Medical Cannabis

Medical Cannabis
Danial Schecter, MD, CCFP
Executive Director
Cannabinoid Medical Clinic
Vocational Rehabilitation
Association
November 7th, 2014
Conflict of Interest
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This program has not received financial
support
Why Cannabinoid Medicine
•  Became aware of the Endocannabinoid
System
•  Realization that traditional pharmaceutical
agents had limited efficacy or intolerable
side effects
•  Listened to stories of patients who
achieved real benefit with improved quality
of life
My first observational study of
Cannabinoids
Learning Objectives
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Understand why cannabinoids are
considered a valid therapeutic choice
Become aware of the medical cannabis
regulations in Canada
Recognize barriers encountered by
workers (and employers) of patients who
use medical cannabis and re-entering the
workforce
The Endocannabinoid System
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Signaling system (similar to hormones)
Important regulatory function in physiologic
and pathophysiologic processes including:
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Neural development
Immune function
Inflammation
Appetite
Metabolism and energy homeostasis
Cardiovascular function
Digestion
Bone development and bone density
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Synaptic plasticity and learning
Pain
Reproduction
Psychiatric disease
Psychomotor behavior
Memory
Wake/sleep cycles
Regulation of stress and emotional
state
The Endocannabinoid System
Distribution of CB1 Receptors
Pharmacologic action of
Phytocannabinoids
∆9-THC is the
only
cannabinoid
that is
psychoactive
Commonly Cited Clinical
Indications
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Chronic neuropathic or
musculoskeletal pain
Nausea and vomiting
due to chemotherapy
or HIV treatment
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Motor disorder (PD,
Huntington, Tourettes)
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Spasticity due to MS
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Glaucoma
Appetite stimulant
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Anxiety, PTSD
Hypnotic
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Autism
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Other... ?
Anticonvulsant
Opioid Sparing Effects of Cannabis
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Cannabinoids exhibit analgesic effects and
may potentiate the antinociceptive effects
of opioids
Cannabinoids may decrease the amount of
opioids required, thereby decreasing
negative side-effects
Importance to Vocational
Rehabilitation Professionals
•  Currently 40 – 50 000 people using
medical cannabis. Projected to grow to
450 000 people in 10 years.
Cannabinoids in Canada
Dronabinol/THC
2.5 – 10 mg THC
(Marinol)
Nabilone
0.25 – 1 mg THC
(Cesamet)
Nabiximols
2.5 mg THC + 2.5 mg CBD
(Sativex)
Herbal Cannabis
THC < 0.5 % to > 17 %
CBD 0 % to 9 %
Oral Capsule
l Start with 2.5 mg qHS and increase up to
10 mg BID
l Approved for chemotherapy induced
nausea and vomiting and anorexia
associated with HIV/AIDS
Availability and Cost:
2.5 mg capsule: $ 2.05 pd
5.0 mg capsule $ 4.10
Oral capsule
l Start with 0.5 mg qHS and slowly titrate to 1
mg BID as tolerated
l Maximum recommended dose is 6 mg/day
l Same indications as Dronabinol
Availability and cost:
0.25 mg capsule: $ 1.64 pd
0.5 mg capsule $ 3.29 pd
1.0 mg capsule: $ 6.58 pd
Oromucosal spray
Start at 1 spray every 4 hrs to a maximum
of 4 sprays on day 1 and increase as
tolerated
l Average dose is 5 sprays/day; limited
experience with doses higher than 12
sprays/day
l Approved for multiple sclerosis associated
neuropathic pain and cancer pain
Availability and Cost:
$ 3-5 per spray
Not covered via ODB
Authorized use via Marihuana for Medical
Purposes Regulations (MMPR – Health
Canada)
l Average 1-2 grams per day (~ 2 – 4 joints)
l Not formally approved as a prescription
drug (no DIN)
Availability and Cost:
3 $ - 12 $ per gram
Available from Licensed Producers
approved by Health Canada
No coverage (Veterans Affairs)
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No longer available in Canada
Available via ODB, no LU code needed
Marihuana for Medical Purposes
Regulations (MMPR)
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Effective as of June 2013 and replaced the MMAR
regime as of April 1st 2014
Can only obtain cannabis from a “Licensed
Producer” (LP)
Able to access cannabis from an LP with a medical
document (prescription) from an authorized health
care provider
Physician able to prescribe according
to his/her judgment/clinical discretion
Licensed Producers
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License granted by Health Canada
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Strict quality control measures
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Tests every lot for contaminants and percentage of
THC and CBD
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Listed on Health Canada’s website
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Only able to sell herbal cannabis, no extracts
(tinctures/oils) or edibles
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Can not have a store-front
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Only 13 listed on Health Canada’s website although
22 approved
Barriers to Re-Entry to the
Workplace
Barriers to Re-Entry to the
Workplace
•  Stigma associated with disclosure of
disability requiring cannabis therapy
•  Until now few medical cannabis users,
companies able to have Zero Tolerance!
•  Medical Review Officers (MRO) do not
have strict guidelines to deal with lab
results
•  US DOT regulated employees not allowed
to use cannabis (recreational or medical)
Employer’s Responsibilities
•  Become informed about the medical
benefits of cannabis
•  Must abide by human rights legislation and
the “duty to accommodate”
•  Develop company policies surrounding the
use of potentially psychoactive medications
•  Accommodate employees in safety
sensitive positions
Employee Rights and
Responsibilities
•  Right to accommodation only if employee
reports use of medical cannabis
•  Respect smoking rules and regulations
(consider vaporizer and edibles)
Issues to consider when reentering the workplace
•  Does the employee hold a safety sensitive
position? May require Independent Medical
Assessment by Occupational Health MD
•  Cannabis may not impair the employee…
may boost productivity
Why can’t I find a physician to
prescribe me cannabis?
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Physicians “are not obliged to authorize the use of
medical marijuana by patients”
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The CMA still believes there is insufficient scientific
evidence available to support the use of marijuana for
clinical purposes.
Why can’t I find a physician to
prescribe me cannabis?
Why can’t I find a physician to
prescribe me cannabis?
Why can’t I find a physician to
prescribe me cannabis?
•  10/80/10 Rule
•  No guidelines (conditions/dosage/titration)
•  Smoked/inhaled
•  Fear of abuse
•  Fear of regulatory bodies
•  Repeating mistakes of Oxycontin
•  Time crunch
Cannabinoid Medical Clinic
•  Doors opened July 14, 2014
•  First clinic seeing patients on a referral
basis only
•  No patient fees for ancillary services, no
affiliations with specific LPs
•  Focus on:
1) Patient care
2) Physician Education
3) Clinical Research
Cannabinoid Medical Clinic
The patient experience:
•  Plan to spend 1-1.5 hours at the clinic
•  Able to complete comprehensive
questionnaire at home on proprietary EMR
•  Sees nurse prior to MD, provides education
about MMPR, THC:CBD, process
•  Following MD sees a “Cannabinoid
Educator”
Our Cannabinoid Educators
•  Educate patients on safe usage,
monitoring , titration and potential side
effects
•  Recommend Licensed Producer
•  Helps with paperwork
•  Demonstrate Vaporizers
•  Available for questions
Take Home Messages
•  Medical Cannabis is a valid treatment that
is prescribed by physicians
•  Effects of medical cannabis are often
different than recreational cannabis
•  Patients often achieve functional
improvements that allows return to work
•  Employers have a duty to accommodate
•  Employees in safety sensitive positions
may benefit from Independent Medical
Evaluation (IME)
Questions

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