have legalized marijuana if the states agree to help with the enforcement priorities listed on the previous slide. Therefore, individuals who possess marijuana for personal use on private property in states who have legalized marijuana will not face DEA prosecution at this time. Because a pharmacist does not possess it for personal use if they are encountering it as part of their daily practice to facilitate safe and appropriate use in patients, in the opinion of some attorneys, a pharmacist dispensing marijuana is not covered by this exception. 

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For this reason, pharmacists have been reluctant to be involved with medical marijuana. Federal prosecution could result in severe consequences such as fines and imprisonment. Another concern is that the pharmacy could lose its DEA registration, leading to the inability to dispense controlled substances.

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It is clear that, a pharmacist must be well versed in the laws of the state where they practice and keep up to date on the changing marketplace where medical marijuana is prescribed and dispensed. Pharmacists must also be diligent in making sure their dispensing of marijuana does not violate any of the DEA enforcement priorities. Being well-versed and currently up to date on the legal aspects of the law and abiding by the DEA priorities should provide protection to the pharmacist who has the patient’s safety and well-being as top priority in relation to marijuana use.

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Who Can Prescribe Medical Marijuana?

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Instead of a prescription like other types of medicine, for medical marijuana, physicians write recommendations to the state asserting that a patient will benefit from cannabis. Provided the patient’s ailment is on the list of qualifying conditions that can be legally treated with cannabis, any licensed physician in a state where medical marijuana is legal can write a recommendation for a patient.

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Though some physicians may choose to focus on cannabis in their practice, any normal doctor can prescribe (recommend) medical marijuana in states where it is legal. To be eligible to make recommendations for medical marijuana, physicians must meet certain state guidelines. These guidelines vary according to state policies and procedures.

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The list of qualifying conditions varies from state to state. Due diligence should be used to check what conditions qualify for medical cannabis if a patient is desiring a recommendation for medical marijuana use. A pharmacist may be involved in helping a patient determine if they are eligible and meet the criteria outlined by the state to receive a marijuana recommendation from a physician. The list of eligible conditions for access to medical marijuana varies from state to state. Many conditions, such as cancer, glaucoma, HIV/AIDS, neuropathic pain, arthritis and other severe and debilitating or terminal illnesses qualify in most states.

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Requirement for Physicians

All states require:

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• A physician in good standing with a valid medical license in the state they practice.

• Physician must be a M.D. or D.O. (Medical Doctor or Doctor of Osteopathic Medicine).

• Physician must register with the state in which they intend to recommend medical cannabis.

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Beyond that, some states have further requirements before the physician can recommend medicinal marijuana.  Some states require specific continuing education programs and others may require a DEA controlled substance registration.

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There are several resources when it comes to searching for a doctor to recommend medical cannabis. Some states have a public registry of doctors who are authorized to recommend medical marijuana that will help a patient identify what physician would be eligible to write a recommendation for medical marijuana.

Getting the Recommendation

Assuming the patient lives in a state where medical marijuana is legal, finding what kind of doctor can recommend medical marijuana should not prove to be problematic.  Some states allow video consultations with a physician in order to receive a certificate of recommendation, while most other states require an in-person visit to a doctor’s office.

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For patients under 18, some states require a recommendation from two or more doctors, before the minor can be issued medical marijuana.

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Once the patient receives a recommendation, he or she or an of-age caregiver can purchase marijuana, possess it, consume it and, in some states, even grow it themselves.

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Could you go to an urgent care center and receive a recommendation from one of the attending physicians for medical marijuana? Or if you find yourself in the emergency room, would the doctor there recommend medical cannabis? Emergency room physicians or those in urgent care settings should not be prescribing medical marijuana. Due to the highly transient nature of medical visits in hospital emergency rooms and urgent care centers, these sites have adopted strict rules involving the administering and prescribing of any medication with a history of abuse.

After the patient receives the recommendation, and the state approves the submission, the patient will receive a medical marijuana card in states that require them.

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The next step is for the patient to find a dispensary where the medical marijuana can be obtained. Once this is done the patient will need to bring either the certified physician’s recommendation or their medical marijuana card, or both depending on the state, and a current driver’s license or another form of picture ID.

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When arriving at a dispensary, the patient must show the required items as dictated by that state. Patients who are there for the first time are asked to fill out a membership registration form and will be given an overview of the dispensary policies, hours, and guidelines. At this point, the patient will most likely be offered a menu that lists dispensary offerings and pricing.  A staff member will advise with recommendations regarding strains, dosages, and products best suited for the patient’s specific needs. This role is best suited by a health care professional, especially a pharmacist.

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Some dispensaries allow on-site consumption and will provide supplies such as marijuana vaporizers to allow the patient to ingest the product in a safe controlled environment. This may be beneficial for a first-time user. 

When do Physicians Recommend Medical Marijuana?

Physicians should carefully evaluate the risks involved before recommending marijuana use. The following suggestions may provide some guidance to physicians who may consider recommending marijuana to their patients yet wish to minimize their malpractice risk.  Physicians should remember that marijuana remains a schedule I drug, that it has not been approved as safe and efficacious by the Food and Drug Administration, and that the use of marijuana by patients holds inherent risk. Therefore, physicians should be very careful, as well as pharmacists, before recommending medical marijuana to a patient.

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Read the following and before recommending marijuana to a patient, consider these questions carefully:

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• Is there documentation that the patient has had failure of all other conventional medications to treat his or her ailment?

• Has the patient been counseled (documented by the patient’s signed informed consent) regarding the medical risks of the use of marijuana—at a minimum to include infection, pulmonary complications, suppression of immunity, impairment of driving skills and habituation?

• Has the patient misused marijuana or other psychoactive and addictive drugs?

• Is periodic drug testing provided to patients who have been prescribed marijuana, and have patients been excluded from being prescribed marijuana who are found to be using other illicit drugs? Who does the drug testing and by what means?

Recommendations continued:

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• Has there been a careful review of the patient’s entire medical history and considerations taken for how long the patient is to use the drug?

• Are patients carefully examined and consistently followed up on if using smoked marijuana as a medical treatment, including pulmonary function testing, evaluation of immune status, and the presence of any super added infection?

• Has due care been exercised in assuring the standardization of the potency and content of the marijuana to be considered for medicinal use and whether it is free of microbial contaminants?

• Because marijuana is a federally controlled substance, has a system been established in the state to track all patients and their source of marijuana, as with other controlled substances?

• What are the licensure requirements in the state in which you practice in order to recommend marijuana?

• Have you shown knowledge, training, or certification in addiction medicine?

• Do you have demonstrable knowledge of the physiologic effects of marijuana, its side effects, and its interaction with other drugs before prescribing it?

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How to Dose Cannabis

The various forms in which cannabis is available (and the many possible ways to consume it) make dosing a bit of a challenge. Finding the right dose of medicinal or recreational cannabis isn’t always easy. Cannabis strains can vary greatly when it comes to cannabinoid and terpene profile, which can make one strain much more potent than another. Furthermore, there are so many methods of consumption, such as smoking dry buds or administering cannabis in the form of oils, topical creams, or edibles which all have differing effective doses and specific pharmacokinetic profiles making it difficult to standardize marijuana doses.

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Yet another factor when it comes to dosing cannabis is that not everyone has the same tolerance. While a seasoned cannabis user may be better able to handle a high dose, the same dosage may be too much for someone else. Starting low and going slow is the key to dose those users who are naïve to the effects of marijuana. Also, drug interactions must be taken into account and this is where the pharmacist can be a key player.

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Case 2

MB is a 54 year old female who is interested in obtaining CBD in a form that she can vaporize. She asks for your opinion on whether or not she should begin to use the CBD to help relieve her anxiety and to help her sleep at night. You note the following on her medication profile:

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• Alprazolam 0.5 mg BID PRN

• Amlodipine 10 mg QD

• Ibuprofen 800 mg TID PRN

• Zolpidem 5 mg QHS

Which of the medications is of concern when looking at potential drug interactions with CBD?

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Benzodiazepines and cannabinoids can both produce sedative effects increasing the likelihood for added patient drowsiness.

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Zolpidem and cannabinoids can both produce sedative effects increasing the likelihood for added patient drowsiness.

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CBD has a potential interaction with Ibuprofen leading to an increase in bleeding risk. Patients should be warned to monitor for signs and symptoms of bleeding or use acetaminophen for pain relief. Both THC and CBD may slow down the metabolism of these drugs. Drugs with this known interaction include the non-steroidal anti-inflammatory drugs, warfarin, and heparin.

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Case 3

One of your friends tells you she has just started micro-dosing with THC. She does not take any medications except a multiple vitamin and an over-the-counter calcium product. She tells you that tonight she is going out to dinner with friends and she wants to order a few glasses of wine. She wants to know if this will be a problem with her THC. What do you tell her?

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Studies have provided compelling evidence that alcohol increases blood THC levels. Alcohol and cannabis together pose even greater dangers driving than when using either one independently. Second, if someone has had too much to drink–to the point they need to vomit to expel the toxins–know that cannabis inhibits nausea and vomiting. By preventing vomiting, there is an even greater risk of suffering from alcohol toxicity.

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Case 4

Which of the following would raise concern if a pharmacist saw the drug on a patient profile and knew the patient was using medical marijuana (CBD)?

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• Warfarin

• Docetaxel

• Sertraline

• Clonazepam

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Answer: All of the above should raise a red flag for the pharmacist. THC and cannabinol (CBN) also inhibit CYP activity, but CBD, of all the plant cannabinoids studied, is the strongest cytochrome P450 competitive inhibitor.

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CYP 450 Drug Interaction

CBD and other plant cannabinoids can potentially interact with many medications by inhibiting the activity of cytochrome P450. When ingested orally, THC is absorbed in the small intestine and then carried to the liver, where it is metabolized by subclasses of CYP 450, specifically the CYP2C and CYP3A enzymes. These liver enzymes also metabolize CBD, converting it into 7-OH-CBD and 6-OH-CBD. There has been relatively little research into the properties of these CBD metabolites.

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The extent to which CBD behaves as a competitive inhibitor of cytochrome P450 depends on how tightly CBD binds to the active site of the metabolic enzyme before and after oxidation. This can change greatly, depending on how—and how much—CBD is administered, the unique attributes of the individual taking this medication, and whether isolated CBD or a whole plant remedy is used. If the dosage of CBD is low enough, it will have no noticeable effect on CYP activity. There is no clearly established cut-off dose, below which CBD does not interact with other drugs. 

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CBD, functioning as a competitive inhibitor of cytochrome P450, slows down the conversion of THC into its more potent metabolite, 11-OH-THC. Consequently, THC remains active for a longer duration, but the peak of the extended buzz is blunted somewhat under the influence of CBD.

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Common Drugs of Concern

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Detection of Marijuana

The very legitimate question of how long marijuana stays in your system may be asked to a pharmacist while counseling a patient. The pharmacist needs to have reliable information to provide to the patient in order to best answer this question.

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The effects of marijuana fade quickly, but the drug can be detected in the body for weeks and sometimes longer. The amount of time the active ingredients and breakdown products of marijuana remain in the system can range from a few hours to 90 days, depending on how often or how much marijuana the person has been using.

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The urine test most commonly used tests for the metabolites of THC. Just to review, recall that some THC metabolites have an elimination half-life of 20 hours whereas others are stored in body fat and have an elimination half-life of 10 to 13 days. It takes five to six half-lives for a substance to be almost entirely eliminated. This is why you see advice that a one-time use is probably not detectable after five to eight days.

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Sites for Detection of Marijuana

Blood and Saliva

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Because marijuana stays in the bloodstream for only a short time, blood tests for marijuana are usually not used. The exceptions are in the case of automobile accidents and some roadside sobriety checkpoints. Blood or saliva tests can show current intoxication. However, unlike blood alcohol concentration tests, they do not indicate a level of intoxication or impairment.

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Hair

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Daily or near-daily cannabis consumption is likely, but not always, detectable by a hair test up to three months later. However, the hair test is not reliably able to detect infrequent cannabis use or determine the amount of cannabis used.

Urine

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Urine tests for marijuana metabolites also only show recent marijuana use, not current intoxication, or impairment. This is because there is a time delay between use and the breaking down of THC to the metabolites that are eliminated in the urine. Because many employers have a zero-tolerance for drug use, most workplaces will use urine tests to detect recent use of drugs.

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False Positive Tests for Marijuana

In most cases, workplace testing for marijuana might entail first screening the sample with an immunoassay test, known as the EMIT or RIA. If positive results are returned, the sample is again screened with a gas chromatograph-mass spectrometer (GCMS), which is much more accurate and therefore false positives are quite rare.

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At one time, ibuprofen was known to cause false marijuana positives. But today’s tests have been adjusted to eliminate that problem. No known substances will cause a marijuana urine test to return a false positive.

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Roadside blood tests have been known to show some false positives in people who have been legally consuming cannabis but were not actively intoxicated at the time of the test. This may be the case in a state where legal consumption of cannabis is permitted, and the patient has past use which is detected but at the current time is not legally intoxicated. While not technically considered a false positive the user may have legally acquired and taken the drug and is legally responsible and sober at the time of the blood test making this a very complicated scenario for law enforcement officers to sort out.

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Factors That Will Influence Detection Time

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The length of time marijuana remains in your body depends on many different factors, including frequency of use, body mass, metabolism, gender and hydration levels.

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Frequency of Use

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There is some evidence that the length of time that marijuana remains in the body is affected by how often the person uses marijuana, how much they use, and how long they have been using. People who use marijuana regularly have reported positive drug test results after 45 days since last use, and people who use more heavily have reported positive tests up to 90 days after the last use.

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In a 2017 study of 136 people who use cannabis subjected to hair tests, the presence of five cannabinoids, THC, THC-OH, THC-COOH, cannabinol and cannabidiol, were present in 77% of the heavy users and 39% of the light users.

Gender

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Women often metabolize THC at a slightly slower rate since they tend to have higher levels of body fat than their male counterparts. What this translates to is that since the female gender has more body fat overall there are more opportunities for the storage of THC and therefore will be detectable for a longer amount of time on a drug test as compared to a male with a lower percentage of body fat.

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Metabolism

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The faster your metabolism, which can be impacted by age, physical activity, and certain health conditions, the faster marijuana will exit your body and be undetectable on a drug test. 

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Body Mass Index (BMI)

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THC metabolites are often stored in the fat cells in your body, so the higher your body fat (or BMI), the slower you’ll likely be able to metabolize and excrete marijuana.

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Hydration

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When you’re dehydrated, you’ll have higher concentrations of THC in the body. Flooding yourself with water won’t make you pass a drug test. It will however, dilute the urine but the user will still test positive for the drug but in a ratio of a lesser quantity.

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Method of Consumption

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The method of use also impacts the detection time. If marijuana is smoked or vaped, the THC levels in the body will drop faster as compared to the oral route of consumption. Edibles take longer to break down in the body due to the slower metabolic process and therefore will remain detectable in your system for a much longer time as compared to vaping or smoking.

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Can You Beat A Drug Test?

While one who has short notice of a random drug test might wish this answer to be YES, there is no proven way to beat a drug test. If a user is required to take a urine test on short notice for employment or other purposes and has recently smoked marijuana, they are probably going to fail the test. This is particularly true if the usage pattern is regular or heavy. The only completely reliable way of passing the test is to stop smoking or ingesting marijuana or cannabis products.

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Although you will see many tips on how to beat a marijuana drug test, most have proven to be urban legends. Some of these questionable techniques will be discussed on the following slides. Please note all of these recommendations have been taken from unreliable internet sources with no scientific proof for their recommendation. However, a pharmacist needs to be aware what their patients may be trying (or reading about) in order to pass a drug test and how to educate them as to why these methods are unreliable.

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Note: You can be fired for failing a drug test even in states where the recreational use of marijuana has been legalized.

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Urban Legends

Washing Your System Out

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This method entails drinking a lot of water or liquids and urinating several times before the test. A user will then take vitamin B-12 to add color back to the urine. Although this may lower the percentage of THC found in the urine by diluting it, it will not totally eliminate THC metabolites and will therefore still be detectable on a drug test.

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Exercising

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Some people will also try to exercise before the test. This may backfire, depending on the test, as it can release stored THC from fat into the blood. Some sites will tell the user to exercise to lose fat this in turn will eliminate possible storage sites from the body where THC can accumulate and show up on a drug test.

Tampering with the Test

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This involves adding something to the urine to contaminate the sample. There are tales of adding Visine, bleach, salt, or detergent to the urine sample, but these items are easily detected by a lab. Several commercial products are sold as urine test adulterants, but none are 100% foolproof. All of them can be detected by the laboratory if a separate test is run for them. No additive is 100% reliable, and all involve a substantial risk of detection. Many drug testing companies claim to test for adulterants, though it isn’t clear how carefully they are performing tests and what adulterants they are testing for.

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Using Drug Screening Agents

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Some companies sell various substances and herbal teas that are allegedly capable of “cleaning” the body’s system of traces of marijuana. There is little evidence that any of them actually work. The catch is that most of them have to be used over an extended period of time, during which the body will naturally eliminate THC anyway. Products range from shampoos, powdered urine kits, and supplement kits that the consumer takes for a required number of days. These supplement kits contain detox agents in tablet and liquid form and also additional dietary fiber to add to the diet.

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Drink Alcohol

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It has been advised that drinking alcohol is a way to quicken the detox process, as it penetrates the fat tissue where the THC is stored. This has never been proven true and certainly is not reliable.

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Consume Creatine

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Creatine is an organic substance found in the muscle tissue that is synthesized in the liver and kidneys. It increases the body’s ability to produce energy rapidly, and it has been postulated to make the detox process faster. Internet sites will recommend taking it in powder or capsule form and to take one serving per day to help the elimination of marijuana from the body.

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Drink Vinegar

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The acidic properties of vinegar have been postulated to help boost the digestive system and eliminate toxins like THC. Internet sites will recommend small quantities for only a few days because consuming large quantities can impact your pH levels and create a very dangerous situation. The user may be told to mix it with lemon juice in order to make the overwhelming smell and taste more palatable.

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Drink Cranberry Juice

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Cranberry juice has been postulated to help remove toxins from the body. For an immediate effect the user will be told to drink two large glasses each day in order to speed up the process. This method is recommended as an add on method to another more “reliable” method.

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Drink Green Tea

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Green tea is famous for its properties that help remove unwanted chemicals from the body. The components of green tea claim to aid the liver in becoming more efficient at clearing toxins from the body (hence its use as an antioxidant) thus postulating the efficient and effective removal of THC from the body.

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Sauna

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Sweating is another way the body removes toxins. Going to the sauna and increasing the sweating process has been suggested as a method to remove THC from the body. This method is suggested as an add on method to other more “reliable” methods.

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Other Herbal Supplements

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Some herbal supplements are advertised as having the ability to enhance the detoxification process. This includes such supplements as psyllium seeds, milk thistle and cayenne.

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Niacin

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Some sites advertise that supplementing with niacin will help flush the body of toxins. Niacin, or vitamin B3, has been promoted to speed up the metabolic process and hence quicken the elimination of THC by the liver. Of note to the pharmacist, warn patients that niacin has some significant side effects such as flushing, itching, rash and can be harmful to the liver if used in large quantities.

Mid-Stream Urine Sample

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Users may be advised not to give the sample from the beginning or end of the urine stream. It is postulated that there will be fewer THC metabolites mid-stream. Also, sites will recommend giving a sample later in the day as opposed to first thing in the morning. 

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Diuretic Use

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Taking a diuretic certainly can increase urine output and thus dilute the urine. Sites will recommend weak diuretics such as coffee, cranberry juice and perhaps even over-the-counter pills used for pre-menstrual water retention.

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On a more dangerous note, a user may be advised to try a more potent diuretic if the drug test happens to be on very short notice. These would include the prescription diuretics used for legitimate medical indications in a medical environment. In this case however, the user who would need to obtain the prescription product for a “non-legitimate” medical indication and may be told they can purchase such medications in Mexico or other foreign countries through the internet. Of course, diuretics can be detected in urine, but are rarely checked except in athletes who may be abusing the drugs to enhance athletic performance.

Foolproof Method

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Do not consume marijuana products if you know you have a drug test or if you have already used such products the old fail proof method of time seems to be the best advice to passing a drug test. Give your body time to eliminate the metabolites of THC from the system naturally.

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A Case of a False Accusation

JP is a 26-year-old chef living in San Diego, California and was shocked when a drug test he took as part of a job application came back positive for marijuana. The problem? JP was certain he had not used marijuana but instead he had taken CBD from hemp to help with sleep and anxiety. Due to his irregular schedule of late nights working as a chef, he has trouble formulating a regular sleeping pattern and he often relies on the hemp derived CBD oil to help him sleep. He was told that the CBD would not show up on drug tests because it was not THC. He comes to your dispensary and asks you how this could possibly happen to him?

“I thought I was in the clear,” JP says. “From everything that I had heard, CBD oil wasn’t supposed to show up on drug tests.” How do you start the conversation with JP?

CBD on Drug Tests

So how can you fail a drug test after taking CBD? The urine test most commonly used doesn’t even look for CBD but instead a compound created by the body when it metabolizes THC. There likely isn’t going to be a laboratory analytical false positive confusing CBD with a THC metabolite. So what is the explanation?

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There are a number of different possibilities to explain what happened. CBD products could have more THC than the label claims. CBD products from hemp sold in retail stores and online aren’t supposed to contain more than 0.3 percent THC but it is possible that the products are not standardized, and the labels are incorrect. Recall we previously discussed a study published in the Journal of American Medicine in 2017 that evaluated 84 CBD products that were available for purchase online, using high-performance liquid chromatography (HPLC). Only 30% of the evaluated products were accurately labeled in terms of CBD content, while 43% contained more CBD than indicated on the label and 26% contained less CBD than the label indicated. In addition, THC was detected in 18 of 84 products. THC levels were possibly high enough in the product JP used to cause him to fail the drug test.

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It’s also possible that over time, the small amounts of THC allowed in CBD products (less than 0.3%) would have built up in JP’s system to detectable levels. It would depend upon how long, how often and at what dose JP was using the CBD oil. All of these factors may have led to him not passing his drug test.

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What do you tell JP about future use of CBD products?

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To increase the likelihood that a product doesn’t have more THC than claimed, look for a manufacturer that can provide a Certificate of Analysis, or COA, for its product. That document shows the results of a company’s testing for THC, CBD and various contaminants. Though that testing is voluntary in most states and the results aren’t confirmed by independent experts, for now it’s the best information available. If a store or website can’t provide JP with a COA, advise him to look for another product. 

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Consider products that are claimed to have CBD only and have COAs showing that they contain zero THC. Also, JP could try tracking his own THC levels with an at-home drug test. If he tested positive but needed to be THC-free, it would be advisable for JP to take at least a month break from the product to clear THC from his system. Unfortunately, this will not help JP if he had a random drug test which did not give him ample time to prepare to flush his system.

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What can you advise JP to do now that he failed the drug test?

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Advise JP to talk to his employer. Suggest he take the documentation from his doctor that shows he was taking CBD to treat anxiety and insomnia. He may even take the actual product in for his employer to see. This should bear the ingredients on the label and help to show that JP did not intentionally take a product with an illegal amount of THC.

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Conclusion

Medical marijuana is a real drug with real side effects. It deserves the same close attention that every other legitimate drug requires. Pharmacists have the skills, training, experience and education to help patients manage marijuana use.

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Many aspects of dispensing medical marijuana are still unclear, but the push for pharmacists to take part is happening. Colleges of pharmacy are creating courses and sponsoring lectures on medical marijuana and national organizations are preparing for the increasing and necessary role of the pharmacist in the medical marijuana industry.

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Active Learning Activity 1

The following website is the resource for The Cannabis Use Disorder Identification Test – Revised (CUDIT-R) that was discussed in earlier slides:

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http://mycannabisiq.ca/wp-content/uploads/2018/07/2010_CUDIT-R-revised-with-scoring-EN.pdf

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A patient is first asked to answer yes or no to the following question, “Have you used any cannabis over the past six months?”

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Your patient answers yes and goes on to take the test. Practice what you would do with an individual who scores a total of 8 and how is that different from the approach you would take with a patient who scores a total of 12. What exact conversation would you have with the patient? Would you notify their primary healthcare provider? Would you notify the physician who recommended the medical marijuana?

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Active Learning Activity 2

As marijuana’s reputation continues to shift from the persona of an illicit drug to a therapeutic drug, pharmacists need to comprehend as much as they can on how to advise patients on its medicinal use. The Cannabis Training Institute (CTI) offers resources for the pharmacist and the pharmacy technician to stay up-to-date.  The CTI offers 3 tracks to successful management of medical marijuana at any point in the process a pharmacist wishes to be involved. Whether applying best business practices, licensing requirements and legislative issues, or delivering customer service the extensive course catalog and offerings will help educate both the pharmacist and the pharmacy technician.

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To apply for courses  clink on the following link: https://cannabistraininginstitute.com/course-catalog/

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Get More Information

More information about marijuana is also available through the following websites:

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• Substance Abuse and Mental Health Services Administration: samhsa.gov

• Drug Enforcement Administration: dea.gov

• Monitoring the Future: monitoringthefuture.org/

• Partnership for Drug-Free Kids: drugfree.org/drug-guide

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References

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• Scavone JL, Sterling RC, Weinstein SP, Van Bockstaele EJ. Impact of cannabis use during stabilization on methadone maintenance treatment. Am J Addict. 2013 Jul-Aug;22(4):344-51. doi: 10.1111/j.1521-0391.2013.12044.x

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