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Medical Marijuana
1. Medical Marijuana
Taha Y. Taha
PharmD/PhD Candidate
UIC College of Pharmacy
Drug Information Rotation
2. Objectives
Discuss the background of medical marijuana
Assess the efficacy and safety of medical marijuana
Explain the legal implications of medical marijuana
3. What is Marijuana?
Dried leaves of the Cannabis sativa plant.
Other species also used for psychoactive properties, such as C. afghanica
or C. indica to make hashish.
Has been used for centuries medicinally and recreationally.
First described as a medicine in Chinese medical references dating to
2373 B.C.
Initially classified as a legitimate medical compound by the U.S.
Pharmacopeia (USP) in 1851, but was criminalized (taxed) by the
“Marihuana Tax Act of 1937” and later removed from USP in 1942.
Currently listed by the Drug Enforcement Administration (DEA) as a
schedule I controlled substance
6. National Institute of Drug Abuse
(NIDA) strains THC content widely
variable (0.001-13%) and none of the
strains are considered to have high
CBD content.
7. Pharmacokinetics
Cannabinoids are highly lipophilic.
Rapidly absorbed into the blood from inhaled marijuana smoke, with plasma levels
becoming detectable within seconds and peak plasma levels noted in fewer than 10
minutes.
Bioavailability from smoking marijuana varies based on depth of inhalation, puff, and
breath-holding duration.
Smoking marijuana through a pipe instead of a cigarette can result in higher
cannabinoid absorption because this results in less side stream smoke.
Slow and erratic absorption orally resulting in irregular plasma levels, and reaching
peak concentrations in 1-2 hours. Cannabinoids are acid-labile and degraded in the
stomach thereby significantly reducing absorption. They also exhibit extensive first-
pass effect.
Crosses placenta and found in breast milk.
8. Social View and Demographics
Characterizing the followers and tweets
of a marijuana-focused Twitter handle.
9.
10.
11. Impact of Legalization – Colorado
November 2000: legalization of medical marijuana.
October 2009: the US Department of Justice issued a directive that it
would not pursue federal prosecution against people who comply
with state laws
After this announcement, applications to Colorado’s medical
marijuana registry increased from 300 per month to 1000 per day.
Colorado now leads the nation in per-capita medical marijuana
registrants.
Colorado physicians have recommended marijuana for an estimated
163,856 patients, more than 2% of Colorado’s population.
12. Medical Use
Potential benefits in stimulating
appetite (especially in AIDS),
chemotherapy-induced nausea and
vomiting (CINV), severe pain, some
forms of spasticity, and glaucoma.
Importance of focusing research
efforts on the therapeutic potential of
synthetic or pharmaceutically pure
cannabinoids.
13. Pharmaceutical Products in the U.S.
Dronabinol (synthetic trans isomer of THC dissolved in sesame oil
contained within a gelatin capsule). FDA-approved for CINV
anorexia associated with weight loss in AIDS patients.
Nabilone, is a synthetic cannabinoid that
mimics the action of THC. It is FDA-
approved for CINV.
14. Other Pharmaceutical Products
Nabiximols is a whole-plant extract of marijuana, and contains THC
and CBD in a 1.08:1.00 ratio. Available as a buccal spray.
Currently in clinical trials (148 studies recruiting) for the treatment of
pain, and is approved for use in Canada and parts of Europe for the
treatment of spasticity from multiple sclerosis.
A liquid containing CBD without THC will also soon become
available in the U.S. through a clinical trial to treat rare forms of
childhood epilepsy (Lennox-Gastaut syndrome and Dravet
syndrome). A phase 2 clinical trial of this drug in patients with
schizophrenia is also currently ongoing.
15. Evidence for Medical Use – N&V
Marijuana:
Crossover studies with fairly small sample size (n<200).
Mainly smoked marijuana vs. oral THC or placebo.
Mixed results.
Bias due to smell and smoke compared to oral form. The variability in smoking
patterns.
Pharmaceutical products:
Dronabinol: superior in treating N&V but increased side effects such as
drowsiness, dizziness, hypotension, lightheadedness, euphoria, and
hallucinations.
Nabiximols: effective for delayed emesis but not for acute emesis after
chemotherapy
Nabilone found to be as effective as N&V medications but with increased side
effects
16. Evidence for Medical Use – Pain
Marijuana:
RCT’s in which vaporized or smoked marijuana was compared to placebo.
Small sample size (<50).
Mixed results but mainly favoring marijuana.
Bias of smell and smoke compared to oral form. Placebo effect.
Pharmaceutical products:
Nabiximols: better than oral THC for pain, but was not effective for
neuropathic pain. One study showed efficacy in RA
Dronabinol: effective for chronic cancer pain.
Nabilone: not effective for neuropathic pain, but was effective for headache
from medication overuse
17. Evidence for Medical Use – Appetite &
Weight Loss
Marijuana:
mostly cross over studies in healthy and HIV patients.
compared smoked marijuana to oral THC or placebo.
showed benefit in increasing caloric intake.
Pharmaceutical product:
Dronabinol: was shown to have similar effect as smoked
marijuana for patients with Alzheimer’s
18. Evidence for Medical Use – Cancer
Some very limited studies in vitro and in vivo suggesting
antineoplastic effect.
Contradictory to the fact that marijuana can cause cancer itself.
Most of the studies that have looked for a link between marijuana
smoking and cancer have been case-control studies in which
individuals with cancer were compared with those without the
disease. In these studies, tobacco smoking was found to be an
important confounder.
22. Safety
Effects of Short-term Use Effects of Long-term Use
Impaired short-term memory Addiction (9% of users)
Impaired motor coordination Altered brain development
Impaired judgment Lower IQ (esp. in adolescents)
Paranoia Symptoms of chronic bronchitis
Psychosis Increased risk of schizophrenia
23. Safety
Twins who used cannabis by age 17 had
odds of other drug use, alcohol
dependence and drug abuse/dependence
that were 2.1 to 5.2 times higher than
those of their co-twins, who did not use
cannabis before age 17.
25. Remaining Challenges
Method of delivery (e.g., smoked, vaporized, oral) and patient individuality (e.g., severity of
condition, inhalation and exhalation habits, functional lung capacity, gastrointestinal
absorption) cause great variability in the effect of medical cannabis.
The lack of quality control (e.g., contaminated products, non-standardized doses) makes it
difficult for clinicians to recommend particular formulations. Other concerns about medical
cannabis include the need for adequate monitoring and prevention of addiction.
Close surveillance of patients will ensure appropriate use of these medications, and training
and education should be made available to providers whose patients use cannabis.
Unfortunately, surveillance, training, and education are not available in most health systems,
which often delimit the patient–physician relationship to a recommendation to use cannabis.
Improved study methodologies, including the use of standard formulations and/or dosages
and larger study populations, are needed for future investigative efforts to determine
appropriate uses of medical cannabis.
27. Physician’s Attitudes Towards
Prescribing – Colorado
76% agreed medical marijuana should be included in
Colorado’s Physician Drug Monitoring Program.
92% agreed that doctors should have ongoing
relationships with patients for whom they recommend
medical marijuana, a stipulation that was not incorporated
into law until June 2010.
28. Physician’s Attitudes Towards
Prescribing – Colorado
80% agreed training should be incorporated into medical
school curricula.
92% agreed that continuing medical education (CME)
about medical marijuana should be made available to
primary care physicians
29. Role of the Pharmacist
Connecticut is the only state in which a pharmacist can
dispense inhaled cannabis for medical use.
Before being dispensed, the product must be deemed
“pharmaceutical grade” by a state-appointed laboratory.
Other states, like Minnesota, are considering legislation
that gives pharmacists a consultative role within the
manufacturing and dispensing process.
30. Role of the Pharmacist
Counsel patients on effects of marijuana on cognition; the
risks associated with inhaled carcinogens, which may
lead to certain types of cancers; respiratory ailments such
as chronic obstructive pulmonary disease; and risks to the
reproductive system.
Assess drug-drug interactions with opioids, barbiturates,
central nervous system depressants and others.
31. Illinois Compassionate Use of Medical
Cannabis Pilot Program Act
Effective January 1st, 2014 and good for 4 years until expired or renewed.
Eligibility: patients with “debilitating medical condition” (see next slide)
How to apply?
Physician approves the patient and mails in a Physician Certification Form
Patient applies for a Medical Marijuana Registry Identification Card via the Illinois
Department of Public Health.
Patient obtains medical marijuana from a registered dispensary (2.5 Oz max in 14 days).
Cultivation centers: managed by Department of Agriculture, maximum of 22 centers.
Dispensaries: managed by IDFPR, maximum of 60 dispensaries.
Taxes paid by cultivation centers
Where to smoke? Legally in the premises of your own home. Illegal elsewhere under the
Smoke Free Illinois Act
32.
33.
34. Pharmacists Role in Illinois?
Joseph Friedman, RPh, MBA
“My dispensary will also have what pharmacists call a
non-sterile lab. Its purpose would be to produce a variety
of dosage forms that will address the needs of each and
every patient.”
“Capabilities will include capsules, topical creams and
ointments, tinctures, oils, oral liquids, and edibles.
Gummy squares and lollipops, for example, help cancer
patients and other people who should not be inhaling
smoke cope with break-through pain.”
35. Others in Illinois
Provide resources for physicians and patients on
obtaining medical marijuana in Illinois.
Medical Marijuana of IL
Good Intentions Chicago
Quantum9
36. Conclusions
As the use of medical marijuana gains greater acceptance, it is likely
that pharmacists will be called upon to counsel patients.
Although dispensing pharmacists might receive some legal
protection from their individual state, they would be clearly violating
federal laws concerning controlled substances and could possibly
risk losing their license.
Pharmacists must also be careful to never recommend a source of
medical marijuana, provide specific instructions for the drug’s use, or
obtain the drug for a patient’s use.
37. References
Hi HL. An archaeological and historical account of cannabis in China. Econ Bot 1974;28:437–48.
Aggarwal SK, Carter GT, Sullivan MD, ZumBrunnen C, Morrill, R, Mayer JD. Medicinal use of cannabis in the United
States: historical perspectives, current trends, and future directions. J Opioid Manag 2009;5:153–68.
Kramer J. Medical Marijuana for Cancer. CA Cancer J Clin 2015;65:109-122.
Volkow N, et al. Adverse Health Effects of Marijuana Use. N Engl J Med 2014;370:2219-27.
• Cavazos-Rehg P, et al. Characterizing the Followers and Tweets of a Marijuana-Focused Twitter Handle. J Med
Internet Res. 2014 Jun; 16(6): e157.
• Kondrad E, et al. Colorado Family Physicians’ Attitudes Toward Medical Marijuana. J Am Board Fam Med
2013;26:52– 60.
• Bachhuber M, et al. Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-
2010. JAMA Intern Med. 2014;174(10):1668-1673.
• Linskey M, et al. Escalation of Drug Use in Early-Onset Cannabis Users vs. Co-twin controls. JAMA 2003;289:427-
433.
• Budney A, et al. Marijuana Dependence and Its Treatment. Addict Sci Clin Pract. 2007;4(1):4–16.
• Borgelt L, et al. The Pharmacologic and Clinical Effects of Medical Cannabis. Pharmacotherapy 2013;33(2):195–
209.
• Burgdorf J, et al. Heterogeneity in the composition of marijuana seized in California. Drug and Alcohol Dependence
2011;117:59– 61.
60% of the decedents possessed a valid opioid analgesic prescription from a single provider. unlikely that improved pain control with the use of marijuana in patients with chronic pain is the primary driver for the observed decline in opioid overdose.
The difficulty in endorsing the medical marijuana protective hypothesis is that medical marijuana laws are heterogeneous across states, engender controversy in state legislatures, and produce varied approaches.
Decreased sperm production, lower weight babies
The Smoke-free Illinois Act prohibits smoking in virtually all public places and workplaces, including offices, theaters, museums, libraries, educational institutions, schools, commercial establishments, enclosed shopping centers and retail stores, restaurants, bars, private clubs and gaming facilities.
