21032018

1

CANNABIS RXMedical Marijuana and the Role of the Pharmacist

By Al Domeika RPh

Dispensary Facility Manager

Prime Wellness of Connecticut

21032018

2

CANNABIS RXMedical Marijuana and the Role of the Pharmacist

By Al Domeika RPh

Dispensary Facility Manager

Prime Wellness of Connecticut

9 | March 2018

Learn the history of cannabis and understand the current laws regarding usage and dispensing cannabis

products

One

Learning

Objectives

Gain knowledge on the pharmacology

of the different components of the

marijuana plant

Two

Learn the different modes of delivery a patient may use cannabis

Three

Learn about drug interactions contraindications and safety concerns regarding cannabis use

Four

Understand the pharmacists role when speaking with patients who use cannabis

Five

10 | March 2018

I DO NOT HAVE any financial arrangements or affiliations with any of the corporate organizations offering

financial support or educational grants to this CME program

bull

Disclosure

Some of the content of my presentation will include discussion of medicinal uses of marijuana products and their

chemical composition that are anecdotal and are not corroborated by the FDA

bull

11 | March 2018

First recorded use in 2737 BC by Chinese

emperor Shen-Nung

History

Effective in treating pain associated with

rheumatoid arthritis

and gout

In 1619 law was passed for farmers in American colonies to grow hemp

History

Useful in making clothing sails and rope

21032018

3

13 | March 2018

Marijuana was restricted by the US Marijuana

Tax Act of 1937

History

Imposed a huge tax that made use and

sale of marijuana

almost impossible

Between 1850-1942 marijuana was listed in the US Pharmacopoeia as a useful medicine for nausea

rheumatism and labor pains

History

Easily accessible in pharmacies and local stores

15 | March 2018

The Controlled Substance Act of 1970 classified marijuana

as a Schedule I drug

History

Made it illegal to possess use buy sell and grow marijuana

In 2003 Canada was the first country in the world to offer medical marijuana to pain-

suffering patients

History

17 | March 2018

In 1996 California became the first state to allow medical marijuana for patients

with a valid doctorrsquos recommendation

History

Other states followedhellip

18 | March 2018

21032018

4

19 | March 2018

Adopted in 2013 urged federal prosecutors to not use resources to prosecute people and

businesses who are compliant with their statersquos marijuana laws

Federal prosecutors should shift their focus on

bull Distribution of marijuana to minors

bull Preventing revenue from the sale of marijuana to criminal enterprises

bull Preventing the diversion of marijuana from states where it is legal under state law in some

form to other states

bull Preventing state-authorized marijuana activity from being used as a cover or pretext for

the trafficking of other illegal drugs or other illegal activity

bull Preventing violence and the use of firearms in the cultivation and

distribution of marijuana

bull Preventing drugged driving and the exacerbation of other

adverse public health consequences associated with marijuana

bull Preventing the growing of marijuana on public lands and

bull Preventing marijuana possession or use on federal property

Jeff Sessions rescinded this memo on January 4th 2018

Cole Memo

20 | March 2018

VIRGINIA LAWS AND PENALTIESOffense Penalty Incarceration Max Fine

Possession

Less than 12 oz (first offense) Misdemeanor 30 days $500

Less than 12 oz (subsequentoffenses)

Misdemeanor 1 year $2500

SaleManufactureTrafficking

frac12 ounce to 5 pounds Felony 1 to 10 years $2500

5 pounds to 100 kg Felony 5 to 30 years $1000

More than 100 kg Felony 20 years to life $100000

To a minor who is at least 3 years younger

Felony 2 to 50 years $100000

Within 1000 feet of school or school bus stop

Felony 1 to 5 years $100000

Manufacture of marijuana Felony 5 to 30 years $10000

Transporting more than 5 lb into the state

Felony 5 to 40 years $1000000

Mandatory Minimum Sentence

21 | March 2018

Year Passed

1 2015

Statute

2 Va Code Ann sect 32-4112 (2015)

Summary

3 Senate Bill 955 allows for the cultivation of industrial hemp by licensed growers of

industrial hemp as part of a university-managed research program The

Department of Agriculture and Consumer Services is in charge of regulating

and establishing industrial hemp research programs by public institutions of

higher education

Virginia Hemp Law

22 | March 2018

Law Signed

1 2015

Qualifying Condition

2 Intractable Epilepsy

Summary

3bull Gives protection to those who are in possession of cannabidiol oil or THC-A oil

(contains at least 15 of CBD or THC-A and less than 5 of THC)

bull Must have a written valid certification issued from a practitioner in the realm of

practice to treat epilepsy

bull No current dispensaries but in 2016 legislation was passed to establish regulations

for the manufacturing of therapeutic oils containing CBD andor THC-A

VIRGINIA CBD-SPECIFIC MARIJUANA LAW

23 | March 2018

Summary

1

bull Bills to expand certifications to include ldquoany diagnosed condition or disease

determined by the practitioner to benefit from such userdquo

bull HB 1251 also increases supply of CBD oil or THC-A oil a processor may dispense

from a 30 day supply to a 90 day supply

bull SB 726 passed 38-0 on 01292018

bull HB 1251 passed 98-0 on 02022018

SB 726 amp HB 1251

24 | March 2018

Minnesota New York Arkansas

STATES THAT UTILIZE PHARMACISTS TO DISPENSE CANNABIS

Pennsylvania Connecticut

Not Yet Operational

21032018

5

CONNECTICUT MARIJUANA LAWSPublic Act 12-55 An Act Concerning the Palliative Use of Marijuana signed into law on May 31 2012 (the ldquoActrdquo)

Designed to enable truly sick patients to engage in the palliative use of marijuana while preventing marijuana from being misused or diverted from its medical purpose

Provides immunity from state criminal and civil penalties for physicians patients caregivers dispensaries and producers who act responsibly in accordance with the law

CONNECTICUT MARIJUANA LAWS

Changed classification from a Schedule I drug to a Schedule II drug

Only pharmacy technicians that have had an active Connecticut pharmacy technician license within 5 years may apply for a dispensary technician license and sell marijuana product

Only pharmacists may apply for a dispensary license and dispense marijuana product

Qualifying Conditions

bull Cancer

bull Glaucoma

bull Positive Status for Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome

bull Parkinsons Disease

bull Multiple Sclerosis

bull Damage to the Nervous Tissue of the Spinal Cord with Objective Neurological Indication of Intractable Spasticity

bull Epilepsy

bull Cachexia

bull Wasting Syndrome

bull Crohns Disease

bull Post-Traumatic Stress Disorder

bull Sickle Cell Disease

bull Post Laminectomy Syndrome with

Chronic Radiculopathy

bull Severe Psoriasis and Psoriatic Arthritis

bull Amyotrophic Lateral Sclerosis

bull Ulcerative Colitis

bull Complex Regional Pain Syndrome28 | March 2018

Patients 18 years

of age or older

Cerebral Palsy

Cystic Fibrosis

Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Terminal Illness Requiring End-Of-Life Care

Uncontrolled Intractable Seizure Disorder

New Debilitating Medical Conditions - Effective 1012016

Patients less than

18 years of age

Cerebral Palsy

Cystic Fibrosis

Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Severe Epilepsy

Terminal Illness Requiring End-Of-Life Care

Uncontrolled Intractable Seizure Disorder

bull Possess an active Connecticut medical license issued by

the Connecticut Department of Public Health

bull Practice within the State of Connecticut

bull Possess an active controlled substance registration

issued by the Connecticut Department of Consumer

Protection that is not subject to limitation

bull Possess an active Drug Enforcement

Administration (DEA) controlled substance

registration that is not subject to limitation

bull Be registered with and able to access the

Connecticut Prescription

Monitoring Program

Physician Requirements

bull Completed a medically reasonable assessment of the patientrsquos medical

history and current medical condition

bull Diagnosed the patient as having a debilitating medical condition

bull Prescribed or determined it is not in the best interest to prescribe

prescription drugs to address the symptoms or effects for which the

certification is being issued

bull Concluded that in the physicianrsquos medical opinion the potential benefits

of the palliative use of marijuana would likely outweigh the health risks to

the patient and

bull Explained the potential risks and benefits of the palliative use of marijuana

to the patient or where the patient lacks legal capacity to the parent

guardian or other person having legal custody of the patient

Physician Requirements

21032018

2

CANNABIS RXMedical Marijuana and the Role of the Pharmacist

By Al Domeika RPh

Dispensary Facility Manager

Prime Wellness of Connecticut

9 | March 2018

Learn the history of cannabis and understand the current laws regarding usage and dispensing cannabis

products

One

Learning

Objectives

Gain knowledge on the pharmacology

of the different components of the

marijuana plant

Two

Learn the different modes of delivery a patient may use cannabis

Three

Learn about drug interactions contraindications and safety concerns regarding cannabis use

Four

Understand the pharmacists role when speaking with patients who use cannabis

Five

10 | March 2018

I DO NOT HAVE any financial arrangements or affiliations with any of the corporate organizations offering

financial support or educational grants to this CME program

bull

Disclosure

Some of the content of my presentation will include discussion of medicinal uses of marijuana products and their

chemical composition that are anecdotal and are not corroborated by the FDA

bull

11 | March 2018

First recorded use in 2737 BC by Chinese

emperor Shen-Nung

History

Effective in treating pain associated with

rheumatoid arthritis

and gout

In 1619 law was passed for farmers in American colonies to grow hemp

History

Useful in making clothing sails and rope

21032018

3

13 | March 2018

Marijuana was restricted by the US Marijuana

Tax Act of 1937

History

Imposed a huge tax that made use and

sale of marijuana

almost impossible

Between 1850-1942 marijuana was listed in the US Pharmacopoeia as a useful medicine for nausea

rheumatism and labor pains

History

Easily accessible in pharmacies and local stores

15 | March 2018

The Controlled Substance Act of 1970 classified marijuana

as a Schedule I drug

History

Made it illegal to possess use buy sell and grow marijuana

In 2003 Canada was the first country in the world to offer medical marijuana to pain-

suffering patients

History

17 | March 2018

In 1996 California became the first state to allow medical marijuana for patients

with a valid doctorrsquos recommendation

History

Other states followedhellip

18 | March 2018

21032018

4

19 | March 2018

Adopted in 2013 urged federal prosecutors to not use resources to prosecute people and

businesses who are compliant with their statersquos marijuana laws

Federal prosecutors should shift their focus on

bull Distribution of marijuana to minors

bull Preventing revenue from the sale of marijuana to criminal enterprises

bull Preventing the diversion of marijuana from states where it is legal under state law in some

form to other states

bull Preventing state-authorized marijuana activity from being used as a cover or pretext for

the trafficking of other illegal drugs or other illegal activity

bull Preventing violence and the use of firearms in the cultivation and

distribution of marijuana

bull Preventing drugged driving and the exacerbation of other

adverse public health consequences associated with marijuana

bull Preventing the growing of marijuana on public lands and

bull Preventing marijuana possession or use on federal property

Jeff Sessions rescinded this memo on January 4th 2018

Cole Memo

20 | March 2018

VIRGINIA LAWS AND PENALTIESOffense Penalty Incarceration Max Fine

Possession

Less than 12 oz (first offense) Misdemeanor 30 days $500

Less than 12 oz (subsequentoffenses)

Misdemeanor 1 year $2500

SaleManufactureTrafficking

frac12 ounce to 5 pounds Felony 1 to 10 years $2500

5 pounds to 100 kg Felony 5 to 30 years $1000

More than 100 kg Felony 20 years to life $100000

To a minor who is at least 3 years younger

Felony 2 to 50 years $100000

Within 1000 feet of school or school bus stop

Felony 1 to 5 years $100000

Manufacture of marijuana Felony 5 to 30 years $10000

Transporting more than 5 lb into the state

Felony 5 to 40 years $1000000

Mandatory Minimum Sentence

21 | March 2018

Year Passed

1 2015

Statute

2 Va Code Ann sect 32-4112 (2015)

Summary

3 Senate Bill 955 allows for the cultivation of industrial hemp by licensed growers of

industrial hemp as part of a university-managed research program The

Department of Agriculture and Consumer Services is in charge of regulating

and establishing industrial hemp research programs by public institutions of

higher education

Virginia Hemp Law

22 | March 2018

Law Signed

1 2015

Qualifying Condition

2 Intractable Epilepsy

Summary

3bull Gives protection to those who are in possession of cannabidiol oil or THC-A oil

(contains at least 15 of CBD or THC-A and less than 5 of THC)

bull Must have a written valid certification issued from a practitioner in the realm of

practice to treat epilepsy

bull No current dispensaries but in 2016 legislation was passed to establish regulations

for the manufacturing of therapeutic oils containing CBD andor THC-A

VIRGINIA CBD-SPECIFIC MARIJUANA LAW

23 | March 2018

Summary

1

bull Bills to expand certifications to include ldquoany diagnosed condition or disease

determined by the practitioner to benefit from such userdquo

bull HB 1251 also increases supply of CBD oil or THC-A oil a processor may dispense

from a 30 day supply to a 90 day supply

bull SB 726 passed 38-0 on 01292018

bull HB 1251 passed 98-0 on 02022018

SB 726 amp HB 1251

24 | March 2018

Minnesota New York Arkansas

STATES THAT UTILIZE PHARMACISTS TO DISPENSE CANNABIS

Pennsylvania Connecticut

Not Yet Operational

21032018

5

CONNECTICUT MARIJUANA LAWSPublic Act 12-55 An Act Concerning the Palliative Use of Marijuana signed into law on May 31 2012 (the ldquoActrdquo)

Designed to enable truly sick patients to engage in the palliative use of marijuana while preventing marijuana from being misused or diverted from its medical purpose

Provides immunity from state criminal and civil penalties for physicians patients caregivers dispensaries and producers who act responsibly in accordance with the law

CONNECTICUT MARIJUANA LAWS

Changed classification from a Schedule I drug to a Schedule II drug

Only pharmacy technicians that have had an active Connecticut pharmacy technician license within 5 years may apply for a dispensary technician license and sell marijuana product

Only pharmacists may apply for a dispensary license and dispense marijuana product

Qualifying Conditions

bull Cancer

bull Glaucoma

bull Positive Status for Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome

bull Parkinsons Disease

bull Multiple Sclerosis

bull Damage to the Nervous Tissue of the Spinal Cord with Objective Neurological Indication of Intractable Spasticity

bull Epilepsy

bull Cachexia

bull Wasting Syndrome

bull Crohns Disease

bull Post-Traumatic Stress Disorder

bull Sickle Cell Disease

bull Post Laminectomy Syndrome with

Chronic Radiculopathy

bull Severe Psoriasis and Psoriatic Arthritis

bull Amyotrophic Lateral Sclerosis

bull Ulcerative Colitis

bull Complex Regional Pain Syndrome28 | March 2018

Patients 18 years

of age or older

Cerebral Palsy

Cystic Fibrosis

Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Terminal Illness Requiring End-Of-Life Care

Uncontrolled Intractable Seizure Disorder

New Debilitating Medical Conditions - Effective 1012016

Patients less than

18 years of age

Cerebral Palsy

Cystic Fibrosis

Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Severe Epilepsy

Terminal Illness Requiring End-Of-Life Care

Uncontrolled Intractable Seizure Disorder

bull Possess an active Connecticut medical license issued by

the Connecticut Department of Public Health

bull Practice within the State of Connecticut

bull Possess an active controlled substance registration

issued by the Connecticut Department of Consumer

Protection that is not subject to limitation

bull Possess an active Drug Enforcement

Administration (DEA) controlled substance

registration that is not subject to limitation

bull Be registered with and able to access the

Connecticut Prescription

Monitoring Program

Physician Requirements

bull Completed a medically reasonable assessment of the patientrsquos medical

history and current medical condition

bull Diagnosed the patient as having a debilitating medical condition

bull Prescribed or determined it is not in the best interest to prescribe

prescription drugs to address the symptoms or effects for which the

certification is being issued

bull Concluded that in the physicianrsquos medical opinion the potential benefits

of the palliative use of marijuana would likely outweigh the health risks to

the patient and

bull Explained the potential risks and benefits of the palliative use of marijuana

to the patient or where the patient lacks legal capacity to the parent

guardian or other person having legal custody of the patient

Physician Requirements

21032018

3

13 | March 2018

Marijuana was restricted by the US Marijuana

Tax Act of 1937

History

Imposed a huge tax that made use and

sale of marijuana

almost impossible

Between 1850-1942 marijuana was listed in the US Pharmacopoeia as a useful medicine for nausea

rheumatism and labor pains

History

Easily accessible in pharmacies and local stores

15 | March 2018

The Controlled Substance Act of 1970 classified marijuana

as a Schedule I drug

History

Made it illegal to possess use buy sell and grow marijuana

In 2003 Canada was the first country in the world to offer medical marijuana to pain-

suffering patients

History

17 | March 2018

In 1996 California became the first state to allow medical marijuana for patients

with a valid doctorrsquos recommendation

History

Other states followedhellip

18 | March 2018

21032018

4

19 | March 2018

Adopted in 2013 urged federal prosecutors to not use resources to prosecute people and

businesses who are compliant with their statersquos marijuana laws

Federal prosecutors should shift their focus on

bull Distribution of marijuana to minors

bull Preventing revenue from the sale of marijuana to criminal enterprises

bull Preventing the diversion of marijuana from states where it is legal under state law in some

form to other states

bull Preventing state-authorized marijuana activity from being used as a cover or pretext for

the trafficking of other illegal drugs or other illegal activity

bull Preventing violence and the use of firearms in the cultivation and

distribution of marijuana

bull Preventing drugged driving and the exacerbation of other

adverse public health consequences associated with marijuana

bull Preventing the growing of marijuana on public lands and

bull Preventing marijuana possession or use on federal property

Jeff Sessions rescinded this memo on January 4th 2018

Cole Memo

20 | March 2018

VIRGINIA LAWS AND PENALTIESOffense Penalty Incarceration Max Fine

Possession

Less than 12 oz (first offense) Misdemeanor 30 days $500

Less than 12 oz (subsequentoffenses)

Misdemeanor 1 year $2500

SaleManufactureTrafficking

frac12 ounce to 5 pounds Felony 1 to 10 years $2500

5 pounds to 100 kg Felony 5 to 30 years $1000

More than 100 kg Felony 20 years to life $100000

To a minor who is at least 3 years younger

Felony 2 to 50 years $100000

Within 1000 feet of school or school bus stop

Felony 1 to 5 years $100000

Manufacture of marijuana Felony 5 to 30 years $10000

Transporting more than 5 lb into the state

Felony 5 to 40 years $1000000

Mandatory Minimum Sentence

21 | March 2018

Year Passed

1 2015

Statute

2 Va Code Ann sect 32-4112 (2015)

Summary

3 Senate Bill 955 allows for the cultivation of industrial hemp by licensed growers of

industrial hemp as part of a university-managed research program The

Department of Agriculture and Consumer Services is in charge of regulating

and establishing industrial hemp research programs by public institutions of

higher education

Virginia Hemp Law

22 | March 2018

Law Signed

1 2015

Qualifying Condition

2 Intractable Epilepsy

Summary

3bull Gives protection to those who are in possession of cannabidiol oil or THC-A oil

(contains at least 15 of CBD or THC-A and less than 5 of THC)

bull Must have a written valid certification issued from a practitioner in the realm of

practice to treat epilepsy

bull No current dispensaries but in 2016 legislation was passed to establish regulations

for the manufacturing of therapeutic oils containing CBD andor THC-A

VIRGINIA CBD-SPECIFIC MARIJUANA LAW

23 | March 2018

Summary

1

bull Bills to expand certifications to include ldquoany diagnosed condition or disease

determined by the practitioner to benefit from such userdquo

bull HB 1251 also increases supply of CBD oil or THC-A oil a processor may dispense

from a 30 day supply to a 90 day supply

bull SB 726 passed 38-0 on 01292018

bull HB 1251 passed 98-0 on 02022018

SB 726 amp HB 1251

24 | March 2018

Minnesota New York Arkansas

STATES THAT UTILIZE PHARMACISTS TO DISPENSE CANNABIS

Pennsylvania Connecticut

Not Yet Operational

21032018

5

CONNECTICUT MARIJUANA LAWSPublic Act 12-55 An Act Concerning the Palliative Use of Marijuana signed into law on May 31 2012 (the ldquoActrdquo)

Designed to enable truly sick patients to engage in the palliative use of marijuana while preventing marijuana from being misused or diverted from its medical purpose

Provides immunity from state criminal and civil penalties for physicians patients caregivers dispensaries and producers who act responsibly in accordance with the law

CONNECTICUT MARIJUANA LAWS

Changed classification from a Schedule I drug to a Schedule II drug

Only pharmacy technicians that have had an active Connecticut pharmacy technician license within 5 years may apply for a dispensary technician license and sell marijuana product

Only pharmacists may apply for a dispensary license and dispense marijuana product

Qualifying Conditions

bull Cancer

bull Glaucoma

bull Positive Status for Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome

bull Parkinsons Disease

bull Multiple Sclerosis

bull Damage to the Nervous Tissue of the Spinal Cord with Objective Neurological Indication of Intractable Spasticity

bull Epilepsy

bull Cachexia

bull Wasting Syndrome

bull Crohns Disease

bull Post-Traumatic Stress Disorder

bull Sickle Cell Disease

bull Post Laminectomy Syndrome with

Chronic Radiculopathy

bull Severe Psoriasis and Psoriatic Arthritis

bull Amyotrophic Lateral Sclerosis

bull Ulcerative Colitis

bull Complex Regional Pain Syndrome28 | March 2018

Patients 18 years

of age or older

Cerebral Palsy

Cystic Fibrosis

Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Terminal Illness Requiring End-Of-Life Care

Uncontrolled Intractable Seizure Disorder

New Debilitating Medical Conditions - Effective 1012016

Patients less than

18 years of age

Cerebral Palsy

Cystic Fibrosis

Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Severe Epilepsy

Terminal Illness Requiring End-Of-Life Care

Uncontrolled Intractable Seizure Disorder

bull Possess an active Connecticut medical license issued by

the Connecticut Department of Public Health

bull Practice within the State of Connecticut

bull Possess an active controlled substance registration

issued by the Connecticut Department of Consumer

Protection that is not subject to limitation

bull Possess an active Drug Enforcement

Administration (DEA) controlled substance

registration that is not subject to limitation

bull Be registered with and able to access the

Connecticut Prescription

Monitoring Program

Physician Requirements

bull Completed a medically reasonable assessment of the patientrsquos medical

history and current medical condition

bull Diagnosed the patient as having a debilitating medical condition

bull Prescribed or determined it is not in the best interest to prescribe

prescription drugs to address the symptoms or effects for which the

certification is being issued

bull Concluded that in the physicianrsquos medical opinion the potential benefits

of the palliative use of marijuana would likely outweigh the health risks to

the patient and

bull Explained the potential risks and benefits of the palliative use of marijuana

to the patient or where the patient lacks legal capacity to the parent

guardian or other person having legal custody of the patient

Physician Requirements

21032018

4

19 | March 2018

Adopted in 2013 urged federal prosecutors to not use resources to prosecute people and

businesses who are compliant with their statersquos marijuana laws

Federal prosecutors should shift their focus on

bull Distribution of marijuana to minors

bull Preventing revenue from the sale of marijuana to criminal enterprises

bull Preventing the diversion of marijuana from states where it is legal under state law in some

form to other states

bull Preventing state-authorized marijuana activity from being used as a cover or pretext for

the trafficking of other illegal drugs or other illegal activity

bull Preventing violence and the use of firearms in the cultivation and

distribution of marijuana

bull Preventing drugged driving and the exacerbation of other

adverse public health consequences associated with marijuana

bull Preventing the growing of marijuana on public lands and

bull Preventing marijuana possession or use on federal property

Jeff Sessions rescinded this memo on January 4th 2018

Cole Memo

20 | March 2018

VIRGINIA LAWS AND PENALTIESOffense Penalty Incarceration Max Fine

Possession

Less than 12 oz (first offense) Misdemeanor 30 days $500

Less than 12 oz (subsequentoffenses)

Misdemeanor 1 year $2500

SaleManufactureTrafficking

frac12 ounce to 5 pounds Felony 1 to 10 years $2500

5 pounds to 100 kg Felony 5 to 30 years $1000

More than 100 kg Felony 20 years to life $100000

To a minor who is at least 3 years younger

Felony 2 to 50 years $100000

Within 1000 feet of school or school bus stop

Felony 1 to 5 years $100000

Manufacture of marijuana Felony 5 to 30 years $10000

Transporting more than 5 lb into the state

Felony 5 to 40 years $1000000

Mandatory Minimum Sentence

21 | March 2018

Year Passed

1 2015

Statute

2 Va Code Ann sect 32-4112 (2015)

Summary

3 Senate Bill 955 allows for the cultivation of industrial hemp by licensed growers of

industrial hemp as part of a university-managed research program The

Department of Agriculture and Consumer Services is in charge of regulating

and establishing industrial hemp research programs by public institutions of

higher education

Virginia Hemp Law

22 | March 2018

Law Signed

1 2015

Qualifying Condition

2 Intractable Epilepsy

Summary

3bull Gives protection to those who are in possession of cannabidiol oil or THC-A oil

(contains at least 15 of CBD or THC-A and less than 5 of THC)

bull Must have a written valid certification issued from a practitioner in the realm of

practice to treat epilepsy

bull No current dispensaries but in 2016 legislation was passed to establish regulations

for the manufacturing of therapeutic oils containing CBD andor THC-A

VIRGINIA CBD-SPECIFIC MARIJUANA LAW

23 | March 2018

Summary

1

bull Bills to expand certifications to include ldquoany diagnosed condition or disease

determined by the practitioner to benefit from such userdquo

bull HB 1251 also increases supply of CBD oil or THC-A oil a processor may dispense

from a 30 day supply to a 90 day supply

bull SB 726 passed 38-0 on 01292018

bull HB 1251 passed 98-0 on 02022018

SB 726 amp HB 1251

24 | March 2018

Minnesota New York Arkansas

STATES THAT UTILIZE PHARMACISTS TO DISPENSE CANNABIS

Pennsylvania Connecticut

Not Yet Operational

21032018

5

CONNECTICUT MARIJUANA LAWSPublic Act 12-55 An Act Concerning the Palliative Use of Marijuana signed into law on May 31 2012 (the ldquoActrdquo)

Designed to enable truly sick patients to engage in the palliative use of marijuana while preventing marijuana from being misused or diverted from its medical purpose

Provides immunity from state criminal and civil penalties for physicians patients caregivers dispensaries and producers who act responsibly in accordance with the law

CONNECTICUT MARIJUANA LAWS

Changed classification from a Schedule I drug to a Schedule II drug

Only pharmacy technicians that have had an active Connecticut pharmacy technician license within 5 years may apply for a dispensary technician license and sell marijuana product

Only pharmacists may apply for a dispensary license and dispense marijuana product

Qualifying Conditions

bull Cancer

bull Glaucoma

bull Positive Status for Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome

bull Parkinsons Disease

bull Multiple Sclerosis

bull Damage to the Nervous Tissue of the Spinal Cord with Objective Neurological Indication of Intractable Spasticity

bull Epilepsy

bull Cachexia

bull Wasting Syndrome

bull Crohns Disease

bull Post-Traumatic Stress Disorder

bull Sickle Cell Disease

bull Post Laminectomy Syndrome with

Chronic Radiculopathy

bull Severe Psoriasis and Psoriatic Arthritis

bull Amyotrophic Lateral Sclerosis

bull Ulcerative Colitis

bull Complex Regional Pain Syndrome28 | March 2018

Patients 18 years

of age or older

Cerebral Palsy

Cystic Fibrosis

Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Terminal Illness Requiring End-Of-Life Care

Uncontrolled Intractable Seizure Disorder

New Debilitating Medical Conditions - Effective 1012016

Patients less than

18 years of age

Cerebral Palsy

Cystic Fibrosis

Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Severe Epilepsy

Terminal Illness Requiring End-Of-Life Care

Uncontrolled Intractable Seizure Disorder

bull Possess an active Connecticut medical license issued by

the Connecticut Department of Public Health

bull Practice within the State of Connecticut

bull Possess an active controlled substance registration

issued by the Connecticut Department of Consumer

Protection that is not subject to limitation

bull Possess an active Drug Enforcement

Administration (DEA) controlled substance

registration that is not subject to limitation

bull Be registered with and able to access the

Connecticut Prescription

Monitoring Program

Physician Requirements

bull Completed a medically reasonable assessment of the patientrsquos medical

history and current medical condition

bull Diagnosed the patient as having a debilitating medical condition

bull Prescribed or determined it is not in the best interest to prescribe

prescription drugs to address the symptoms or effects for which the

certification is being issued

bull Concluded that in the physicianrsquos medical opinion the potential benefits

of the palliative use of marijuana would likely outweigh the health risks to

the patient and

bull Explained the potential risks and benefits of the palliative use of marijuana

to the patient or where the patient lacks legal capacity to the parent

guardian or other person having legal custody of the patient

Physician Requirements

21032018

5

CONNECTICUT MARIJUANA LAWSPublic Act 12-55 An Act Concerning the Palliative Use of Marijuana signed into law on May 31 2012 (the ldquoActrdquo)

Designed to enable truly sick patients to engage in the palliative use of marijuana while preventing marijuana from being misused or diverted from its medical purpose

Provides immunity from state criminal and civil penalties for physicians patients caregivers dispensaries and producers who act responsibly in accordance with the law

CONNECTICUT MARIJUANA LAWS

Changed classification from a Schedule I drug to a Schedule II drug

Only pharmacy technicians that have had an active Connecticut pharmacy technician license within 5 years may apply for a dispensary technician license and sell marijuana product

Only pharmacists may apply for a dispensary license and dispense marijuana product

Qualifying Conditions

bull Cancer

bull Glaucoma

bull Positive Status for Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome

bull Parkinsons Disease

bull Multiple Sclerosis

bull Damage to the Nervous Tissue of the Spinal Cord with Objective Neurological Indication of Intractable Spasticity

bull Epilepsy

bull Cachexia

bull Wasting Syndrome

bull Crohns Disease

bull Post-Traumatic Stress Disorder

bull Sickle Cell Disease

bull Post Laminectomy Syndrome with

Chronic Radiculopathy

bull Severe Psoriasis and Psoriatic Arthritis

bull Amyotrophic Lateral Sclerosis

bull Ulcerative Colitis

bull Complex Regional Pain Syndrome28 | March 2018

Patients 18 years

of age or older

Cerebral Palsy

Cystic Fibrosis

Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Terminal Illness Requiring End-Of-Life Care

Uncontrolled Intractable Seizure Disorder

New Debilitating Medical Conditions - Effective 1012016

Patients less than

18 years of age

Cerebral Palsy

Cystic Fibrosis

Irreversible Spinal Cord Injury with Objective Neurological Indication of Intractable Spasticity

Severe Epilepsy

Terminal Illness Requiring End-Of-Life Care

Uncontrolled Intractable Seizure Disorder

bull Possess an active Connecticut medical license issued by

the Connecticut Department of Public Health

bull Practice within the State of Connecticut

bull Possess an active controlled substance registration

issued by the Connecticut Department of Consumer

Protection that is not subject to limitation

bull Possess an active Drug Enforcement

Administration (DEA) controlled substance

registration that is not subject to limitation

bull Be registered with and able to access the

Connecticut Prescription

Monitoring Program

Physician Requirements

bull Completed a medically reasonable assessment of the patientrsquos medical

history and current medical condition

bull Diagnosed the patient as having a debilitating medical condition

bull Prescribed or determined it is not in the best interest to prescribe

prescription drugs to address the symptoms or effects for which the

certification is being issued

bull Concluded that in the physicianrsquos medical opinion the potential benefits

of the palliative use of marijuana would likely outweigh the health risks to

the patient and

bull Explained the potential risks and benefits of the palliative use of marijuana

to the patient or where the patient lacks legal capacity to the parent

guardian or other person having legal custody of the patient

Physician Requirements

21032018

6

bull Qualifying patient must be a Connecticut resident

bull Qualifying patient cannot be an inmate confined in a correctional institution or facility under the supervision of

the Connecticut Department of Corrections

Qualifications for a Registration Certificate

INITIAL CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity and Pharmacology

34 | March 2018

Strain Diversity

Sativa Indica

35 | March 2018

bull Produces more euphoric uplifting

energizing effect typically used for daytime

bull Plant grows high with thin whispy leaves

Sativabull Produces more relaxing lethargic body

effects typically used in the evening

bull Plant grows shorter with fatter leaves

Indica

Strain Diversity

TESTING

21032018

7

37 | March 2018

Group of chemical compounds that interact with the endocannabinoid system

CANNABINOIDS

ENDOCANNABINOID SYSTEM

System of the body that controls many body functionsbull Memory

bull Mood

bull Sleep

bull Appetite

bull Pain

bull Immune response

Affects physiological responses

bull Circulation

bull Energy metabolism

bull Organ function

39 | March 2018

CB1 Receptors

Present in the brain and spinal cord

Found in areas concerned with movement postural control pain memory cognition and emotion

Also found in appetite controlling areas like

the hypothalamus

Are NOT present in cardiopulmonary centers in the brain

CANNABINOID RECEPTORS

CB2 Receptors

Expressed primarily in immune tissues

Can mediate regulation of cytokine release from immune cells

May modulate clinical conditions such as inflammatory pain post-operative pain

chronic pain

bull Group of chemical compounds that interact with the endocannabinoid system

bull Found naturally in the body called

endocannabinoids

bull Anandamide

bull 2-Arachidonoylglycerol (2-AG)

bull Found in high concentrations in cannabis

bull Each cannabinoid may have its own or shared therapeutic benefit

CANNABINOIDS

21032018

8

43 | March 2018

bull Known for being strongly psychoactive

bull Stimulates endocannabinoid system by

binding to CB1 and CB2 receptors

THC (d-9 Tetrahydrocannabinol)CANNABINOIDS

bull Health Benefits

gt Analgesicgt Sleep

gt Antidepressantgt Antispasmodicgt Antiemetic

gt Appetite stimulant

gt Antioxidantgt Reduces

intraocular eye pressure

44 | March 2018

bull Does not bind directly to CB1 or CB2 receptors

bull Stimulates activity in both receptors

gt Causes increased release in 2-AG

gt Inhibits activity of fatty acid amide hydroxylase (FAAH)

which slows deterioration of anandamide

bull Inhibits THCrsquos effects on CB1 receptors

bull Binds directly to G-protein coupled

receptor TRPV-1

bull Activates 5-HT1A serotonin receptor

bull Affinity to histamine receptors

bull Found to inhibit ID-1 gene

CBD (Cannabidiol)CANNABINOIDS

45 | March 2018

bull Non-psychoactive

bull Suppresses psychoactivity of THC

bull Ideal for elderly children and patients that prefer to

remain clear-headed

bull Extremely valuable in treating seizure disorders

bull Often as effective as THC in pain management

bull Calming effect

bull Can provide a focusing effect

CBD (Cannabidiol)CANNABINOIDS

46 | March 2018

CBN (Cannabinol)

bull Oxidation process of THC

bull Partial agonist of CB2 receptors and

weak agonist of CB1 receptors

bull Strongly sedative

bull Useful in treatment of insomnia

CANNABINOIDS

CBG (Cannabigerol)

bull Non-psychoactive

bull Inhibits uptake of GABA ndash decreases

anxiety and muscle tension

bull Anti-inflammatory

47 | March 2018

Cannabichromene

bull Non-psychoactive

bull Inflammation pain relief

anxiety stress

CBC

Cannabidiolic

bull Anti-inflammatory

digestive aid

CBD-A

Tetrahydrocannabinolic acid

bull Non-psychoactive

bull Changes to THC after

decarboxylation (heat)

bull Anti-inflammatory

appetite antispasmodic

THC-A

CANNABINOIDS

48 | March 2018

bull Organic hydrocarbons found in the

essential oils in plants that give cannabis

itrsquos aroma

bull Contained in many familiar plants found

in the natural world

bull Every strain has a unique terpene profile

bull Works in synergy with cannabinoids

(entourage effect)

bull Contain separate therapeutic effects

Terpenes

21032018

9

49 | March 2018

Aroma Pine

Also found in pine needles rosemary basil dill

Medicinal value bronchodilator antiseptic anti-inflammatory

Pinene

50 | March 2018

Aroma Musky Earthy

Also found in Mango Thyme Hops

Effects Relaxing Sedating

ldquoCouch-lockrdquo

Medical value Anti-oxidant Muscle tension Pain Inflammation Depression Sleep

Allows THC to take effect more

quickly by allowing it to cross the blood-brain barrier more easily

Myrcene

51 | March 2018

Aroma Citrus

Also found in Fruit rinds Rosemary Peppermint

Medicinal value Anti-fungal Heartburn GI complications Depression Anxiolytic

Limonene

52 | March 2018

Aroma Peppery Spicy

Also found in Black pepper Basil Cloves Cotton

Medical value Gastro-protective Anti-inflammatory Pain relief

May selectively activate CB2 receptors

Caryophyllene

53 | March 2018

Aroma Floral

Also found in Lavender Spring Flowers Rosewood

Medicinal value Calming Effect Anti-Anxiety Sedative Effect Analgesic Anti-

Epileptic

Linalool

54 | March 2018

21032018

10

55 | March 2018 56 | March 2018

INITIAL CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

58 | March 2018

Drug Interactions

59 | March 2018

Drug Interactions

THC metabolized by CYP2C9 and CYP3A4 enzymes

bull Medications that may be increased by THC

administration Amiodarone Atorvastatin

Carvedilol Metoprolol Ritonavir Simvastatin

Verapamil

bull Clopidogrel effects may be decreased

bull Amiodarone Metronidazole Fluoxetine

Fluconazole may inhibit THC elimination

bull Ketoconazole has been shown to increase

peak concentrations of THC

bull Poor metabolizers of CYP2C9 can have THC

concentrations increase three-fold

60 | March 2018

Drug Interactions

THC may also induce CYP1A2 enzyme

bull Smoked cannabis has been shown to

increase the metabolism of theophylline and

chlorpromazine

bull 50 decrease in plasma concentrations

bull Induction seems to be occur in smoked

marijuana not oral administration and is

dose specific

21032018

11

61 | March 2018

Drug Interactions

THC strongly binds to blood plasma proteins

bull Caution patients on warfarin

bull One study has shown an increased response

with a patient smoking 4 to 5 marijuana

cigarettes per week

62 | March 2018

Drug Interactions

CBD is a substrate of CYP3A4 and CYP2C19 enzymes

bull Medications that may have an

increased effect

Amitriptylene

Clobazepam

Diazepam

Propranolol

Warfarin

63 | March 2018

Drug Interactions

Pharmacodynamic interactions should be expected between

marijuana and

bull Drugs with sympathomimetic activity

(tachycardia hypertension)

bull Central nervous system depressants

(drowsiness ataxia) and

bull Drugs with anticholinergic effects

(tachycardia drowsiness)

Cannabis medicines (smoked oral sublingual or vaporized)

may increase effects of

bull Alcohol

bull Benzodiazepines

bull Opiates

64 | March 2018

The Pharmacistrsquos Role

Prescription Monitoring Program (PMP)

bull Controlled substances as well as marijuana card

activation and marijuana purchases will show up on

the report

bull Physicians can monitor patientrsquos usage

bull Before dispensing any marijuana product the

pharmacist checks the PMP

bull Double check to make sure patients remain with one dispensary and are not over their monthly limit

bull Review any new controlled medications that may have been added since last visit and counsel if

appropriate

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

Modes of delivery 66 | March 2018

INHALANTS

21032018

12

67 | March 2018

INHALANTS

Fast-acting produces an effect within 5 minutes

Effects last for approximately 2 hours

Easy to titrate dose

Can cause throat irritation

Hard to determine dosage

Appropriate for patients who need instant relief and to

minimize side effects

68 | March 2018

Inhalants

Smoking

bull Easiest and most widely used

bull Achieved via rolled paper pipes

water pipes

bull Odor can be pronounced

bull No proven association with lung

cancer

bull Not healthiest option

bull Burns off many of the medicinal

properties

Vaporization

bull Heats product without burning

bull ldquoConvection ovenrdquo

bull Avoids irritating toxins

bull Heats product between 250 ndash 400

degrees

bull Less odor and smoke produced

bull Many different varieties of vaporizers on

the market from pens to desktop units

69 | March 2018

Tinctures Sprays Dissolvable Strips

Sublinguals

70 | March 2018

SUBLINGUALS

Under the tongue application

Delayed action (takes approximately 30 minutes

before effect)

Longer duration of action (three to four hours)

Specific dosing

Appropriate for those individuals who need quick relief

who cannot inhale cannabis

71 | March 2018

Edibles Capsules Oils

Consumables

72 | March 2018

CONSUMABLES

Effects delayed (30 minutes to 2 hours)

Effects can last anywhere from 4 to 8 hours

Effects are much stronger

Specific dosing

Bioavailability can range from 10-20

Appropriate for those patients who need long term relief

21032018

13

73 | March 2018

Other Routes of Administration

Topical Rectal74 | March 2018

bull Dronabinol = synthetic delta-9-

tetrahydrocannbinol in sesame oil

bull Lacks other cannabinoids and terpinoids

found in natural cannabis

bull More psychoactive than natural

cannabis

bull Slow onset and poor bioavailability

bull More expensive than natural cannabis

bull Studies have shown that inhaled

cannabis have higher success rates than

oral administration of synthetic THC

What About Marinol

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain Diversity and Pharmacology

Medications

Modes of delivery

Side effects and safety76 | March 2018

Short-Term Side Effects

Mood reactions (euphoria relaxation anxiety time-distortion)

Rapid heartbeat

Facial flushing

Red eyes

Dry mouth

Headaches

Dizziness

Coughing

SIDE EFFECTS

Long-Term Side Effects

Severe chronic bronchitis

Range of cognitive deficits

Receptor down-regulation (decline in receptor density)

77 | March 2018

RisksWarnings

Contraindicationsbull Pregnancy nursingbull Lower birth weightsbull Endocannabinoids involved in several aspects

of fetal and childhood development

bull Cannabinoids are passed along breast milk

bull Serious mental disorders (ie schizophrenia)

Use with caution for patients withbull Heart conditionsbull Respiratory conditions

bull History of drug alcohol abuse

78 | March 2018

RisksWarnings

In case of overdosebull May potentiate worsen side

effects

bull Will resolve after stopping medication

bull Drinking water and eating may help as well as fresh air

bull Do not consume cannabis in a public

place or where it may pose harm to others

bull Never operate a vehicle after consuming marijuana

bull Keep this medicine out of reach of

children or pets

21032018

14

The Pharmacistrsquos Role

80 | March 2018

Massachusetts College of

Pharmacy and Health Sciences

Yale University

Saint Francis Hospital and

Medical Center

Studies

81 | March 2018

Human Reduction Strategy Minimizes harm tobull Individualbull Others impacted by the harmed person

bull SocietyStudies shown benefits when adding cannabis to opioid therapybull Decreased painbull May allow lower doses of opioids = lower side effects

Studies concluded states with medical marijuana laws have lower incidence of opioid mortality rates

Cannabis and Opioids

My Own Opiate Research Project

bull Monitoring MME

bull Document initial MME MME 1 year later

bull October ndash February 2017 October ndash February 2018

bull 65 Total Patientsbull 38 Active Patients (Patients receiving product within 2 months of documentation)

bull 21 Patients decreased MME (55)

bull 11 Patients remained stagnant (29)

bull 6 Patients increased MME (16)

bull 27 Non-Active Patients (Those patients who have not received product within 2 months)

bull 8 Patients decreased MME (30)

bull 11 Patients remained stagnant (40)

bull 8 Patients increased MME (30)

21032018

15

Dependence is estimated to be around 9

bull Nicotine 32

bull Heroin 23

bull Cocaine 17

bull Alcohol 15

bull Stimulants 11

DEPENDENCY

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx

21032018

7

37 | March 2018

Group of chemical compounds that interact with the endocannabinoid system

CANNABINOIDS

ENDOCANNABINOID SYSTEM

System of the body that controls many body functionsbull Memory

bull Mood

bull Sleep

bull Appetite

bull Pain

bull Immune response

Affects physiological responses

bull Circulation

bull Energy metabolism

bull Organ function

39 | March 2018

CB1 Receptors

Present in the brain and spinal cord

Found in areas concerned with movement postural control pain memory cognition and emotion

Also found in appetite controlling areas like

the hypothalamus

Are NOT present in cardiopulmonary centers in the brain

CANNABINOID RECEPTORS

CB2 Receptors

Expressed primarily in immune tissues

Can mediate regulation of cytokine release from immune cells

May modulate clinical conditions such as inflammatory pain post-operative pain

chronic pain

bull Group of chemical compounds that interact with the endocannabinoid system

bull Found naturally in the body called

endocannabinoids

bull Anandamide

bull 2-Arachidonoylglycerol (2-AG)

bull Found in high concentrations in cannabis

bull Each cannabinoid may have its own or shared therapeutic benefit

CANNABINOIDS

21032018

8

43 | March 2018

bull Known for being strongly psychoactive

bull Stimulates endocannabinoid system by

binding to CB1 and CB2 receptors

THC (d-9 Tetrahydrocannabinol)CANNABINOIDS

bull Health Benefits

gt Analgesicgt Sleep

gt Antidepressantgt Antispasmodicgt Antiemetic

gt Appetite stimulant

gt Antioxidantgt Reduces

intraocular eye pressure

44 | March 2018

bull Does not bind directly to CB1 or CB2 receptors

bull Stimulates activity in both receptors

gt Causes increased release in 2-AG

gt Inhibits activity of fatty acid amide hydroxylase (FAAH)

which slows deterioration of anandamide

bull Inhibits THCrsquos effects on CB1 receptors

bull Binds directly to G-protein coupled

receptor TRPV-1

bull Activates 5-HT1A serotonin receptor

bull Affinity to histamine receptors

bull Found to inhibit ID-1 gene

CBD (Cannabidiol)CANNABINOIDS

45 | March 2018

bull Non-psychoactive

bull Suppresses psychoactivity of THC

bull Ideal for elderly children and patients that prefer to

remain clear-headed

bull Extremely valuable in treating seizure disorders

bull Often as effective as THC in pain management

bull Calming effect

bull Can provide a focusing effect

CBD (Cannabidiol)CANNABINOIDS

46 | March 2018

CBN (Cannabinol)

bull Oxidation process of THC

bull Partial agonist of CB2 receptors and

weak agonist of CB1 receptors

bull Strongly sedative

bull Useful in treatment of insomnia

CANNABINOIDS

CBG (Cannabigerol)

bull Non-psychoactive

bull Inhibits uptake of GABA ndash decreases

anxiety and muscle tension

bull Anti-inflammatory

47 | March 2018

Cannabichromene

bull Non-psychoactive

bull Inflammation pain relief

anxiety stress

CBC

Cannabidiolic

bull Anti-inflammatory

digestive aid

CBD-A

Tetrahydrocannabinolic acid

bull Non-psychoactive

bull Changes to THC after

decarboxylation (heat)

bull Anti-inflammatory

appetite antispasmodic

THC-A

CANNABINOIDS

48 | March 2018

bull Organic hydrocarbons found in the

essential oils in plants that give cannabis

itrsquos aroma

bull Contained in many familiar plants found

in the natural world

bull Every strain has a unique terpene profile

bull Works in synergy with cannabinoids

(entourage effect)

bull Contain separate therapeutic effects

Terpenes

21032018

9

49 | March 2018

Aroma Pine

Also found in pine needles rosemary basil dill

Medicinal value bronchodilator antiseptic anti-inflammatory

Pinene

50 | March 2018

Aroma Musky Earthy

Also found in Mango Thyme Hops

Effects Relaxing Sedating

ldquoCouch-lockrdquo

Medical value Anti-oxidant Muscle tension Pain Inflammation Depression Sleep

Allows THC to take effect more

quickly by allowing it to cross the blood-brain barrier more easily

Myrcene

51 | March 2018

Aroma Citrus

Also found in Fruit rinds Rosemary Peppermint

Medicinal value Anti-fungal Heartburn GI complications Depression Anxiolytic

Limonene

52 | March 2018

Aroma Peppery Spicy

Also found in Black pepper Basil Cloves Cotton

Medical value Gastro-protective Anti-inflammatory Pain relief

May selectively activate CB2 receptors

Caryophyllene

53 | March 2018

Aroma Floral

Also found in Lavender Spring Flowers Rosewood

Medicinal value Calming Effect Anti-Anxiety Sedative Effect Analgesic Anti-

Epileptic

Linalool

54 | March 2018

21032018

10

55 | March 2018 56 | March 2018

INITIAL CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

58 | March 2018

Drug Interactions

59 | March 2018

Drug Interactions

THC metabolized by CYP2C9 and CYP3A4 enzymes

bull Medications that may be increased by THC

administration Amiodarone Atorvastatin

Carvedilol Metoprolol Ritonavir Simvastatin

Verapamil

bull Clopidogrel effects may be decreased

bull Amiodarone Metronidazole Fluoxetine

Fluconazole may inhibit THC elimination

bull Ketoconazole has been shown to increase

peak concentrations of THC

bull Poor metabolizers of CYP2C9 can have THC

concentrations increase three-fold

60 | March 2018

Drug Interactions

THC may also induce CYP1A2 enzyme

bull Smoked cannabis has been shown to

increase the metabolism of theophylline and

chlorpromazine

bull 50 decrease in plasma concentrations

bull Induction seems to be occur in smoked

marijuana not oral administration and is

dose specific

21032018

11

61 | March 2018

Drug Interactions

THC strongly binds to blood plasma proteins

bull Caution patients on warfarin

bull One study has shown an increased response

with a patient smoking 4 to 5 marijuana

cigarettes per week

62 | March 2018

Drug Interactions

CBD is a substrate of CYP3A4 and CYP2C19 enzymes

bull Medications that may have an

increased effect

Amitriptylene

Clobazepam

Diazepam

Propranolol

Warfarin

63 | March 2018

Drug Interactions

Pharmacodynamic interactions should be expected between

marijuana and

bull Drugs with sympathomimetic activity

(tachycardia hypertension)

bull Central nervous system depressants

(drowsiness ataxia) and

bull Drugs with anticholinergic effects

(tachycardia drowsiness)

Cannabis medicines (smoked oral sublingual or vaporized)

may increase effects of

bull Alcohol

bull Benzodiazepines

bull Opiates

64 | March 2018

The Pharmacistrsquos Role

Prescription Monitoring Program (PMP)

bull Controlled substances as well as marijuana card

activation and marijuana purchases will show up on

the report

bull Physicians can monitor patientrsquos usage

bull Before dispensing any marijuana product the

pharmacist checks the PMP

bull Double check to make sure patients remain with one dispensary and are not over their monthly limit

bull Review any new controlled medications that may have been added since last visit and counsel if

appropriate

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

Modes of delivery 66 | March 2018

INHALANTS

21032018

12

67 | March 2018

INHALANTS

Fast-acting produces an effect within 5 minutes

Effects last for approximately 2 hours

Easy to titrate dose

Can cause throat irritation

Hard to determine dosage

Appropriate for patients who need instant relief and to

minimize side effects

68 | March 2018

Inhalants

Smoking

bull Easiest and most widely used

bull Achieved via rolled paper pipes

water pipes

bull Odor can be pronounced

bull No proven association with lung

cancer

bull Not healthiest option

bull Burns off many of the medicinal

properties

Vaporization

bull Heats product without burning

bull ldquoConvection ovenrdquo

bull Avoids irritating toxins

bull Heats product between 250 ndash 400

degrees

bull Less odor and smoke produced

bull Many different varieties of vaporizers on

the market from pens to desktop units

69 | March 2018

Tinctures Sprays Dissolvable Strips

Sublinguals

70 | March 2018

SUBLINGUALS

Under the tongue application

Delayed action (takes approximately 30 minutes

before effect)

Longer duration of action (three to four hours)

Specific dosing

Appropriate for those individuals who need quick relief

who cannot inhale cannabis

71 | March 2018

Edibles Capsules Oils

Consumables

72 | March 2018

CONSUMABLES

Effects delayed (30 minutes to 2 hours)

Effects can last anywhere from 4 to 8 hours

Effects are much stronger

Specific dosing

Bioavailability can range from 10-20

Appropriate for those patients who need long term relief

21032018

13

73 | March 2018

Other Routes of Administration

Topical Rectal74 | March 2018

bull Dronabinol = synthetic delta-9-

tetrahydrocannbinol in sesame oil

bull Lacks other cannabinoids and terpinoids

found in natural cannabis

bull More psychoactive than natural

cannabis

bull Slow onset and poor bioavailability

bull More expensive than natural cannabis

bull Studies have shown that inhaled

cannabis have higher success rates than

oral administration of synthetic THC

What About Marinol

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain Diversity and Pharmacology

Medications

Modes of delivery

Side effects and safety76 | March 2018

Short-Term Side Effects

Mood reactions (euphoria relaxation anxiety time-distortion)

Rapid heartbeat

Facial flushing

Red eyes

Dry mouth

Headaches

Dizziness

Coughing

SIDE EFFECTS

Long-Term Side Effects

Severe chronic bronchitis

Range of cognitive deficits

Receptor down-regulation (decline in receptor density)

77 | March 2018

RisksWarnings

Contraindicationsbull Pregnancy nursingbull Lower birth weightsbull Endocannabinoids involved in several aspects

of fetal and childhood development

bull Cannabinoids are passed along breast milk

bull Serious mental disorders (ie schizophrenia)

Use with caution for patients withbull Heart conditionsbull Respiratory conditions

bull History of drug alcohol abuse

78 | March 2018

RisksWarnings

In case of overdosebull May potentiate worsen side

effects

bull Will resolve after stopping medication

bull Drinking water and eating may help as well as fresh air

bull Do not consume cannabis in a public

place or where it may pose harm to others

bull Never operate a vehicle after consuming marijuana

bull Keep this medicine out of reach of

children or pets

21032018

14

The Pharmacistrsquos Role

80 | March 2018

Massachusetts College of

Pharmacy and Health Sciences

Yale University

Saint Francis Hospital and

Medical Center

Studies

81 | March 2018

Human Reduction Strategy Minimizes harm tobull Individualbull Others impacted by the harmed person

bull SocietyStudies shown benefits when adding cannabis to opioid therapybull Decreased painbull May allow lower doses of opioids = lower side effects

Studies concluded states with medical marijuana laws have lower incidence of opioid mortality rates

Cannabis and Opioids

My Own Opiate Research Project

bull Monitoring MME

bull Document initial MME MME 1 year later

bull October ndash February 2017 October ndash February 2018

bull 65 Total Patientsbull 38 Active Patients (Patients receiving product within 2 months of documentation)

bull 21 Patients decreased MME (55)

bull 11 Patients remained stagnant (29)

bull 6 Patients increased MME (16)

bull 27 Non-Active Patients (Those patients who have not received product within 2 months)

bull 8 Patients decreased MME (30)

bull 11 Patients remained stagnant (40)

bull 8 Patients increased MME (30)

21032018

15

Dependence is estimated to be around 9

bull Nicotine 32

bull Heroin 23

bull Cocaine 17

bull Alcohol 15

bull Stimulants 11

DEPENDENCY

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx

21032018

8

43 | March 2018

bull Known for being strongly psychoactive

bull Stimulates endocannabinoid system by

binding to CB1 and CB2 receptors

THC (d-9 Tetrahydrocannabinol)CANNABINOIDS

bull Health Benefits

gt Analgesicgt Sleep

gt Antidepressantgt Antispasmodicgt Antiemetic

gt Appetite stimulant

gt Antioxidantgt Reduces

intraocular eye pressure

44 | March 2018

bull Does not bind directly to CB1 or CB2 receptors

bull Stimulates activity in both receptors

gt Causes increased release in 2-AG

gt Inhibits activity of fatty acid amide hydroxylase (FAAH)

which slows deterioration of anandamide

bull Inhibits THCrsquos effects on CB1 receptors

bull Binds directly to G-protein coupled

receptor TRPV-1

bull Activates 5-HT1A serotonin receptor

bull Affinity to histamine receptors

bull Found to inhibit ID-1 gene

CBD (Cannabidiol)CANNABINOIDS

45 | March 2018

bull Non-psychoactive

bull Suppresses psychoactivity of THC

bull Ideal for elderly children and patients that prefer to

remain clear-headed

bull Extremely valuable in treating seizure disorders

bull Often as effective as THC in pain management

bull Calming effect

bull Can provide a focusing effect

CBD (Cannabidiol)CANNABINOIDS

46 | March 2018

CBN (Cannabinol)

bull Oxidation process of THC

bull Partial agonist of CB2 receptors and

weak agonist of CB1 receptors

bull Strongly sedative

bull Useful in treatment of insomnia

CANNABINOIDS

CBG (Cannabigerol)

bull Non-psychoactive

bull Inhibits uptake of GABA ndash decreases

anxiety and muscle tension

bull Anti-inflammatory

47 | March 2018

Cannabichromene

bull Non-psychoactive

bull Inflammation pain relief

anxiety stress

CBC

Cannabidiolic

bull Anti-inflammatory

digestive aid

CBD-A

Tetrahydrocannabinolic acid

bull Non-psychoactive

bull Changes to THC after

decarboxylation (heat)

bull Anti-inflammatory

appetite antispasmodic

THC-A

CANNABINOIDS

48 | March 2018

bull Organic hydrocarbons found in the

essential oils in plants that give cannabis

itrsquos aroma

bull Contained in many familiar plants found

in the natural world

bull Every strain has a unique terpene profile

bull Works in synergy with cannabinoids

(entourage effect)

bull Contain separate therapeutic effects

Terpenes

21032018

9

49 | March 2018

Aroma Pine

Also found in pine needles rosemary basil dill

Medicinal value bronchodilator antiseptic anti-inflammatory

Pinene

50 | March 2018

Aroma Musky Earthy

Also found in Mango Thyme Hops

Effects Relaxing Sedating

ldquoCouch-lockrdquo

Medical value Anti-oxidant Muscle tension Pain Inflammation Depression Sleep

Allows THC to take effect more

quickly by allowing it to cross the blood-brain barrier more easily

Myrcene

51 | March 2018

Aroma Citrus

Also found in Fruit rinds Rosemary Peppermint

Medicinal value Anti-fungal Heartburn GI complications Depression Anxiolytic

Limonene

52 | March 2018

Aroma Peppery Spicy

Also found in Black pepper Basil Cloves Cotton

Medical value Gastro-protective Anti-inflammatory Pain relief

May selectively activate CB2 receptors

Caryophyllene

53 | March 2018

Aroma Floral

Also found in Lavender Spring Flowers Rosewood

Medicinal value Calming Effect Anti-Anxiety Sedative Effect Analgesic Anti-

Epileptic

Linalool

54 | March 2018

21032018

10

55 | March 2018 56 | March 2018

INITIAL CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

58 | March 2018

Drug Interactions

59 | March 2018

Drug Interactions

THC metabolized by CYP2C9 and CYP3A4 enzymes

bull Medications that may be increased by THC

administration Amiodarone Atorvastatin

Carvedilol Metoprolol Ritonavir Simvastatin

Verapamil

bull Clopidogrel effects may be decreased

bull Amiodarone Metronidazole Fluoxetine

Fluconazole may inhibit THC elimination

bull Ketoconazole has been shown to increase

peak concentrations of THC

bull Poor metabolizers of CYP2C9 can have THC

concentrations increase three-fold

60 | March 2018

Drug Interactions

THC may also induce CYP1A2 enzyme

bull Smoked cannabis has been shown to

increase the metabolism of theophylline and

chlorpromazine

bull 50 decrease in plasma concentrations

bull Induction seems to be occur in smoked

marijuana not oral administration and is

dose specific

21032018

11

61 | March 2018

Drug Interactions

THC strongly binds to blood plasma proteins

bull Caution patients on warfarin

bull One study has shown an increased response

with a patient smoking 4 to 5 marijuana

cigarettes per week

62 | March 2018

Drug Interactions

CBD is a substrate of CYP3A4 and CYP2C19 enzymes

bull Medications that may have an

increased effect

Amitriptylene

Clobazepam

Diazepam

Propranolol

Warfarin

63 | March 2018

Drug Interactions

Pharmacodynamic interactions should be expected between

marijuana and

bull Drugs with sympathomimetic activity

(tachycardia hypertension)

bull Central nervous system depressants

(drowsiness ataxia) and

bull Drugs with anticholinergic effects

(tachycardia drowsiness)

Cannabis medicines (smoked oral sublingual or vaporized)

may increase effects of

bull Alcohol

bull Benzodiazepines

bull Opiates

64 | March 2018

The Pharmacistrsquos Role

Prescription Monitoring Program (PMP)

bull Controlled substances as well as marijuana card

activation and marijuana purchases will show up on

the report

bull Physicians can monitor patientrsquos usage

bull Before dispensing any marijuana product the

pharmacist checks the PMP

bull Double check to make sure patients remain with one dispensary and are not over their monthly limit

bull Review any new controlled medications that may have been added since last visit and counsel if

appropriate

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

Modes of delivery 66 | March 2018

INHALANTS

21032018

12

67 | March 2018

INHALANTS

Fast-acting produces an effect within 5 minutes

Effects last for approximately 2 hours

Easy to titrate dose

Can cause throat irritation

Hard to determine dosage

Appropriate for patients who need instant relief and to

minimize side effects

68 | March 2018

Inhalants

Smoking

bull Easiest and most widely used

bull Achieved via rolled paper pipes

water pipes

bull Odor can be pronounced

bull No proven association with lung

cancer

bull Not healthiest option

bull Burns off many of the medicinal

properties

Vaporization

bull Heats product without burning

bull ldquoConvection ovenrdquo

bull Avoids irritating toxins

bull Heats product between 250 ndash 400

degrees

bull Less odor and smoke produced

bull Many different varieties of vaporizers on

the market from pens to desktop units

69 | March 2018

Tinctures Sprays Dissolvable Strips

Sublinguals

70 | March 2018

SUBLINGUALS

Under the tongue application

Delayed action (takes approximately 30 minutes

before effect)

Longer duration of action (three to four hours)

Specific dosing

Appropriate for those individuals who need quick relief

who cannot inhale cannabis

71 | March 2018

Edibles Capsules Oils

Consumables

72 | March 2018

CONSUMABLES

Effects delayed (30 minutes to 2 hours)

Effects can last anywhere from 4 to 8 hours

Effects are much stronger

Specific dosing

Bioavailability can range from 10-20

Appropriate for those patients who need long term relief

21032018

13

73 | March 2018

Other Routes of Administration

Topical Rectal74 | March 2018

bull Dronabinol = synthetic delta-9-

tetrahydrocannbinol in sesame oil

bull Lacks other cannabinoids and terpinoids

found in natural cannabis

bull More psychoactive than natural

cannabis

bull Slow onset and poor bioavailability

bull More expensive than natural cannabis

bull Studies have shown that inhaled

cannabis have higher success rates than

oral administration of synthetic THC

What About Marinol

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain Diversity and Pharmacology

Medications

Modes of delivery

Side effects and safety76 | March 2018

Short-Term Side Effects

Mood reactions (euphoria relaxation anxiety time-distortion)

Rapid heartbeat

Facial flushing

Red eyes

Dry mouth

Headaches

Dizziness

Coughing

SIDE EFFECTS

Long-Term Side Effects

Severe chronic bronchitis

Range of cognitive deficits

Receptor down-regulation (decline in receptor density)

77 | March 2018

RisksWarnings

Contraindicationsbull Pregnancy nursingbull Lower birth weightsbull Endocannabinoids involved in several aspects

of fetal and childhood development

bull Cannabinoids are passed along breast milk

bull Serious mental disorders (ie schizophrenia)

Use with caution for patients withbull Heart conditionsbull Respiratory conditions

bull History of drug alcohol abuse

78 | March 2018

RisksWarnings

In case of overdosebull May potentiate worsen side

effects

bull Will resolve after stopping medication

bull Drinking water and eating may help as well as fresh air

bull Do not consume cannabis in a public

place or where it may pose harm to others

bull Never operate a vehicle after consuming marijuana

bull Keep this medicine out of reach of

children or pets

21032018

14

The Pharmacistrsquos Role

80 | March 2018

Massachusetts College of

Pharmacy and Health Sciences

Yale University

Saint Francis Hospital and

Medical Center

Studies

81 | March 2018

Human Reduction Strategy Minimizes harm tobull Individualbull Others impacted by the harmed person

bull SocietyStudies shown benefits when adding cannabis to opioid therapybull Decreased painbull May allow lower doses of opioids = lower side effects

Studies concluded states with medical marijuana laws have lower incidence of opioid mortality rates

Cannabis and Opioids

My Own Opiate Research Project

bull Monitoring MME

bull Document initial MME MME 1 year later

bull October ndash February 2017 October ndash February 2018

bull 65 Total Patientsbull 38 Active Patients (Patients receiving product within 2 months of documentation)

bull 21 Patients decreased MME (55)

bull 11 Patients remained stagnant (29)

bull 6 Patients increased MME (16)

bull 27 Non-Active Patients (Those patients who have not received product within 2 months)

bull 8 Patients decreased MME (30)

bull 11 Patients remained stagnant (40)

bull 8 Patients increased MME (30)

21032018

15

Dependence is estimated to be around 9

bull Nicotine 32

bull Heroin 23

bull Cocaine 17

bull Alcohol 15

bull Stimulants 11

DEPENDENCY

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx

21032018

9

49 | March 2018

Aroma Pine

Also found in pine needles rosemary basil dill

Medicinal value bronchodilator antiseptic anti-inflammatory

Pinene

50 | March 2018

Aroma Musky Earthy

Also found in Mango Thyme Hops

Effects Relaxing Sedating

ldquoCouch-lockrdquo

Medical value Anti-oxidant Muscle tension Pain Inflammation Depression Sleep

Allows THC to take effect more

quickly by allowing it to cross the blood-brain barrier more easily

Myrcene

51 | March 2018

Aroma Citrus

Also found in Fruit rinds Rosemary Peppermint

Medicinal value Anti-fungal Heartburn GI complications Depression Anxiolytic

Limonene

52 | March 2018

Aroma Peppery Spicy

Also found in Black pepper Basil Cloves Cotton

Medical value Gastro-protective Anti-inflammatory Pain relief

May selectively activate CB2 receptors

Caryophyllene

53 | March 2018

Aroma Floral

Also found in Lavender Spring Flowers Rosewood

Medicinal value Calming Effect Anti-Anxiety Sedative Effect Analgesic Anti-

Epileptic

Linalool

54 | March 2018

21032018

10

55 | March 2018 56 | March 2018

INITIAL CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

58 | March 2018

Drug Interactions

59 | March 2018

Drug Interactions

THC metabolized by CYP2C9 and CYP3A4 enzymes

bull Medications that may be increased by THC

administration Amiodarone Atorvastatin

Carvedilol Metoprolol Ritonavir Simvastatin

Verapamil

bull Clopidogrel effects may be decreased

bull Amiodarone Metronidazole Fluoxetine

Fluconazole may inhibit THC elimination

bull Ketoconazole has been shown to increase

peak concentrations of THC

bull Poor metabolizers of CYP2C9 can have THC

concentrations increase three-fold

60 | March 2018

Drug Interactions

THC may also induce CYP1A2 enzyme

bull Smoked cannabis has been shown to

increase the metabolism of theophylline and

chlorpromazine

bull 50 decrease in plasma concentrations

bull Induction seems to be occur in smoked

marijuana not oral administration and is

dose specific

21032018

11

61 | March 2018

Drug Interactions

THC strongly binds to blood plasma proteins

bull Caution patients on warfarin

bull One study has shown an increased response

with a patient smoking 4 to 5 marijuana

cigarettes per week

62 | March 2018

Drug Interactions

CBD is a substrate of CYP3A4 and CYP2C19 enzymes

bull Medications that may have an

increased effect

Amitriptylene

Clobazepam

Diazepam

Propranolol

Warfarin

63 | March 2018

Drug Interactions

Pharmacodynamic interactions should be expected between

marijuana and

bull Drugs with sympathomimetic activity

(tachycardia hypertension)

bull Central nervous system depressants

(drowsiness ataxia) and

bull Drugs with anticholinergic effects

(tachycardia drowsiness)

Cannabis medicines (smoked oral sublingual or vaporized)

may increase effects of

bull Alcohol

bull Benzodiazepines

bull Opiates

64 | March 2018

The Pharmacistrsquos Role

Prescription Monitoring Program (PMP)

bull Controlled substances as well as marijuana card

activation and marijuana purchases will show up on

the report

bull Physicians can monitor patientrsquos usage

bull Before dispensing any marijuana product the

pharmacist checks the PMP

bull Double check to make sure patients remain with one dispensary and are not over their monthly limit

bull Review any new controlled medications that may have been added since last visit and counsel if

appropriate

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

Modes of delivery 66 | March 2018

INHALANTS

21032018

12

67 | March 2018

INHALANTS

Fast-acting produces an effect within 5 minutes

Effects last for approximately 2 hours

Easy to titrate dose

Can cause throat irritation

Hard to determine dosage

Appropriate for patients who need instant relief and to

minimize side effects

68 | March 2018

Inhalants

Smoking

bull Easiest and most widely used

bull Achieved via rolled paper pipes

water pipes

bull Odor can be pronounced

bull No proven association with lung

cancer

bull Not healthiest option

bull Burns off many of the medicinal

properties

Vaporization

bull Heats product without burning

bull ldquoConvection ovenrdquo

bull Avoids irritating toxins

bull Heats product between 250 ndash 400

degrees

bull Less odor and smoke produced

bull Many different varieties of vaporizers on

the market from pens to desktop units

69 | March 2018

Tinctures Sprays Dissolvable Strips

Sublinguals

70 | March 2018

SUBLINGUALS

Under the tongue application

Delayed action (takes approximately 30 minutes

before effect)

Longer duration of action (three to four hours)

Specific dosing

Appropriate for those individuals who need quick relief

who cannot inhale cannabis

71 | March 2018

Edibles Capsules Oils

Consumables

72 | March 2018

CONSUMABLES

Effects delayed (30 minutes to 2 hours)

Effects can last anywhere from 4 to 8 hours

Effects are much stronger

Specific dosing

Bioavailability can range from 10-20

Appropriate for those patients who need long term relief

21032018

13

73 | March 2018

Other Routes of Administration

Topical Rectal74 | March 2018

bull Dronabinol = synthetic delta-9-

tetrahydrocannbinol in sesame oil

bull Lacks other cannabinoids and terpinoids

found in natural cannabis

bull More psychoactive than natural

cannabis

bull Slow onset and poor bioavailability

bull More expensive than natural cannabis

bull Studies have shown that inhaled

cannabis have higher success rates than

oral administration of synthetic THC

What About Marinol

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain Diversity and Pharmacology

Medications

Modes of delivery

Side effects and safety76 | March 2018

Short-Term Side Effects

Mood reactions (euphoria relaxation anxiety time-distortion)

Rapid heartbeat

Facial flushing

Red eyes

Dry mouth

Headaches

Dizziness

Coughing

SIDE EFFECTS

Long-Term Side Effects

Severe chronic bronchitis

Range of cognitive deficits

Receptor down-regulation (decline in receptor density)

77 | March 2018

RisksWarnings

Contraindicationsbull Pregnancy nursingbull Lower birth weightsbull Endocannabinoids involved in several aspects

of fetal and childhood development

bull Cannabinoids are passed along breast milk

bull Serious mental disorders (ie schizophrenia)

Use with caution for patients withbull Heart conditionsbull Respiratory conditions

bull History of drug alcohol abuse

78 | March 2018

RisksWarnings

In case of overdosebull May potentiate worsen side

effects

bull Will resolve after stopping medication

bull Drinking water and eating may help as well as fresh air

bull Do not consume cannabis in a public

place or where it may pose harm to others

bull Never operate a vehicle after consuming marijuana

bull Keep this medicine out of reach of

children or pets

21032018

14

The Pharmacistrsquos Role

80 | March 2018

Massachusetts College of

Pharmacy and Health Sciences

Yale University

Saint Francis Hospital and

Medical Center

Studies

81 | March 2018

Human Reduction Strategy Minimizes harm tobull Individualbull Others impacted by the harmed person

bull SocietyStudies shown benefits when adding cannabis to opioid therapybull Decreased painbull May allow lower doses of opioids = lower side effects

Studies concluded states with medical marijuana laws have lower incidence of opioid mortality rates

Cannabis and Opioids

My Own Opiate Research Project

bull Monitoring MME

bull Document initial MME MME 1 year later

bull October ndash February 2017 October ndash February 2018

bull 65 Total Patientsbull 38 Active Patients (Patients receiving product within 2 months of documentation)

bull 21 Patients decreased MME (55)

bull 11 Patients remained stagnant (29)

bull 6 Patients increased MME (16)

bull 27 Non-Active Patients (Those patients who have not received product within 2 months)

bull 8 Patients decreased MME (30)

bull 11 Patients remained stagnant (40)

bull 8 Patients increased MME (30)

21032018

15

Dependence is estimated to be around 9

bull Nicotine 32

bull Heroin 23

bull Cocaine 17

bull Alcohol 15

bull Stimulants 11

DEPENDENCY

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx

21032018

10

55 | March 2018 56 | March 2018

INITIAL CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

58 | March 2018

Drug Interactions

59 | March 2018

Drug Interactions

THC metabolized by CYP2C9 and CYP3A4 enzymes

bull Medications that may be increased by THC

administration Amiodarone Atorvastatin

Carvedilol Metoprolol Ritonavir Simvastatin

Verapamil

bull Clopidogrel effects may be decreased

bull Amiodarone Metronidazole Fluoxetine

Fluconazole may inhibit THC elimination

bull Ketoconazole has been shown to increase

peak concentrations of THC

bull Poor metabolizers of CYP2C9 can have THC

concentrations increase three-fold

60 | March 2018

Drug Interactions

THC may also induce CYP1A2 enzyme

bull Smoked cannabis has been shown to

increase the metabolism of theophylline and

chlorpromazine

bull 50 decrease in plasma concentrations

bull Induction seems to be occur in smoked

marijuana not oral administration and is

dose specific

21032018

11

61 | March 2018

Drug Interactions

THC strongly binds to blood plasma proteins

bull Caution patients on warfarin

bull One study has shown an increased response

with a patient smoking 4 to 5 marijuana

cigarettes per week

62 | March 2018

Drug Interactions

CBD is a substrate of CYP3A4 and CYP2C19 enzymes

bull Medications that may have an

increased effect

Amitriptylene

Clobazepam

Diazepam

Propranolol

Warfarin

63 | March 2018

Drug Interactions

Pharmacodynamic interactions should be expected between

marijuana and

bull Drugs with sympathomimetic activity

(tachycardia hypertension)

bull Central nervous system depressants

(drowsiness ataxia) and

bull Drugs with anticholinergic effects

(tachycardia drowsiness)

Cannabis medicines (smoked oral sublingual or vaporized)

may increase effects of

bull Alcohol

bull Benzodiazepines

bull Opiates

64 | March 2018

The Pharmacistrsquos Role

Prescription Monitoring Program (PMP)

bull Controlled substances as well as marijuana card

activation and marijuana purchases will show up on

the report

bull Physicians can monitor patientrsquos usage

bull Before dispensing any marijuana product the

pharmacist checks the PMP

bull Double check to make sure patients remain with one dispensary and are not over their monthly limit

bull Review any new controlled medications that may have been added since last visit and counsel if

appropriate

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

Modes of delivery 66 | March 2018

INHALANTS

21032018

12

67 | March 2018

INHALANTS

Fast-acting produces an effect within 5 minutes

Effects last for approximately 2 hours

Easy to titrate dose

Can cause throat irritation

Hard to determine dosage

Appropriate for patients who need instant relief and to

minimize side effects

68 | March 2018

Inhalants

Smoking

bull Easiest and most widely used

bull Achieved via rolled paper pipes

water pipes

bull Odor can be pronounced

bull No proven association with lung

cancer

bull Not healthiest option

bull Burns off many of the medicinal

properties

Vaporization

bull Heats product without burning

bull ldquoConvection ovenrdquo

bull Avoids irritating toxins

bull Heats product between 250 ndash 400

degrees

bull Less odor and smoke produced

bull Many different varieties of vaporizers on

the market from pens to desktop units

69 | March 2018

Tinctures Sprays Dissolvable Strips

Sublinguals

70 | March 2018

SUBLINGUALS

Under the tongue application

Delayed action (takes approximately 30 minutes

before effect)

Longer duration of action (three to four hours)

Specific dosing

Appropriate for those individuals who need quick relief

who cannot inhale cannabis

71 | March 2018

Edibles Capsules Oils

Consumables

72 | March 2018

CONSUMABLES

Effects delayed (30 minutes to 2 hours)

Effects can last anywhere from 4 to 8 hours

Effects are much stronger

Specific dosing

Bioavailability can range from 10-20

Appropriate for those patients who need long term relief

21032018

13

73 | March 2018

Other Routes of Administration

Topical Rectal74 | March 2018

bull Dronabinol = synthetic delta-9-

tetrahydrocannbinol in sesame oil

bull Lacks other cannabinoids and terpinoids

found in natural cannabis

bull More psychoactive than natural

cannabis

bull Slow onset and poor bioavailability

bull More expensive than natural cannabis

bull Studies have shown that inhaled

cannabis have higher success rates than

oral administration of synthetic THC

What About Marinol

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain Diversity and Pharmacology

Medications

Modes of delivery

Side effects and safety76 | March 2018

Short-Term Side Effects

Mood reactions (euphoria relaxation anxiety time-distortion)

Rapid heartbeat

Facial flushing

Red eyes

Dry mouth

Headaches

Dizziness

Coughing

SIDE EFFECTS

Long-Term Side Effects

Severe chronic bronchitis

Range of cognitive deficits

Receptor down-regulation (decline in receptor density)

77 | March 2018

RisksWarnings

Contraindicationsbull Pregnancy nursingbull Lower birth weightsbull Endocannabinoids involved in several aspects

of fetal and childhood development

bull Cannabinoids are passed along breast milk

bull Serious mental disorders (ie schizophrenia)

Use with caution for patients withbull Heart conditionsbull Respiratory conditions

bull History of drug alcohol abuse

78 | March 2018

RisksWarnings

In case of overdosebull May potentiate worsen side

effects

bull Will resolve after stopping medication

bull Drinking water and eating may help as well as fresh air

bull Do not consume cannabis in a public

place or where it may pose harm to others

bull Never operate a vehicle after consuming marijuana

bull Keep this medicine out of reach of

children or pets

21032018

14

The Pharmacistrsquos Role

80 | March 2018

Massachusetts College of

Pharmacy and Health Sciences

Yale University

Saint Francis Hospital and

Medical Center

Studies

81 | March 2018

Human Reduction Strategy Minimizes harm tobull Individualbull Others impacted by the harmed person

bull SocietyStudies shown benefits when adding cannabis to opioid therapybull Decreased painbull May allow lower doses of opioids = lower side effects

Studies concluded states with medical marijuana laws have lower incidence of opioid mortality rates

Cannabis and Opioids

My Own Opiate Research Project

bull Monitoring MME

bull Document initial MME MME 1 year later

bull October ndash February 2017 October ndash February 2018

bull 65 Total Patientsbull 38 Active Patients (Patients receiving product within 2 months of documentation)

bull 21 Patients decreased MME (55)

bull 11 Patients remained stagnant (29)

bull 6 Patients increased MME (16)

bull 27 Non-Active Patients (Those patients who have not received product within 2 months)

bull 8 Patients decreased MME (30)

bull 11 Patients remained stagnant (40)

bull 8 Patients increased MME (30)

21032018

15

Dependence is estimated to be around 9

bull Nicotine 32

bull Heroin 23

bull Cocaine 17

bull Alcohol 15

bull Stimulants 11

DEPENDENCY

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx

21032018

11

61 | March 2018

Drug Interactions

THC strongly binds to blood plasma proteins

bull Caution patients on warfarin

bull One study has shown an increased response

with a patient smoking 4 to 5 marijuana

cigarettes per week

62 | March 2018

Drug Interactions

CBD is a substrate of CYP3A4 and CYP2C19 enzymes

bull Medications that may have an

increased effect

Amitriptylene

Clobazepam

Diazepam

Propranolol

Warfarin

63 | March 2018

Drug Interactions

Pharmacodynamic interactions should be expected between

marijuana and

bull Drugs with sympathomimetic activity

(tachycardia hypertension)

bull Central nervous system depressants

(drowsiness ataxia) and

bull Drugs with anticholinergic effects

(tachycardia drowsiness)

Cannabis medicines (smoked oral sublingual or vaporized)

may increase effects of

bull Alcohol

bull Benzodiazepines

bull Opiates

64 | March 2018

The Pharmacistrsquos Role

Prescription Monitoring Program (PMP)

bull Controlled substances as well as marijuana card

activation and marijuana purchases will show up on

the report

bull Physicians can monitor patientrsquos usage

bull Before dispensing any marijuana product the

pharmacist checks the PMP

bull Double check to make sure patients remain with one dispensary and are not over their monthly limit

bull Review any new controlled medications that may have been added since last visit and counsel if

appropriate

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain diversity

Medications

Modes of delivery 66 | March 2018

INHALANTS

21032018

12

67 | March 2018

INHALANTS

Fast-acting produces an effect within 5 minutes

Effects last for approximately 2 hours

Easy to titrate dose

Can cause throat irritation

Hard to determine dosage

Appropriate for patients who need instant relief and to

minimize side effects

68 | March 2018

Inhalants

Smoking

bull Easiest and most widely used

bull Achieved via rolled paper pipes

water pipes

bull Odor can be pronounced

bull No proven association with lung

cancer

bull Not healthiest option

bull Burns off many of the medicinal

properties

Vaporization

bull Heats product without burning

bull ldquoConvection ovenrdquo

bull Avoids irritating toxins

bull Heats product between 250 ndash 400

degrees

bull Less odor and smoke produced

bull Many different varieties of vaporizers on

the market from pens to desktop units

69 | March 2018

Tinctures Sprays Dissolvable Strips

Sublinguals

70 | March 2018

SUBLINGUALS

Under the tongue application

Delayed action (takes approximately 30 minutes

before effect)

Longer duration of action (three to four hours)

Specific dosing

Appropriate for those individuals who need quick relief

who cannot inhale cannabis

71 | March 2018

Edibles Capsules Oils

Consumables

72 | March 2018

CONSUMABLES

Effects delayed (30 minutes to 2 hours)

Effects can last anywhere from 4 to 8 hours

Effects are much stronger

Specific dosing

Bioavailability can range from 10-20

Appropriate for those patients who need long term relief

21032018

13

73 | March 2018

Other Routes of Administration

Topical Rectal74 | March 2018

bull Dronabinol = synthetic delta-9-

tetrahydrocannbinol in sesame oil

bull Lacks other cannabinoids and terpinoids

found in natural cannabis

bull More psychoactive than natural

cannabis

bull Slow onset and poor bioavailability

bull More expensive than natural cannabis

bull Studies have shown that inhaled

cannabis have higher success rates than

oral administration of synthetic THC

What About Marinol

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain Diversity and Pharmacology

Medications

Modes of delivery

Side effects and safety76 | March 2018

Short-Term Side Effects

Mood reactions (euphoria relaxation anxiety time-distortion)

Rapid heartbeat

Facial flushing

Red eyes

Dry mouth

Headaches

Dizziness

Coughing

SIDE EFFECTS

Long-Term Side Effects

Severe chronic bronchitis

Range of cognitive deficits

Receptor down-regulation (decline in receptor density)

77 | March 2018

RisksWarnings

Contraindicationsbull Pregnancy nursingbull Lower birth weightsbull Endocannabinoids involved in several aspects

of fetal and childhood development

bull Cannabinoids are passed along breast milk

bull Serious mental disorders (ie schizophrenia)

Use with caution for patients withbull Heart conditionsbull Respiratory conditions

bull History of drug alcohol abuse

78 | March 2018

RisksWarnings

In case of overdosebull May potentiate worsen side

effects

bull Will resolve after stopping medication

bull Drinking water and eating may help as well as fresh air

bull Do not consume cannabis in a public

place or where it may pose harm to others

bull Never operate a vehicle after consuming marijuana

bull Keep this medicine out of reach of

children or pets

21032018

14

The Pharmacistrsquos Role

80 | March 2018

Massachusetts College of

Pharmacy and Health Sciences

Yale University

Saint Francis Hospital and

Medical Center

Studies

81 | March 2018

Human Reduction Strategy Minimizes harm tobull Individualbull Others impacted by the harmed person

bull SocietyStudies shown benefits when adding cannabis to opioid therapybull Decreased painbull May allow lower doses of opioids = lower side effects

Studies concluded states with medical marijuana laws have lower incidence of opioid mortality rates

Cannabis and Opioids

My Own Opiate Research Project

bull Monitoring MME

bull Document initial MME MME 1 year later

bull October ndash February 2017 October ndash February 2018

bull 65 Total Patientsbull 38 Active Patients (Patients receiving product within 2 months of documentation)

bull 21 Patients decreased MME (55)

bull 11 Patients remained stagnant (29)

bull 6 Patients increased MME (16)

bull 27 Non-Active Patients (Those patients who have not received product within 2 months)

bull 8 Patients decreased MME (30)

bull 11 Patients remained stagnant (40)

bull 8 Patients increased MME (30)

21032018

15

Dependence is estimated to be around 9

bull Nicotine 32

bull Heroin 23

bull Cocaine 17

bull Alcohol 15

bull Stimulants 11

DEPENDENCY

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx

21032018

12

67 | March 2018

INHALANTS

Fast-acting produces an effect within 5 minutes

Effects last for approximately 2 hours

Easy to titrate dose

Can cause throat irritation

Hard to determine dosage

Appropriate for patients who need instant relief and to

minimize side effects

68 | March 2018

Inhalants

Smoking

bull Easiest and most widely used

bull Achieved via rolled paper pipes

water pipes

bull Odor can be pronounced

bull No proven association with lung

cancer

bull Not healthiest option

bull Burns off many of the medicinal

properties

Vaporization

bull Heats product without burning

bull ldquoConvection ovenrdquo

bull Avoids irritating toxins

bull Heats product between 250 ndash 400

degrees

bull Less odor and smoke produced

bull Many different varieties of vaporizers on

the market from pens to desktop units

69 | March 2018

Tinctures Sprays Dissolvable Strips

Sublinguals

70 | March 2018

SUBLINGUALS

Under the tongue application

Delayed action (takes approximately 30 minutes

before effect)

Longer duration of action (three to four hours)

Specific dosing

Appropriate for those individuals who need quick relief

who cannot inhale cannabis

71 | March 2018

Edibles Capsules Oils

Consumables

72 | March 2018

CONSUMABLES

Effects delayed (30 minutes to 2 hours)

Effects can last anywhere from 4 to 8 hours

Effects are much stronger

Specific dosing

Bioavailability can range from 10-20

Appropriate for those patients who need long term relief

21032018

13

73 | March 2018

Other Routes of Administration

Topical Rectal74 | March 2018

bull Dronabinol = synthetic delta-9-

tetrahydrocannbinol in sesame oil

bull Lacks other cannabinoids and terpinoids

found in natural cannabis

bull More psychoactive than natural

cannabis

bull Slow onset and poor bioavailability

bull More expensive than natural cannabis

bull Studies have shown that inhaled

cannabis have higher success rates than

oral administration of synthetic THC

What About Marinol

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain Diversity and Pharmacology

Medications

Modes of delivery

Side effects and safety76 | March 2018

Short-Term Side Effects

Mood reactions (euphoria relaxation anxiety time-distortion)

Rapid heartbeat

Facial flushing

Red eyes

Dry mouth

Headaches

Dizziness

Coughing

SIDE EFFECTS

Long-Term Side Effects

Severe chronic bronchitis

Range of cognitive deficits

Receptor down-regulation (decline in receptor density)

77 | March 2018

RisksWarnings

Contraindicationsbull Pregnancy nursingbull Lower birth weightsbull Endocannabinoids involved in several aspects

of fetal and childhood development

bull Cannabinoids are passed along breast milk

bull Serious mental disorders (ie schizophrenia)

Use with caution for patients withbull Heart conditionsbull Respiratory conditions

bull History of drug alcohol abuse

78 | March 2018

RisksWarnings

In case of overdosebull May potentiate worsen side

effects

bull Will resolve after stopping medication

bull Drinking water and eating may help as well as fresh air

bull Do not consume cannabis in a public

place or where it may pose harm to others

bull Never operate a vehicle after consuming marijuana

bull Keep this medicine out of reach of

children or pets

21032018

14

The Pharmacistrsquos Role

80 | March 2018

Massachusetts College of

Pharmacy and Health Sciences

Yale University

Saint Francis Hospital and

Medical Center

Studies

81 | March 2018

Human Reduction Strategy Minimizes harm tobull Individualbull Others impacted by the harmed person

bull SocietyStudies shown benefits when adding cannabis to opioid therapybull Decreased painbull May allow lower doses of opioids = lower side effects

Studies concluded states with medical marijuana laws have lower incidence of opioid mortality rates

Cannabis and Opioids

My Own Opiate Research Project

bull Monitoring MME

bull Document initial MME MME 1 year later

bull October ndash February 2017 October ndash February 2018

bull 65 Total Patientsbull 38 Active Patients (Patients receiving product within 2 months of documentation)

bull 21 Patients decreased MME (55)

bull 11 Patients remained stagnant (29)

bull 6 Patients increased MME (16)

bull 27 Non-Active Patients (Those patients who have not received product within 2 months)

bull 8 Patients decreased MME (30)

bull 11 Patients remained stagnant (40)

bull 8 Patients increased MME (30)

21032018

15

Dependence is estimated to be around 9

bull Nicotine 32

bull Heroin 23

bull Cocaine 17

bull Alcohol 15

bull Stimulants 11

DEPENDENCY

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx

21032018

13

73 | March 2018

Other Routes of Administration

Topical Rectal74 | March 2018

bull Dronabinol = synthetic delta-9-

tetrahydrocannbinol in sesame oil

bull Lacks other cannabinoids and terpinoids

found in natural cannabis

bull More psychoactive than natural

cannabis

bull Slow onset and poor bioavailability

bull More expensive than natural cannabis

bull Studies have shown that inhaled

cannabis have higher success rates than

oral administration of synthetic THC

What About Marinol

CONSULTATION

Symptoms associated with their diagnosis

Other health conditions

Allergies

Marijuana history

Strain Diversity and Pharmacology

Medications

Modes of delivery

Side effects and safety76 | March 2018

Short-Term Side Effects

Mood reactions (euphoria relaxation anxiety time-distortion)

Rapid heartbeat

Facial flushing

Red eyes

Dry mouth

Headaches

Dizziness

Coughing

SIDE EFFECTS

Long-Term Side Effects

Severe chronic bronchitis

Range of cognitive deficits

Receptor down-regulation (decline in receptor density)

77 | March 2018

RisksWarnings

Contraindicationsbull Pregnancy nursingbull Lower birth weightsbull Endocannabinoids involved in several aspects

of fetal and childhood development

bull Cannabinoids are passed along breast milk

bull Serious mental disorders (ie schizophrenia)

Use with caution for patients withbull Heart conditionsbull Respiratory conditions

bull History of drug alcohol abuse

78 | March 2018

RisksWarnings

In case of overdosebull May potentiate worsen side

effects

bull Will resolve after stopping medication

bull Drinking water and eating may help as well as fresh air

bull Do not consume cannabis in a public

place or where it may pose harm to others

bull Never operate a vehicle after consuming marijuana

bull Keep this medicine out of reach of

children or pets

21032018

14

The Pharmacistrsquos Role

80 | March 2018

Massachusetts College of

Pharmacy and Health Sciences

Yale University

Saint Francis Hospital and

Medical Center

Studies

81 | March 2018

Human Reduction Strategy Minimizes harm tobull Individualbull Others impacted by the harmed person

bull SocietyStudies shown benefits when adding cannabis to opioid therapybull Decreased painbull May allow lower doses of opioids = lower side effects

Studies concluded states with medical marijuana laws have lower incidence of opioid mortality rates

Cannabis and Opioids

My Own Opiate Research Project

bull Monitoring MME

bull Document initial MME MME 1 year later

bull October ndash February 2017 October ndash February 2018

bull 65 Total Patientsbull 38 Active Patients (Patients receiving product within 2 months of documentation)

bull 21 Patients decreased MME (55)

bull 11 Patients remained stagnant (29)

bull 6 Patients increased MME (16)

bull 27 Non-Active Patients (Those patients who have not received product within 2 months)

bull 8 Patients decreased MME (30)

bull 11 Patients remained stagnant (40)

bull 8 Patients increased MME (30)

21032018

15

Dependence is estimated to be around 9

bull Nicotine 32

bull Heroin 23

bull Cocaine 17

bull Alcohol 15

bull Stimulants 11

DEPENDENCY

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx

21032018

14

The Pharmacistrsquos Role

80 | March 2018

Massachusetts College of

Pharmacy and Health Sciences

Yale University

Saint Francis Hospital and

Medical Center

Studies

81 | March 2018

Human Reduction Strategy Minimizes harm tobull Individualbull Others impacted by the harmed person

bull SocietyStudies shown benefits when adding cannabis to opioid therapybull Decreased painbull May allow lower doses of opioids = lower side effects

Studies concluded states with medical marijuana laws have lower incidence of opioid mortality rates

Cannabis and Opioids

My Own Opiate Research Project

bull Monitoring MME

bull Document initial MME MME 1 year later

bull October ndash February 2017 October ndash February 2018

bull 65 Total Patientsbull 38 Active Patients (Patients receiving product within 2 months of documentation)

bull 21 Patients decreased MME (55)

bull 11 Patients remained stagnant (29)

bull 6 Patients increased MME (16)

bull 27 Non-Active Patients (Those patients who have not received product within 2 months)

bull 8 Patients decreased MME (30)

bull 11 Patients remained stagnant (40)

bull 8 Patients increased MME (30)

21032018

15

Dependence is estimated to be around 9

bull Nicotine 32

bull Heroin 23

bull Cocaine 17

bull Alcohol 15

bull Stimulants 11

DEPENDENCY

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx

21032018

15

Dependence is estimated to be around 9

bull Nicotine 32

bull Heroin 23

bull Cocaine 17

bull Alcohol 15

bull Stimulants 11

DEPENDENCY

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx

21032018

16

Number of Deaths from

Cannabis

2001 ndash 2014

FOR MORE INFORMATION

bull httpwwwtikun-olaminfo (Israeli site that has studied cannabis for quite a while)

bull PubMed wwwncbinlmnihgov

bull wwwmedicalcannabiscom (Mark A Ware MBBS MRCP)

bull wwwhealercom (Dr Dustin Sulak)

bull CErsquos and CMErsquos available

bull wwwthemedicalcannabisinstitueorg

bull wwwtheanswerpagecom

bull Books

bull Cannabis Pharmacy by Michael Backes (Black Dog amp Leventhal Publishers) 2014

bull Medical Cannabis What Clinicians Need to Know and Why by Gregory L Smith (Aylesbury

Press) 2016

REFERENCESbull httpwwwcgactgovcurrentpubchap_420fhtmbull Department of Consumer Protection Physician Requirements and Eligibility httpwwwctgovdcpcwpviewaspa=4287ampq=509622ampdcpNav=[55378]bull httpwwwleaflycomknowledge-centercannabis-101sativa-indica-and-hybrid-whats-the-difference-between-cannabis-tybull httpwwwleafsciencecomendocannabinoid-systembull httpwwwleafsciencecomcannabinoidsbull httpwwwcannlabscomthe-sciencecannabinoidsbull httpwwwleaflycomknowledge-centercannabis-101terpenes-the-flavors-of-cannabis-aromatherapybull httpwwwpharmacytimescompublicationsissue2014December2014Drug-Interactions-with-Marijuanabull httpwwwcannlabscomthe-sciencecannabinoidsbull httpswwwncbinlmnihgovpubmed18025276bull httpwwwncbinlmnihgovpmcarticlesPMC2797098bull httpdrugwarfactsorgcmsq=node30sthash7KJIYwtjdpbsbull httparchintejamanetworkcomarticleaspxarticleid=1898878bull Clinical Pharmacology amp Therapeutics (2011) 90 6 844ndash851 doi101038clpt2011188bull Cannabis Pharmacy (2014) 34-41 Michael Backesbull R Musty and R Rossi 2001 Effects of smoked cannabis and oral delta-9-tetrahydrocannabinol on nausea and emesis after cancer chemotherapy a review of state clinical trials Journal of

Cannabis Therapeutics 1 29-56 bull Board of Pharmacy State of Tennessee 1983 Annual Report Evaluation of Marijuana and Tetrahydrocannabinol in Treatment of Nausea andor Vomiting Associated with Cancer Therapy

Unresponsive to Conventional Anti-Emetic Therapy Efficacy and Toxicity p 5bull Jusko WJ Gardner MJ Mangione A et al Factors affecting theophylline clearances age tobacco marijuana cirrhosis congestive heart failure obesity oral contraceptives benzodiazepines

barbiturates and ethanol J Pharm Sci 1979681358-1366bull Yamreudeewong W Wong HK Brausch LM et al Probable interaction between warfarin and marijuana smoking Ann Pharmacother 2009431347-1353bull httpnhttpswwwdrugabusegovrelated-topicstrends-statisticsoverdose-death-ratesbull normlorgstatesbull httpemedicinemedscapecomarticle1361971-overviewa4bull httpsteephilllabcomterpenes-and-cannabisbull httpmaryjanesdiarycomterpenesbull wwwmayoclinicorgdrugs-supplementsmarijuanasafetyHRB-20059701bull httpswwwmedicaljanecom20130803cannabigerol-cbg-is-a-minor-cannabinoid-with-major-impactbull httpwwwgoverningcomgov-datasafety-justicestate-marijuana-laws-map-medical-recreationalhtmlbull httpwwwgoverningcomtopicspublic-justice-safetygov-trump-marijuana-sessions-obama-colehtmlbull httpnormlorglawsitemvirginia-penalties-2bull httpwtvrcom20180207Virginia-likely-to-expand-medical-marijuanabull httpwwwgwpharmcomMechanism-of-Actionaspx