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| == Definition/Description: == | | == Introduction == |
| | [[File:Cannabis oil.jpeg|right|frameless]] |
| | Cannabis sativa (C. sativa) is a flowering, fast growing shrub, commonly known as hemp, cannabis, or marijuana. It originates from Central Asia, and is widely distributed in temperate and tropical areas. For thousands of years, Cannabis sativa has been utilized as a medicine and for recreational and spiritual purposes.<ref>Maule WJ. Medical uses of marijuana (Cannabis sativa): fact or fallacy?. British journal of biomedical science. 2015 Jan 1;72(2):85-91.</ref> Phytocannabinoids are a family of compounds that are found in some flowering plants (such as cannabis plant), which is known for its psychotogenic and euphoric effects;<ref>Gülck T, Møller BL. Phytocannabinoids: origins and biosynthesis. Trends in Plant Science. 2020 Jul 6.</ref> the main psychotropic constituent of cannabis is Tetrahydrocannabinol (THC).<ref name=":2">PubChem [Internet]. Bethesda (MD): National Library of Medicine (US), National Center for Biotechnology Information; 2004-. PubChem Compound Summary for CID 16078, Dronabinol; [cited 2022 Jan. 29]. Available from: <nowiki>https://pubchem.ncbi.nlm.nih.gov/compound/Dronabinol</nowiki></ref> THC is one of the at least 113 recognized cannabinoids in C. sativa. The pharmacological effects of cannabinoids are a result of interactions between those compounds and cannabinoid receptors, CB1 and CB2, located in many parts of the human body<ref>Breijyeh,Z.;Jubeh,B.Bufo, S.A.; Karaman, R.; Scrano, L. Cannabis: A Toxin-Producing Plant with Potential Therapeutic Uses.Toxins 2021, 13, 117. Available from: <nowiki>https://res.mdpi.com/d_attachment/toxins/toxins-13-00117/article_deploy/toxins-13-00117.pdf</nowiki> |
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| As a result of cannabis decriminalization and legalization throughout the world, healthcare professionals are faced with more questions from patients regarding cannabis and its use. Healthcare professionals have a responsibility to provide evidence-based guidance on this important medical and social issue. Cannabis has significant health benefits and therapeutic applications to a vast array of medical conditions explored in this page. As with any medical substance, cannabis use also presents with associated risks. This page describes the many uses of cannabis in relation to specific patient populations. This page also compares the risks of cannabis from a medical standpoint with other commonly used drugs. The purpose of this page is to provide a comprehensive, up-to-date educational resource for healthcare professionals, patients, and caregivers guided by current evidence-based research. Additionally, the information presented will attempt to dispel many myths and help clear the smoke around issues surrounding the cannabis plant. This page will be updated continually in the future. This page is dedicated to past and future patients.
| | (accessed 5.4.2021) |
| | </ref>. |
| | * Many people around the world believe that the drug should be readily available for both medical and recreational use; however governments around the world still have strict laws about its usage. |
| | * Each country has its own laws and regulations surrounding the drug; some places are more relaxed, whist others still believe the drug should be an illegal substance<ref>best in Au [https://bestinau.com.au/marijuana-laws-from-around-the-world-where-is-cannabis-legal/ Where is cannabis legal] Available from:https://bestinau.com.au/marijuana-laws-from-around-the-world-where-is-cannabis-legal/ (accessed 5.4.2021)</ref>. |
| | Cannabidiol (CBD), the major non-psychoactive constituent of ''Cannabis sativa'' L., has gained popularity as a potential treatment for certain conditions<ref name=":3">Argueta DA, Ventura CM, Kiven S, Sagi V, Gupta K. A balanced approach for cannabidiol use in chronic pain. Frontiers in pharmacology. 2020 Apr 30;11:561.</ref> See below). |
| | == Types of medicinal cannabis products == |
| | [[File:Cannabis pills.jpeg|right|frameless|400x400px]] |
| | Cannabis is a complex plant comprising more than 500 constituents, including approximately 100 cannabinoids. The main active ingredients used for medical purposes are tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the psychoactive part of cannabis that produces a ‘high’, and has been used to treat symptoms such as nausea, pain and muscle spasticity. CBD has no psychoactive properties, and has been used to treat several inflammatory disorders and epilepsy.<ref name=":3" /> |
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| == Etiology/Origin<br> == | | Medicinal cannabis products can come in three main forms: |
| | # Pharmaceutical: Natural and synthetic medical-grade products with standardized content. The three main products are: |
| | #* Dronabinol: Synthetic form of THC<ref name=":2" /> |
| | #* Nabilone: Synthetic form of THC |
| | #* Nabiximols: Chemically pure 50:50 mixture of TCH and CBD. |
| | # Medicinal-grade herbal cannabis: Produced and processed in controlled standard conditions to a medical grade, free of adulterants, higher levels of CBD and other cannabinoids, and contains lower levels of THC. This is provided in herbal form, or processed as an oil, balm, capsule or pill. |
| | # Herbal cannabis on the illegal market: Potentially unstable THC and CBD, and may contain adulterants.<ref name=":0">RACGP [https://www.racgp.org.au/advocacy/position-statements/view-all-position-statements/clinical-and-practice-management/medical-cannabis Medicinal Cannabis] Available from:https://www.racgp.org.au/advocacy/position-statements/view-all-position-statements/clinical-and-practice-management/medical-cannabis (accessed 5.4.2021)</ref> |
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| The plant was first named “cannabis” by a German physician by the name of Leonhart Fuchs in 1542 A.D. Prior to 1542 A.D, throughout the world, it was known as an important medication. <ref name="Scientific American">Jacobson R. Medical Marijuana: How the Evidence Stacks Up [Internet]. Scientific American. [cited 2016Apr17]. Retrieved from: http://www.scientificamerican.com/article/medical-marijuana-how-the-evidence-stacks-up/</ref> | | == The Evidence == |
| | [[File:Evidence.jpeg|right|frameless]] |
| | At present, the evidence base for the use of medicinal cannabis products is limited.<ref>O’Brien K. Medicinal cannabis: Issues of evidence. European Journal of Integrative Medicine. 2019 Jun 1;28:114-20.</ref> The current evidence base for the use of medicinal cannabis products is heterogeneous, comprising a small number of randomized clinical trials when stratified by condition, symptom or intervention type.<ref>Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV. Cannabinoids for medical use. JAMA [Internet]. 2015; 313 (24): 2456.</ref> <ref name=":0" />These studies are of variable quality, including those with high risk of bias (eg incomplete outcome data), low statistical power, and short follow-up time. |
| | * Recent reviews and analyses indicate there may be some therapeutic benefits of medicinal cannabis products in certain conditions but further research on the treatment efficacy and longer term side effects are warranted. |
| | * Currently, most research and evidence on medicinal cannabis products have come from five clinical conditions: [[Multiple Sclerosis (MS)|multiple sclerosis]]; [[Palliative Care Competence Framework for Physiotherapists|palliative care]]; [[epilepsy]]; nausea and vomiting; and [[Chronic Pain|chronic non-cancer pain]].<ref name=":0" /> |
| | * As there is limited scientific evidence to support the use of medicinal cannabis in most conditions, and in many cases the evidence is for its use together with other medicines, it should be used only when approved treatments have been tried and have failed to manage conditions and symptoms.<ref name=":1">Aust Government [https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-australia-patient-information Guidance on medicinal cannabis] Available from:https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-australia-patient-information (accessed 5.4.2021)</ref> |
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| One of the first medical reports in western medicine regarding cannabis was William B ‘O Shaughnessy’s, “On the Preparations of the Indian Hemp, or Gunjah.” Published in 1848, this report analyzed several medical indications and the effect an indian hemp preparation had on them. In rheumatism, O’ Shaughnessy found “alleviation of pain in most, remarkable increase of appetite in all, unequivocal aphrodisia, and great mental cheerfulness.” His report observed the effect of cannabis preparations on hydrophobia, cholera, tetanus, infantile convulsions, and delirium tremens. In the conclusion O’ Shaughnessy reports, “in hemp the profession has gained an anti-convulsive remedy of the greatest value.” <ref>O'Shaughnessy WB. On the Preparations of the Indian Hemp, or Gunjah: Cannabis Indica Their Effects on the Animal System in Health, and their Utility in the Treatment of Tetanus and other Convulsive Diseases [Internet]. Provincial Medical Journal and Retrospect of the Medical Sciences. U.S. National Library of Medicine; [cited 2016Apr14]. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2490264/</ref>
| | === Chronic Pain === |
| | The International Association for the Study of Pain (IASP) taskforce looked at all the available research published in peer-reviewed journals on the use of medicinal cannabis for pain management, from preclinical studies to human trials. |
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| Following O’Shaughnessy’s report, in 1850 cannabis was added to the official handbook of medications, ''The United States Pharmacopeia''. Within the handbook it was regarded as an official medication for a wide-range of ailments. <ref name="Scientific American" />
| | They concluded overall the studies’ “quality, rigour, and transparency of reporting” of benefits and harms needs to be improved across the board. The IASP taskforce demands higher quality data, for example through randomized controlled trials, to determine the safety and efficacy of using medicinal cannabis for pain<ref>IASP Position Statement on the Use of Cannabinoids to Treat Pain Available from:https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=11145&navItemNumber=643 (accessed 5.4.2021) |
| | </ref> |
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| [[Image:CannabisFluidExtract pre1937.jpg|frame|right|300px|Cannabis Fluid Extract, 1906]]
| | === Multiple sclerosis === |
| | Anout 50% of the studies in a recent systematic reviews showed that medicinal cannabis products may be effective for pain, spasticity, sleep and bladder function. The other half had inconclusive results.<ref name=":0" /> |
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| Today, cannabis has been difficult to study as a complete plant substance from a pharmaceutical standpoint. ''The Journal of the American Medical Association'' (''JAMA)'' reports “cannabis is a complex of more than 400 compounds including flavonoids and terpenoids and approximately 70 cannabinoids other than delta 9 tetrahydrocannabinol (THC). These cannabinoids have individual, interactive, and even entourage effects (effects of a compound that are only appreciable in the presence of other compounds) that are not fully understood and that contribute to the net effect of marijuana.” Additionally, “patients will need to experiment with different strains and doses to achieve the desired effects, without much input or oversight from physicians.”Additionally, ''JAMA'' reports, “The federal government and states should support medical marijuana research” <ref name="Cart Before the Horse">D'Souza DC, Ranganathan M. Medical Marijuana Is the Cart Before the Horse. The Journal of The American Medical Association. 2015Jun23;313(24):2431–2.</ref>
| | === Epilepsy === |
| | A number of studies have found low evidence for the use of medicinal cannabis products for the treatment of paediatric epilepsy, and for patients up to aged 25 years, especially when first-line treatments (ie anti-epileptic drugs) have been found to be ineffective. The numbers needed to treat are as follows: |
| | * 50% or greater reduction in seizure frequency: 8 |
| | * Complete seizure freedom: 17 |
| | * Improvement in parental-reported [[Quality of Life|quality of life]]: 5 |
| | * The numbers needed to harm for any adverse event was 3, and serious adverse event was 23. |
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| Currently, evidence suggests cannabis may be “an effective treatment for chronic pain, neuropathic pain, muscle spasm due to multiple sclerosis or paraplegia. In most states with medical marijuana laws, marijuana can be used to treat severe or chronic pain and severe or persistent muscle spasms.” Cannabis use can be "certified by a physician but it cannot be prescribed by a physician due to its schedule I status." <ref>Thompson AE. Medical Marijuana. The Journal of The American Medical Association. 2015Jun23;313(24):2508.</ref> <br>
| | === Palliative care === |
| | The use of medicinal cannabis products in palliative care is currently unclear. |
| | [[File:Pain stress brain.png|right|frameless]] |
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| == Anatomy<br> == | | === Nausea and vomiting === |
| | A small number of studies have found relief of nausea and vomiting in patients with [[Oncology|cancer]] who are undergoing [[Chemotherapy Side Effects and Syndromes|chemotherapy]]; however, the evidence is lacking and some were compared with now out-of-date practices. |
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| Humans and drugs have a long, complex relationship. Drugs are predominantly developed from plants because humans have receptors throughout their bodies for the compounds produced from plants. “The synthesis of THC by Raphael Mechoulam led researchers to discover a signaling system. The signaling system of the endocannabinoid system started evolving more than 500 million years ago. The endocannabinoid system and their receptors are found in fish, reptiles, earthworms, leeches, amphibians, birds, and mammals. The evolution of the cannabinoid signaling system indicates it plays a functional role in physiology.” <ref name="project CBD">Lee M. [Internet]. Projectcbd.org. 2016 [cited 14 April 2016]. Available from:https://www.projectcbd.org/article/brain-and-marijuana-book-excerpt</ref><br>
| | === Chronic non-cancer pain === |
| | There is some evidence available for the treatment of [[Neuropathic Pain|neuropathic pain]] using medicinal cannabis products; however, the magnitude of effect is small. One systematic review found that the numbers needed to treat was 22 for a 30% reduction and 26 for a 50% reduction in self-reported pain intensity<ref name=":0" /> |
| | == Side Effects == |
| | Like all prescription medicines, medicinal cannabis products can have side effects. The extent of effects of these can vary with the type of medicinal cannabis product and between individuals. |
| | * In general, the side effects of CBD-rich products are less than those for high-THC products, but because the required doses for CBD can be quite high in conditions such as pediatric epilepsies, a proportion of patients encounter side-effects with these CBD doses. |
| | * The known side-effects from medicinal cannabis treatment (both CBD and THC) include fatigue and sedation, vertigo, nausea and vomiting, fever, decreased or increased appetite, dry mouth, and diarrhea. |
| | * THC (and products high in THC) have been associated with convulsions, feeling high or feeling dissatisfied, [[depression]], confusion, hallucinations, paranoid delusions, psychosis, and cognitive distortion (having thoughts that are not true)<ref name=":1" />. |
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| Cannabinoid receptors belong to a superfamily of G-protein receptors. G-protein receptors are involved in many disease processes. <br>Cannabinoid G-Protein coupled receptors were initially discovered by Professor Allyn Howett and William Devane. These researchers “mapped the brain's cannabinoid receptor and discovered the main mental and physiological centers cannabis works upon. “<br><ref>Marijuana Research: Discovery of the Cannabinoid Receptor System [Internet]. Drug Science . [cited 2016Apr14]. Retrieved from: http://www.drugscience.org/petition/c3d.html</ref>
| | == Relevance to Physical Therapy == |
| | Physiotherapists should be able to educate patients on the reported benefits of cannabis (eg chronic pain, MS, spasticity, and chemotherapy-induced nausea and vomiting) as well as potential adverse effects. Also, trends in the medical use of cannabis can be studied in relation to the extant laws of the country of practice to understand what is allowed in a region concerning the use of medicinal cannabis. |
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| “Within the brain cannabinoid receptors can be found in the hippocampus (memory), cerebral cortex (higher cognition), cerebellum (motor coordination), basal ganglia (movement), hypothalamus (appetite), amygdyla (emotion), and elsewhere. There are few cannabinoid receptors in the brainstem (respiration and heart beat) which explains why you cannot fatally overdose on cannabis.” <ref name="project CBD" />
| | == Summary of Evidence by Condition == |
| | {| class="wikitable" |
| | !Condition |
| | !Products |
| | !Current evidence quality |
| | |- |
| | ! colspan="3" |Multiple sclerosis |
| | |- |
| | |Pain |
| | |Dronabinol, THC extracts |
| | |Low to high and inconsistent |
| | |- |
| | |Disability and its progression |
| | | |
| | |None |
| | |- |
| | |Spasticity |
| | |Nabiximols and THC:CBD |
| | |Low and inconsistent |
| | |- |
| | |Bladder function |
| | | |
| | |None |
| | |- |
| | |Ataxia and tremor |
| | | |
| | |None |
| | |- |
| | |Sleep |
| | | |
| | |None |
| | |- |
| | |Quality of life |
| | |Nabiximols and THC:CBD |
| | |Low and inconsistent |
| | |- |
| | ! colspan="3" |Epilepsy |
| | |- |
| | | rowspan="4" |To reduce and/or eliminate the number of seizures |
| | |CBD when used in conjunction with anti-epileptic drugs |
| | |Low to very low |
| | |- |
| | |Oral cannabis extracts (OCEs) |
| | |Very low |
| | |- |
| | |CBD:THC |
| | |Very low |
| | |- |
| | |Cannabis sativa |
| | |Very low |
| | |- |
| | | rowspan="5" |Quality of life |
| | |CBD |
| | |Low |
| | |- |
| | |Oral cannabis extracts (OCEs) |
| | |Very low |
| | |- |
| | |CBD:THC |
| | |Very low |
| | |- |
| | |Cannabis sativa |
| | |Very low |
| | |- |
| | |THC |
| | |Very low |
| | |- |
| | ! colspan="3" |Palliative care |
| | |- |
| | |Alzheimer's disease |
| | |Dronabinol |
| | |Unclear |
| | |- |
| | | rowspan="3" |Advanced cancer symptom control |
| | |Dronabinol, THC:CBD, THC |
| | |Unclear but some evidence against use |
| | |- |
| | |Cannabis sativa |
| | |Unclear |
| | |- |
| | |Nabilone |
| | |Unclear |
| | |- |
| | ! colspan="3" |Nausea and vomiting |
| | |- |
| | | rowspan="7" | |
| | |Dronabinol |
| | |Low to moderate |
| | |- |
| | |Nabilone |
| | |Very low to moderate |
| | |- |
| | |THC |
| | |Low, insufficient evidence |
| | |- |
| | |Levonantradol |
| | |Low to moderate |
| | |- |
| | |THC:CBD |
| | |Insufficient evidence |
| | |- |
| | |Cannabis sativa extract |
| | |Unclear |
| | |- |
| | |Naximols |
| | |Insufficient evidence |
| | |- |
| | ! colspan="3" |Chronic non-cancer pain |
| | |- |
| | | rowspan="7" | |
| | |Nabiximols |
| | |Moderate to high |
| | |- |
| | |Dronabinol |
| | |Low to moderate |
| | |- |
| | |Nabilone |
| | |Very low |
| | |- |
| | |Cannabis sativa |
| | |Very low |
| | |- |
| | |THC extract |
| | |Moderate |
| | |- |
| | |THC:CBD extract |
| | |Low to moderate |
| | |- |
| | |Ajulemic acid |
| | |Very low |
| | |} |
| | Nabiximols is a TGA-registered medicine, under the tradename Sativex. It is a standardised extract of cannabis, containing roughly equal amounts of THC and CBD. |
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| Another reason cannabis is impossible to overdose on is because “when the brain is stimulated by high doses of THC, it produces pregnenolone – a 3,000 percent increase – that inhibits the effects of THC.” <ref>Pregnenolone Can Protect the Brain from Cannabis Intoxication [Internet]. Science. [cited 2016Apr19]. Retrieved from: http://science.sciencemag.org/content/343/6166/94.full</ref>
| | Dronabinol is a synthetic form of THC. |
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| Lisa Matsuda is responsible for discovering the DNA sequence that “encodes the THC receptor in the rat’s brain.” Matsuda also cloned the cannabis receptor. <br> The cloning of the cannabis receptor enabled researchers to discover cannabinoid agonists and cannabinoid antagonists. Researchers were also able to discover cannabinoid receptors. “The CB1 receptor is a central nervous system receptor and is responsible for the high. THC binds to the CB1 receptor creating the high.”<ref>Matsuda LA, Lolait SJ, Brownstein MJ, Young AC, Bonner TI. Structure of a cannabinoid receptor and functional expression of the cloned cDNA. Nature. 1990;346:561–4. [PubMed] [Ref list] )</ref><br>CB2 receptors are found throughout the peripheral nervous system and the immune system. “CB2 receptors are present in the gut, liver, spleen, heart, kidneys, bones, blood vessels, lymph cells, endocrine glands, and reproductive organs.” THC stimulates the CB2 receptors but this does not result in a "high" because they are not found in the brain. “Therefore, the CB1 receptors mediates the high and the CB2 receptor controls the immune response.”<ref>Munro S, Thomas KL, Abu-Shaar M. Molecular characterization of a peripheral receptor for cannabinoids. Nature. 1993)</ref>
| | Nabilone is a cannabinoid synthesised in the laboratory, and has actions similar to THC although its chemical structure is different. |
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| Endocannabinoids: “The discovery of cannabinoid receptors lead to Mechoulam’s discovery of the naturally occurring endogenous (made internally) cannabinoid. The endocannabinoids are responsible for an array of medical implications. The endocannabinoids attach to the same receptors that THC attaches to. Currently, there are two endocannabinoids. Anandamide and 2-AG (2-arichidonoylglycerol) which bind to both CB1 and CB2 receptors."<ref name="project CBD" />
| | Ajulemic acid is a cannabinoid synthesised in the laboratory. It is similar to a breakdown product (metabolite) of THC but does not have psychoactive properties.<ref name=":1" /> |
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| According to an editorial in the 2015 June issue of the Journal of the American Medical Association (JAMA), it states, “The endocannabinoid system is involved in axon elongation, neurogenesis, neural maturation and specification, glia formation, neuronal migration, and synaptic pruning. Furthermore, the endocannabinoid system evolves during adolescence.”<ref name="Cart Before the Horse" />
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| Cannabis as an analgesic: <br>How cannabis works as an analgesic: <br>It has been shown that following harmful stimuli, endocannabinoids are elevated in different areas of the brainstem. An important aspect of its analgesic effects has been noted to be “modulation of descending inhibitory inputs from the brainstem to spinal nociceptive neurons.” Furthermore, studies have shown that the peri aqueductal gray area as well as the rostral ventral medial medulla are affected by noxious stimuli. Cannabis has been shown to inhibit these areas and this explains its analgesic effect to some degree.<ref>Wilson RL, Nicoll RA. Endocannabinoid Signaling in the Brain [Internet]. Science. [cited 2016Apr19]. Retrieved from: http://science.sciencemag.org/content/296/5568/678.full</ref>
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| == Classification<br> ==
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| The Federal classification of cannabis as a medicine: <br>The US Department of Health and Human Services: Patent # 6630507: Titled "Cannabinoids as Antioxidants and NeuroProtectants"
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| The US Department of Health and Human Services states: "Cannabinoids have been found to have antioxidant properties and are found to have particular application as neuroprotectants, for example in limiting neurological damage following ischemic insults, such as stroke and trauma, or in the treatment of neurodegenerative diseases, such as Alzheimer's Disease, Parkinson's Disease and HIV dementia."<ref name="6630507">Patent US6630507 - Cannabinoids as antioxidants and neuroprotectants [Internet]. Google Books. [cited 2016Apr10]. Retrieved from: http://www.google.com/patents/us6630507</ref><br><br>
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| Cannabis as a plant:
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| [[Image:CannabisSativa-ViennaDioscurides.jpg|frame|right|300px|Cannabis sativa from Vienna Dioscurides, 512 AD.]]Cannabis is classified as a member of the cannabaceae plant family. Cannabis is classified under the single species of hemp (C. sativa). The female version of hemp is considered “marijuana” and consists of the indica, sativa, and ruderalis varieties. Cannabis has thousands of varieties and the effects of each variety are different. Hops belongs to the cannabaceae plant family as well. Hops is used in the production of beer, a celebrated legal drug. <br><ref>Classification | USDA PLANTS [Internet]. Classification | USDA PLANTS. [cited 2016Apr13]. Retrieved from: http://plants.usda.gov/java/classificationservlet?source=display</ref><ref>The Editors of Encyclopædia Britannica. cannabis [Internet]. Encyclopedia Britannica Online. Encyclopedia Britannica; [cited 2016Apr13]. Retrieved from: http://www.britannica.com/plant/cannabis-plant</ref>
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| == Federal Classification<br> ==
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| The Federal classification of cannabis legally: Schedule 1 narcotic, no accepted medical value.<br>As defined by the United States Controlled Substance Act (CSA).
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| “Schedule I drugs are defined as:
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| (A) The drug or other substance has a high potential for abuse.
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| (B) The drug or other substance has no currently accepted medical use in treatment in the United States.
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| (C) There is a lack of accepted safety for use of the drug or other substance under medical supervision.”<br><ref>Controlled Substance Schedules [Internet]. Resources -. [cited 2016Apr10]. Retrieved from: http://www.deadiversion.usdoj.gov/schedules/</ref><br>
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| == Indications ==
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| <div>
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| This section of the page will be continuously updated.
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| Cancer:
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| Manuel Guzman and his team of researchers discovered cannabis inhibits cancer tumor growth. The study found cannabinoids “inihibit gliomas in animals by modulating key cell signaling pathways, mostly the endoplasmic reticulum stress response, thereby inducing antitumoral actions such as the apoptotic death of tumor cells and the inhibition of tumor angiogenesis<span style="line-height: 1.5em; font-size: 13.28px;">.”</span><ref name="guzman">Guzman M, Blazquez C, Casanova LL, Planas A, Pulgar TGD, Villanueva C, et al. Inhibition of tumor angiogenesis by cannabinoids - FASEB J [Internet]. [cited 2016Apr13]. Retrieved from: http://www.fasebj.org/content/17/3/529.full</ref>
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| The National Cancer Institute states: “Cannabis and cannabinoids have been studied in the laboratory and the clinic for relief of pain, nausea and vomiting, anxiety, and loss of appetite.”<ref name="cancer">Cannabis and Cannabinoids [Internet]. National Cancer Institute. [cited 2016Apr16]. Retrieved from: http://www.cancer.gov/about-cancer/treatment/cam/patient/cannabis-pdq</ref>
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| Additionally, the institute explains, “Cannabis has been shown to kill cancer cells in the laboratory.” However, cannabis is not approved by the FDA in the treatment of cancer either as an adjunct or as an alternative treatment method. <ref name="cancer" /><br>
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| Glaucoma:
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| The discovery of the effects of cannabis reducing intraocular pressure in glaucoma patients prompted the federal government to establish an investigational drug program known as the ''Compassionate Investigational New Drug Program'' (IND). This program assessed the benefits and risks of cannabis use through the ''Missoula Chronic Clinical Cannabis use study.'' The origins of this program and study derive from a patient, Robert Randall, who found regular cannabis use reduced the halo’s associated with glaucoma and enabled him to see better by reducing his intraocular pressure. Robert Randall had been caught cultivating cannabis. Subsequently, Randall went through a lengthy court proceeding that was based on the fact that no conventional pharmaceutical drug could manage his glaucoma symptoms like cannabis could. Cannabis kept Randall from going blind. Randall’s case was dismissed and the federal government began the IND with seven other patients. The report found cannabis has “clinical effectiveness in treating glaucoma, chronic musculoskeletal pain, spasm and nausea, and spasticity due to multiple sclerosis.” Therefore, the clinical studies conducted by the federal government state that cannabis is an effective medicine for several conditions. <ref>Russo, Ethan, Mary Lynn Mathre, Al Byrne, Robert Velin, Paul J. Back, Juan Sanchez Ramos, and Kristin A. Kirlin. "Chronic Cannabis Use in the Compassionate Investigational New Drug Program." Taylor &amp;amp;amp;amp;amp;amp;amp; Francis. Web. 18 Apr. 2016</ref>
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| Post Traumatic Stress Disorder:
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| A study from the Hadassah University Hospital outpatient clinic in Jerusalem, Israel yielded promising results for those suffering from unremitting chronic PTSD. The open-label study conducted over the span of three weeks on ten patients explored "tolerance, safety, and preliminary effects of delta-9-THC as an add-on treatment for patients with chronic PTSD." To evaluate the effects of the medication intervention, the study used the “Clinician-Administered PTSD scale (CAPS), the Clinical Global Impression Scale (CGI), the Pittsburg Sleep Quality Index (PSQI), the self- reported Nightmare Frequency Questionnaire (NFQ), and the clinician- administered Nightmare Effects Survey (NES). The study used a 5 milligram (mg) oral dose of THC administered twice daily. Only three of the patients reported adverse reactions to the drug.” Interestingly, those were not severe enough to discontinue treatment. The study “yielded statistically significant improvements in global symptom severity, sleep quality, the frequency of nightmares, and PTSD hyperarousal symptoms." The study verifies the therapeutic application of cannabinoids in treating PTSD symptoms. <ref>Roitman, Pablo, Raphael Mechoulam, Rena Cooper-Kazaz, and Arieh Shalev. "Preliminary, Open-Label, Pilot Study of Add-On Oral Δ9-Tetrahydrocannabinol in Chronic Post-Traumatic Stress Disorder." Clinical Drug Investigation Clin Drug Investig 34.8 (2014): 587-91.</ref>
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| A 2014 study from the ''Journal of Psychoactive Drugs f''ound'' ''“A 75% reduction of Clinician Administered Post-Traumatic Stress Scale (CAPS) symptoms in patients using cannabis.” This study confirms that cannabis reduces symptoms of PTSD in individuals using cannabis as compared with those who do not. <ref>Greer, George R., Charles S. Grob, and Adam L. Halberstadt. "PTSD Symptom Reports of Patients Evaluated for the New Mexico Medical Cannabis Program." Journal of Psychoactive Drugs 46.1 (2014): 73-77. Web. Cannabis and PTSD symptom reduction</ref>
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| In the July 2015 issue of ''The American Legion'', a magazine dedicated to those serving the United States, veterans make it clear they want access to medical marijuana specifically for “pain and PTSD”. The article notes "Veterans Affairs (VA) prohibits its physicians from discussing cannabis use, even in states where medical marijuana is legal." Scott Murphy, the founder of, Veterans for Safe Access and Compassionate Care, contends "medical marijuana can help reduce their (veterans) opiate dependence and leads to fewer suicides." The article states former veterans are saying "narcotic painkillers, sleeping pills, amphetamines, antidepressants and drugs they are being prescribed are dangerous, if not lethal." With the mounting evidence illustrating the benefits of cannabis to those serving our country the article pinpoints "VA acknowledges that veterans who use medical marijuana may lose access to some medical care." The article shows how medical marijuana can play an important role in recovery for veterans returning home from war. <ref>Olson K. The Cannabis Question. The American Legion. 2015Jul;179(1):24.fckLRVeterans want medical cannabis option.</ref> <br><br>
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| Multiple Sclerosis:<br> A 2015 study from the ''Journal of The American Medical Association (JAMA)'', “Cannabinoids for Medical Use A Systematic Review and Meta-Analysis”, found "moderate quality evidence to support the use of cannabinoids for the treatment of chronic pain and spasticity." The report highlights two studies that found a "50% reduction in spasticity symptoms." Additionally, two other studies found a “30% reduction in spasticity symptoms.” The report looked at studies which included the following: an oral mucosal spray of CBD/THC (nabiximols), orally ingested synthetic THC (Dronabinol), a synthetic cannabinoid derivative mimicking THC (nabilone), oral capsules of combined THC/CBD, smoked THC of low potency and questionable quality ranging from 2.5%-9.4%, and an oral tablet of pure >98% natural delta-9-THC. The systematic review and meta-analysis, although indicating "moderate quality evidence", should be re-evaluated due to inherent flaws in the report. Many of the beneficial compounds found in the natural cannabis plant went ignored. The low concentrations of the smoked THC indicates a much-needed re-evaluation of the samples used. The review should include the entire cannabinoid profile of the sample. Furthermore, these studies indicate the federal government’s scheduling of cannabis as a schedule I drug needs to be changed based on scientific evidence. <ref name="pain and spasticity">Whiting PF, Wolff RF, Deshpande S, Nisio MD, Duffy S, Hernandez AV, et al. Cannabinoids for Medical Use. Jama. 2015;313(24):2460–8.Use of cannabinoids for chronic pain and spasticity</ref>
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| Chronic Pain: ''JAMA's'' 2015 study found patients using cannabis had a reduction in pain symptoms. One of the studies found at least a 30% reduction in pain symptoms compared to those using placebo for those suffering from chronic pain disorders. The trial with the greatest reduction in pain symptoms found smoked THC reported the greatest beneficial effect. Again, this study should be re-visited due to the questionable quality of the smoked cannabis used. Seven of the trials for the indication of chronic pain assessed nabiximols, an oral mucosal spray consisting of 27mg THC and 25mg CBD. Pain conditions studied in this assessment were neuropathic pain and cancer pain. The systematic review and meta analysis indicates the federal government’s schedule I status of cannabis needs to be changed based on scientific evidence.<ref name="pain and spasticity" />
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| Epilepsy: <br>A report of a parent survey of cannabidiol-enriched cannabis use in pediatric treatment-resistant epilepsy found a drastic improvement in seizure symptoms with little side effects in children who did not respond to on average, 12 anti-epileptic medications prior to cannabidiol-enriched cannabis treatment. The report even notes children that were able to reduce seizures entirely as well as additional positive behavioral findings. The report states "sixteen (84%) of the 19 parents reported a reduction in their child's seizure frequency while taking cannabidiol-enriched cannabis. Of these, two (11%) reported complete seizure freedom, eight (42%) reported a greater than 80% reduction in seizure frequency, and six (32%) reported a 25-60% seizure reduction. Other beneficial effects included increased alertness, better mood, and improved sleep. Side effects included drowsiness and fatigue." <ref>Porter BE, Jacobson C. Report of a parent survey of cannabidiol-enriched cannabis use in pediatric treatment-resistant epilepsy [Internet]. Epilepsy &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; behavior : E&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;B. U.S. National Library of Medicine; [cited 2016Apr10]. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4157067/</ref>
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| Fibromyalgia :<br>One study compared 28 fibromyalgia patients who were users compared to 28 who were not. The route of administration was roughly equal. "54% were self-administering cannabis via smoking, 46% via oral ingestion, and 43% combined both smoking and oral administration." Interestingly, the percentages of various cannabinoids in the products the patients were using were not reported. "Information was recorded via the standard Visual Analogue Scale (VAS), the Fibromyalgia Impact Questionnaire (FIQ), Pittsburg Sleep Quality Index (PSQI), and Short Form 36 Health Survey (SF-36)." The study found the VAS showed a "statistically significant reduction in pain and stiffness and enhanced relaxation as well as increased somnolence or a feeling of well-being". Mental health scores on the SF-36 were "significantly higher in users than non-users." The article states "no other differences of statistical significance were recorded in other items of the SF-36, FIQ, or the PSQI." <ref>Fiz, Jimena, Marta Durán, Dolors Capellà, Jordi Carbonell, and Magí Farré. "Cannabis Use in Patients with Fibromyalgia: Effect on Symptoms Relief and Health-Related Quality of Life." PLoS ONE. Public Library of Science. Web. 06 Apr. 201</ref> <br>
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| Alzheimer’s, Huntington’s, and Parkinson’s Disease: <br>A report from the Lancent Journal of Neurology reports cannabis has significant therapeutic potential in the treatment of Alzheimer's, Huntington's, and Parkinson's Disease. <ref>Baker D, Pryce G, Giovannoni G, Thompson AJ. The therapeutic potential of cannabis. The Lancet Neurology. 2003;2(5):291–8.</ref><br><br><br>
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| </div>
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| == Safety ==
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| No reported overdoses: <br>Today, no deaths have ever been recorded due to a “cannabis overdose”. Therefore, it is reasonable to assume, from a health perspective, that cannabis is safer than many legal and illegal drugs.<ref>Internet]. Overdose Death Rates. 2015 [cited 2016Apr11]. Retrieved from: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates</ref> "Every 19 minutes someone overdoses from a prescription drug overdose."<ref>Paulozzi L, Baldwin G, Franklin G, Kerlikowske G, Jones C, Ghiya N, et al. CDC Grand Rounds: Prescription Drug Overdoses—a U.S. Epidemic [Internet]. Jamanetwork.com. JAMA ; 2012 [cited 2016Apr15]. Retrieved from: http://jama.jamanetwork.com/article.aspx?articleid=1356004</ref>Therefore, it's safe to assume, that cannabis is safer compared to prescription drugs.
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| <br>Cannabis and the Lungs: <br>A report from The National Institute of Drug Abuse (NIDA) attempted to find a link between cannabis and impaired pulmonary function. Contrary to common public misconception, the report found no link between cannabis and lung disease. In fact, the report found cannabis plays a protective role in lung function. <ref>Tashkin DP, Simmons MS, Sherrill DL, Coulson AH. Heavy habitual marijuana smoking does not cause an accelerated decline in FEV1 with age. Am J Respir Crit Care Med American Journal of Respiratory and Critical Care Medicine. 1997;155(1):141–8.</ref>
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| <br>
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| Cannabis and the Brain: <br>Robert Heath's 1976 study was sensationalized and has since been debunked. Robert Heath's unethical experiment poisoned Rhesus Monkeys with smoke by cutting off their oxygen supply while administering cannabis filled cigarettes. This study is the source of the claim that cannabis causes brain damage. <ref>Harper JW, Heath RG, Myers WA. Effects of cannabis sativa on ultrastructure of the synapse in monkey brain. J Neurosci Res Journal of Neuroscience Research. 1977;3(2):87–93.</ref>
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| <br>
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| Cannabis Compared to Alcohol: <br>A “Comparative risk assessment of alcohol, tobacco, cannabis and other illicit drugs using the margin of exposure approach” states <br> “Specifically, the results confirm that the risk of cannabis may have been overestimated in the past. At least for the endpoint of mortality, the MOE for THC/cannabis in both individual and population-based assessments would be above safety thresholds (e.g. 100 for data based on animal experiments). In contrast, the risk of alcohol may have been commonly underestimated.”<br>Therefore, it can be assumed from a health standpoint, that cannabis is significantly safer than alcohol. <ref>Lachenmeier DW, Rehm J. Comparative risk assessment of alcohol, tobacco, cannabis and other illicit drugs using the margin of exposure approach [Internet]. Scientific Reports. Nature Publishing Group; [cited 2016Apr15]. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4311234/http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4311234</ref>
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| <br>
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| [[Image:Comparative risk MOE assessment.jpg|border|center|600px|Compares the margin of exposure for numerous drugs for daily use.]]<br><br><br><br>
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| == Risks ==
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| Risks:
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| It has been recommended that the age at which medical marijuana exposure can occur needs further research. A J''AMA'' editorial states “brain development occurs until age 25, the endocannabinoid system is involved in brain development, cannabinoid exposure during critical periods of development is associated with long-lasting changes in behavior and cognition." <ref name="Cart Before the Horse" />However, the report does not explcitly state how the long-lasting changes in behavior and cognition could result specifically in adolescent impairments. Furthermore, alcohol is readily available to those 21 years of age and the same discussion is not happening.
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| Physical risks of regular cannabis use in patients include “symptoms of chronic bronchitis and increased rate of respiratory tract infections and pneumonia.” However, cannabis does not need to be smoked therefore these risks can be easily avoided. <ref name="physical risks">Hill KP. Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems. Jama. 2015;313(24):2474–81.</ref>
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| The physical effects of regular cannabis use are mild compared to legal substances like alcohol. Cannabis is 9% addictive in adult users which is less than alcohol, prescription narcotics, and cigarettes.<ref>Arkowitz H. Experts Tell the Truth about Pot [Internet]. Scientific American. [cited 2016Apr13]. Retrieved from: http://www.scientificamerican.com/article/the-truth-about-pot/</ref>
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| The 2015 ''JAMA'' report notes withdrawal symptoms are characterized by “anxiety, irritability, craving, dysphoria, and insomnia.”<ref name="physical risks" /> These withdrawal symptoms are mild compared to alcohol. Alcohol withdrawal can cause seizures<ref>Rogawski MA. Update on the Neurobiology of Alcohol Withdrawal Seizures [Internet]. Epilepsy Currents. Blackwell Science Inc; [cited 2016Apr13]. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1312739/</ref> and is widely available for individuals over 21 years or older even though brain development continues until 25 years of age.<ref>Aamodt S, Cox T. Brain Maturity Extends Well Beyond Teen Years [Internet]. NPR. NPR; [cited 2016Apr14]. Retrieved from: http://www.npr.org/templates/story/story.php?storyid=141164708</ref>
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| <br>
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| Synthetic Cannabinoids are not a safe alternative: Medical cannabis prohibition has created a market many are exploiting, the consequences of which are worse than cannabis itself. Synthetic cannabinoids are no exception. A 2015 ''JAMA ''report stated synthetic cannabinoids can cause adverse health effects that "include but are not limited to excited delirium, acute kidney injury, seizures, psychosis, hallucinations, cardiotoxic effects, coma, and death-with some users dying before they could reach the emergency department." Natural cannabis does not cause these adverse effects and cannot cause death strictly from use. In the report, users stated they tried the synthetic cannabinoids "out of curiosity for experimentation (91%), a desire to get high (89%), to relax (71%), and to get high without risking a positive drug test (71%)." More importantly to note is the sale and manufacturing of these substances flourishes due to lack of regulation. Currently, many shops will market these products as a "safe" form of getting high or as an alternative to cannabis. Marketing aims towards younger individuals who can legally buy these products in "smoke shops" if they are 18 years old which is before the human brain is fully developed. These unsafe and toxic products illustrate a common side effect of prohibition which is people using more harmful products than cannabis under the assumption that they are much safer. <ref>Trecki J, Gerona RR, Schwartz MD. Synthetic Cannabinoid-Related Illnesses and Deaths. Journal of The American Medical Association. 2015Jul9;:103–7.fckLRSynthetic cannabinoids JAMA</ref>
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| <br>
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| Edibles and Proper Dosing: The edibles industry has been under a lot of pressure since recreational marijuana has been implemented. The edibles industry needs to step up its ability to properly dose products for the sake of medical patients seeking relief. <br>A recent research letter in ''JAMA’s'' 2015 issue analyzed edibles from Los Angeles, San Francisco, and Seattle Washingt<ref name="Cart Before the Horse" />on, some of the largest medical cannabis markets in the country. Although the results of the study were limited and are not generalizable they illustrate the need for greater quality control in the medical cannabis industry with respect to accurate dosing specifically with respect to edibles. Over 50% of the edibles in the study were not within the 10% margin of detectable THC and CBD concentrations. 60% of the edibles examined were under-dosed. Many people respond to edibles poorly because they lack education regarding the pharmacological action of them. Edibles take longer to work and are metabolized stronger through the liver. <ref>Sharma P, Murthy P, Bharath MMS. Chemistry, Metabolism, and Toxicology of Cannabis: Clinical Implications [Internet]. Iranian Journal of Psychiatry. Tehran University of Medical Sciences; [cited 2016Apr10]. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3570572/</ref>People lacking education in edibles take too many too quickly not understanding they take time to be absorbed. People need to be more educated regarding edible cannabis products and the industry needs to work on more accurate dosing for the sake of medical patients fighting chronic conditions. <ref>Vandrey R, Raber JC, Raber ME, Douglass B, Miller C, Bonn-Miller MO. Cannabinoid Dose and Label Accuracy in Edible Medical Cannabis Products. Jama. 2015;313(24):2491.</ref><br>
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| <br>
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| Contraindications: According to ''JAMA'' “Explicit contraindications such as schizophrenia, bipolar disorder, or substance dependence need to be identified along with measures to minimize the likelihood that persons with contraindications would be able to obtain medical marijuana.”<ref name="Cart Before the Horse" /> However, these contraindications are not conclusive.
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| == Drug Interactions ==
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| A study in JAMA found a “25% reduction in opioid related deaths in states with medical marijuana programs.”<ref>Hayes MJ, Brown MS. Medical Cannabis Laws and Opioid Mortality [Internet]. JAMA Network. [cited 2016Apr13]. Retrieved from: http://archinte.jamanetwork.com/article.aspx?articleid=1898878</ref> The study states, “Medical marijuana laws, when implemented, may represent a promising approach for stemming runaway rates of nonintentional opioid analgesic effects.” As the epidemic negatively impacts the country, politicians like Elizabeth Warren call for more studies to be done on cannabis to curb the destructive effects of the opioid epidemic.<ref>Holpuch A. Elizabeth Warren asks CDC to consider legal marijuana as alternative painkiller [Internet]. The Guardian. Guardian News and Media; 2016 [cited 2016Apr13]. Retrieved from: http://www.theguardian.com/us-news/2016/feb/12/elizabeth-warren-medical-marijuana-painkiller-opioid-abuse</ref><br>
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| Additionally, “there is some evidence of cross-tolerance between cannabinoids and opioids.”<ref name="Cart Before the Horse" />
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| == Relevance to Physical Therapy ==
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| Few studies have been done in relation to cannabinoids as an adjunct to physical therapy treatment. However, two future areas of research could focus on professional athletic populations and patients with neurological or movement related disorders.
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| Many athletes of various backgrounds and professions support the use of cannabis.
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| It has been reported that over half of the NFL uses cannabis throughout the course of the season.<ref>Freeman M. NFL Players View Pot as a Savior [Internet]. Bleacher Report. [cited 2016Apr13]. Retrieved from: http://bleacherreport.com/articles/2486218-banned-but-bountiful-marijuana-coveted-by-nfl-players-as-invaluable-painkiller</ref><br>
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| Former NFL running back Ricky Williams says, “The teams don’t care, you know, they weren’t trying to take care of me. So, I had to take care of myself. One of the ways I took care of myself was using cannabis.” <ref>Samuel E. Ricky Williams recommends NFL players use marijuana for pain [Internet]. NY Daily News. [cited 2016Apr16]. Retrieved from: http://www.nydailynews.com/sports/football/ricky-williams-recommends-nfl-players-marijuana-pain-article-1.2517890</ref>
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| Former quarterback for the Chicago Bears Jim McMahon reports, "With my chronic pain, all my surgeries I've had. The arthritis. It's getting me through the day. It's helped so many people: epileptics, cancer patients... it helps me every day. I feel a heck of a lot better than when I had to take all those pain pills."<ref>O'leary D. Ex-Bears QB McMahon says medical marijuana got him off pills [Internet]. NY Daily News. [cited 2016Apr16]. Retrieved from: http://www.nydailynews.com/sports/football/ex-bears-qb-mcmahon-medical-marijuana-pills-article-1.2513260</ref><br>
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| In action sports athletic populations cannabis is widely used and accepted. Canadian snowboarder Ross Rebagliati had to fight to keep his gold medal from the 1998 Olympic Games after testing positive for 17 nanograms of THC in a millimeter of his urine. Rebagliati states <br>“It's not like alcohol, where you feel invincible. You can analyze the risk at a higher level and you can make a better decision with your heightened awareness. For an experienced user — and I emphasize experienced user — if you are charging hard, it can give you a brain check, make you more aware of the risks and the opportunities."
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| Seven times X Games Gold Medalist, Tanner Hall, one of the most influential skiers in the world, endorses the use of cannabis. Tanner Hall has suffered severe injuries throughout his career and credits cannabis to help aid his recovery. Hall says, “Drugs are stupid, dude. I know that. Let's keep it natural." Hall continues, "Under the FIS rules, you can drink as much alcohol as you can, take crazy pills with a prescription. But if you happen to set that little tree on fire and smell it, you're out. Think about that. Big up to Washington and Colorado for leading the charge."<ref>Blevins J. Acceptance of pot grows like weeds in sports world [Internet]. - The Denver Post. [cited 2016Apr16]. Retrieved from: http://www.denverpost.com/marijuana/ci_24809236/acceptance-pot-grows-like-weeds</ref><br>
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| Based off these subjective reports, physical therapists could evaluate the effects of cannabis and develop ways to objectively report differences in performance in athletic populations.
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| It is well documented that exercise is neuroprotective. Many people are limited in their ability to exercise as a result of pain, spasticity, or neurological problems such as unremitting seizures. Cannabis’ ability to reduce pain, reduce spasticity, and reduce seizures could alter the course of a patient’s physical therapy care. More research needs to be conducted regarding physical therapy and cannabis therapeutics. Based off of clinical research done on cannabis and its effects on parkinson’s disease, epilepsy, spasticity and pain associated with multiple sclerosis and paraplegia, it is reasonable to propose research interventions combining both exercise and cannabis. Additionally, the role of a physical therapist is to advocate for patients. If a physical therapist notes improvement in a chronic condition due to the use of cannabis, then he or she should advocate for access to the substance.
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| == Case Reports/ Case Studies:<br> ==
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| This page will be continually updated in the future.
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| HIV:<br>Woolridge E, Barton S, Samuel J, Osorio J, Dougherty A, Holdcroft A. Cannabis use in HIV for pain and other medical symptoms. J Pain Symptom Manage 2005;29(4):358-67.<br>http://www.ncbi.nlm.nih.gov/pubmed/15857739
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| Multiple Sclerosis:
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| Consroe P, Musty R, Rein J, Tillery W, Pertwee R. The perceived effects of smoked cannabis on patients with multiple sclerosis. European Neurology 1997;38:44-48.<br>http://www.ncbi.nlm.nih.gov/pubmed/9252798
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| Chong MS, Wolff K, Wise K, Tanton C, Winstock A, Silber E. Cannabis use in patients with multiple sclerosis. Mult Scler 2006;12(5):646-51.<br>http://www.ncbi.nlm.nih.gov/pubmed/17086912
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| Spinal Cord Injury:
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| Malec J, Harvey RF, Cayner JJ. Cannabis effect on spasticity in spinal cord injury. Archives of Physical Medicine and Rehabilitation 1982;63:116-118.<br>http://www.ncbi.nlm.nih.gov/pubmed/6978699
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| Crohn's Disease: <br>Lal S, Prasad N, Ryan M, Tangri S, Silverberg MS, Gordon A, Steinhart H. Cannabis use amongst patients with inflammatory bowel disease. Eur J Gastroenterol Hepatol 2011;23(10):891-6.<br>http://www.ncbi.nlm.nih.gov/pubmed/21795981<br><br>
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| == Resources <br> ==
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| For information regarding your states cannabis laws: <br>http://norml.org/
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| For information regarding which strains you or your patient's are using:
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| https://www.leafly.com/
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| For information regarding cannabis therapeutics for different conditions including veterans: <br>http://www.safeaccessnow.org/
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| Realm of Caring: Pediatric Epilepsy
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| https://www.theroc.us/
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| Information on legal issues: Marijuana policy project:
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| https://www.mpp.org/
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| Drug policy information:
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| http://www.drugpolicy.org/
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| <br><br>
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| == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
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| see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
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| <div class="researchbox">
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| <rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=169y_86ceC_-bu0xhVp8W0LNFt6JjWkKQVWt20NBFGwPUebovR|charset=UTF-8|short|max=10</rss>
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| </div>
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| == References ==
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| see [[Adding References|adding references tutorial]].
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| | ==References== |
| <references /> | | <references /> |
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| [[Category:Bellarmine_Student_Project]] | | [[Category:Bellarmine_Student_Project]] |
| | [[Category:Global Health]] |
| | [[Category:Pharmacology]] |
| | [[Category:Pain]] |
