HempWorx cannabidiol oil sales in Canada put on hold again . More stories from CBC Manitoba's investigative I-Team. With files from. With Canada's legalization of cannabis set for this summer, new market Phivida Holdings founder John Belfontaine shared his own story about a month to its management team to replicate success they had at Red Bull. The fact that a consumer-cannabis product has captured the attention of Tilray, a separate Canadian cannabis company, also experienced its.
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Whether any of these CBD products will do anyone any good or bad is moot. You need to differentiate, he says, between the extremely high doses of pharmaceutical-grade pure CBD that participants in the handful of successful studies were given and the dietary supplements available over the counter or online. Two cannabis-based pharmaceutical drugs, manufactured in the UK, are licensed for prescription but only for very specific uses.
One couple even said it gave them palpitations and a sleepless night. All these people had different conditions, expectations and situations. McGuire published his own study in August, in which CBD was shown to reduce psychotic episodes in people with schizophrenia. The daily dose was 1,mg of pure CBD. And a study in which CBD seemed to ease anxiety, published in Nature in , administered a single dose of mg, an hour and a half before giving participants a public speaking task.
But he is obliged to point out that the product is a dietary supplement, and no clinical claims can be made for it. These beneficial compounds include a range of phytocannabinoids, terpenes and flavonoids that work together. The truth is that no one knows precisely what any of these molecules are doing to us.
It is a case of finding the effects first and working backwards to understand the mechanisms. An earlier version referred to a beer from Cloud 9 Brewing. The brewery changed its name to Green Times Brewing in September. Knowledge is rapidly expanding and has led to a change in attitudes toward medical cannabis. A popular example of this change was the apology by Dr Sanjay Gupta in for not better appreciating cannabis as a potential therapeutic drug.
Relatedly, some regional differences in the accessibility of medical cannabis have been reported. Examination of patient forums suggests that one reason for these regional differences may be a lack of physicians willing to prescribe medical cannabis in these regions. Providing physicians with evidence-based guidelines and training in prescribing practices will likely decrease such barriers to accessibility of medical cannabis.
Regardless, an incidence of dependency of one per eleven is still significantly lower than those of approved pharmaceuticals commonly used for chronic pain management. With the introduction of the MMPR in Canada, physicians are advised to follow the guidance set forth by their provincial college. The aim of the MMPR is to treat medical cannabis like other narcotics used for medicinal purposes whenever possible.
Under the MMPR, the patient must consult with a medical doctor or a qualified nurse practitioner. These medical documents are treated similarly to prescriptions. They must meet specific requirements, including patient name, date of birth, physician information, including license number and signature, a daily allotment in grams, and a length of time for the access not exceeding 1 year.
While there is no legal requirement for licensed producers to follow strain and THC recommendations, many will abide by the request of the physician. Dispensaries and compassion clubs are not permitted under MMPR, so appropriate steps should be taken to ensure a patient is only being referred to Health Canada-approved organizations.
Once the patients purchase the medication from the company, it is shipped to their home, or that of their caretaker. Alternatively, arrangements may be made for the licensed producer to transfer the drug to the health care prescriber, from which it can then be obtained by the patients. It should be noted that Health Canada neither approves nor regulates medical cannabis like it does pharmaceutical drugs. Thus, the medical document issued by physicians for medical cannabis is distinct from, and only partially analogous to, a prescription.
Instead, the medical document can be viewed as a recommendation to the medical cannabis program. In Quebec, a distinction is made that physicians should not provide such a document unless it is part of a recognized research project and only for specified conditions.
Other provincial colleges will have their own requirements. A recent decision by the Supreme Court of Canada has overturned the original requirements for licensed producers and patients to only sell and consume dried cannabis. This decision allows the sale of fresh, dried, and oil forms of cannabis to patients. Though, as of writing, no licensed producer has yet to be granted permission to sell fresh and oil alternative forms to patients.
As mentioned, prescription and recommendation of medical cannabis at this point is largely nonspecific. Patients are recommended to the medical cannabis program but not necessarily a specific strain. Increasingly, an understanding of how specific strains of medical cannabis can offer benefit for specific ailments is appreciated by those recommending the use of medical cannabis. Unfortunately, the body of evidence supporting these practices is limited, due to an overall lack of investigation, which prevents physicians from making informed decisions to best improve the risk—benefit relationship of medical cannabis in their patients.
Many colleges recommend that Canadian physicians treat medical cannabis as they would any other prescribed narcotic drug. This often includes the use of patient—physician agreements on appropriate use and informed consent of the new medication. Physicians should also consider other following factors when recommending medical cannabis to their patients. MMPR requires the recommending physician allot a set amount of cannabis to which a patient will have access on a daily basis. Medical cannabis programs report average patient use of between 0.
However, patients report using up to 10 g of cannabis per day for self-medication purposes. Both the amount the patients currently use for self-identified medical reasons and their preferred route of administration should be taken into consideration when recommending an amount of medical cannabis. Given that evidence supporting the use of specific medical cannabis strains for various pain ailments is lacking, recommending a strain type to a patient can be difficult.
The decision is often determined by a number of factors, including financial concerns, potential risk to the patient, and specific goals of the patient such as to improve sleep or to avoid feeling high. Typically, recommendations are made based on medical history, cannabis use history, and financial barriers.
Once all of these factors have been considered, a strain is selected by the clinician from a range of varieties recommended for medical use by Health Canada from authorized licensed producers. Each licensed producer produces different strains suitable for various medical purposes. Patients with a history of cannabis use and no significant risk factors are initially prescribed a strain with higher THC content and maximal CBD content.
If patients fail to get relief from their initial strains, an increase in the THC content is recommended in a stepwise fashion, as long as serious risk factors are not present. If risk factors are present, the risk—benefit analysis for this patient must be readdressed. Many colleges recommend indicating an amount of THC a patient would be permitted to access with a licensed producer. Unfortunately, the current regulatory environment in Canada does not require a licensed producer adhere to the recommendation.
Likewise, there is rarely any guidance on prescribing strains with CBD content. Many patients have concerns about medical cannabis smoke, which contains many of the same carcinogenic chemicals as tobacco smoke. Inhalation by vaporization is the most effective route at delivering the medicinal cannabinoid content of medical cannabis, 75 and both dried and extracted medical cannabis can be used in a vaporizer.
Sometimes, vaporization can be burdensome for patients. Indeed, loading a vaporizer requires some degree of dexterity, which may be limited in certain populations of pain patients, such as those with rheumatoid arthritis and osteoarthritis.
Patients may also complain of the temperature of vapor created by vaporization. Many patients require fairly extensive education regarding the use of a vaporizer. Oral ingestion of medical cannabis typically refers to consumption of cannabis oils or edibles. These are generally produced by infusing a lipophilic substance, like an oil or butter, with cannabis, which is then used in drops or in food.
Indeed, a number of recipes have become available online for the use of cannabis oil and butter in food, though some patients dislike the strong flavor. For patients with respiratory illnesses, the oral route is preferable. This method is limited, however, by lower absorption and bioavailability than for inhaled cannabis. Another potential concern is a lack of research on the effectiveness and safety of orally consumed cannabis for pain conditions. Given the increased latency of effect onset from orally consumed medical cannabis, patients should be cautioned to wait an adequate amount of time to feel the effects of the cannabis before readministering.
While issues of dosing and effectiveness exist for orally administered cannabis, it is typically well tolerated by patients. Sublingual tinctures are another, less common, route of administration for medical cannabis. Typically, these tinctures are extracted with ethanol, but vinegars and glycerine may also be used. The extracts are dropped under the tongue and held for a period of time sufficient to permit absorption by the branches of the lingual artery, including the sublingual and deep lingual arteries.
If used properly, onset of action and bioavailability may be faster and higher for this route compared with oral administration, as is often observed with other drugs. However, the use of tinctures is not widespread today, and evidence supporting the therapeutic use of tinctures is limited. Moreover, patients often complain of the taste. In Canada, there is currently a sublingual cannabinoid pharmaceutical known as Sativex.
This is approved for multiple sclerosis MS -related neuropathic pain or spasticity and for cancer-related pain. A case series has also been published on its effectiveness for fibromyalgia.
Alternative routes of administration include transdermal ointments and balms, ophthalmic drops, and rectal suppositories. While rarely used, all of these routes may have therapeutic potential for patients, though little research has been done to assess this likelihood.
When introducing a patient to medical cannabis for the first time, it is important to schedule frequent follow-ups until a strain has been selected that meets the treatment goals of both patient and physician. Since this process may require changes such as route of administration, an active follow-up schedule may be required to provide the patient with adequate knowledge to continue safely and confidently. Once a patient has been stabilized, follow-up visits should focus on monitoring for adverse reactions, including dependence.
In Canada, the medical document that is produced to allow a patient access to cannabis acts as a license. Several contraindications have been identified for medical cannabis recommendations. Due in part to the illicit nature of cannabis, research is lacking and there is a significant knowledge gap in this area, and medical cannabis recommendations should always be made with careful consideration of the current health status of the patient. As previously mentioned, individuals suffering from, or at a high risk of developing, schizophrenia or other psychotic illnesses should only be recommended the use of cannabis under well-monitored conditions.
The use of strains with minimal or no THC content is recommended. Recently, Kim et al found that cannabis use was significantly associated with lower rates of remission of bipolar spectrum patients over a 2-year follow-up period. It is estimated that C. However, mild rhinoconjunctivitis symptoms can be treated with antihistamines, intranasal steroids, and nasal decongestants.
Findings from the currently available research suggest that the safety profile of the short-term use of medical cannabis is acceptable.
The most commonly reported adverse effect was dizziness Rates of serious adverse effects did not vary between the group of participants assigned to medical cannabis and controls.
A year-old, single male patient reporting chronic lower back pain due to diagnoses of spinal stenosis, degenerative disc disease, and neuropathic pain including sciatica for over 20 years presented at our clinic.
The patient also had diagnoses of gastroesophageal reflux disease, irritable bowel syndrome, and anxiety. At the time of meeting, the patient was using nabilone 0. After several unsuccessful attempts at pain control using physiotherapy, chiropractic, osteopathy, acupuncture, corticosteroid injections, oxycodone, and Percocet, the patient confided he turned to illicit cannabis for pain relief on a daily basis, primarily in the evening after work.
The patient also indicated he did not see a need for pregabalin, and had begun the process of lowering his daily dose. Surprisingly, the patient also reported far fewer symptoms of his irritable bowel syndrome, claiming near-remission. A year-old, married male patient reporting fibromyalgia for 5 years, and osteoarthritis, torn shoulder tendon, and spinal stenosis for over 20 years was referred to our clinic.
The patient also had a history of severe obesity, sleep apnea, restless legs syndrome, and anxiety. Signs of neuropathic pain included widespread allodynia and positive DN4 score. Physiotherapy, corticosteroid injections, codeine, and a number of anti-inflammatory medications were unsuccessful at achieving adequate analgesia.
The patient was inexperienced with cannabis, except for intermittent use on weekends. The patient was prescribed 1. A year-old, single female patient reporting neuropathic pain secondary to MS diagnosis of over 20 years was referred to our clinic by her pain intervention physician. The patient was actively taking gabapentin 2, mg daily and celecoxib mg daily. The patient could not tolerate the use of opiate medications, claiming dissatisfaction with their sedative effects.
Failed pain interventions included IV lidocaine and lumbar radiofrequency ablation. The patient was prescribed 1 g per day of cannabis containing 2. This review documents some of the relevant history and current research literature on medical cannabis. It draws to attention the key concerns in the Canadian medical system and provides updated treatment approaches to help clinicians work with their patients in achieving adequate pain control, reduced narcotic and other medication use and their adverse effects , and enhanced quality of life.
RCTs using large population samples are needed in order to identify the specific strains and concentrations that will work best with selected cohorts. Cannabis-based medicine is a rapidly emerging field of which all pain physicians need to be aware. National Center for Biotechnology Information , U. Journal List J Pain Res v. Published online Sep Find articles by Sara L Bober. Find articles by Jason M Moreau. Author information Copyright and License information Disclaimer.
This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https: By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. This article has been cited by other articles in PMC. Abstract Cannabis has been widely used as a medicinal agent in Eastern medicine with earliest evidence in ancient Chinese practice dating back to BC.
Medical cannabis in history and society Cannabis sativa cannabis has been used therapeutically for almost 5, years, beginning in traditional Eastern medicine. Open in a separate window. Cannabis and cancer Medical cannabis is also used for some cancer patients to relieve symptoms including nausea and vomiting often caused by some cancer treatments such as chemotherapy and radiation therapy , loss of appetite, and pain.
Pharmacokinetics To date, most pharmacokinetic studies of cannabinoids have focused on the bioavailability of inhaled THC, which varies substantially in the literature, likely due to differences in factors such as breath-hold length, source of cannabis material, and method of inhalation.
Acquisition cost Medical cannabis is not typically covered by insurance plans in Canada. Social stigma Many chronic pain patients considering medical cannabis anticipate disapproval from their friends and family. Lack of understanding of route of administration Many chronic pain patients have limited or no experience using cannabis. Physicians Credibility—criminality—clinical evidence In , upward of 1, studies were published on cannabinoids.
Prescribing considerations As mentioned, prescription and recommendation of medical cannabis at this point is largely nonspecific. Amount MMPR requires the recommending physician allot a set amount of cannabis to which a patient will have access on a daily basis. Strain selection and recommendation Given that evidence supporting the use of specific medical cannabis strains for various pain ailments is lacking, recommending a strain type to a patient can be difficult.
Route of administration Many patients have concerns about medical cannabis smoke, which contains many of the same carcinogenic chemicals as tobacco smoke.
Follow-up frequency When introducing a patient to medical cannabis for the first time, it is important to schedule frequent follow-ups until a strain has been selected that meets the treatment goals of both patient and physician. Contraindications Several contraindications have been identified for medical cannabis recommendations. Psychosis As previously mentioned, individuals suffering from, or at a high risk of developing, schizophrenia or other psychotic illnesses should only be recommended the use of cannabis under well-monitored conditions.
Bipolar disorder Recently, Kim et al found that cannabis use was significantly associated with lower rates of remission of bipolar spectrum patients over a 2-year follow-up period. Cannabis allergies It is estimated that C.
Adverse effects Findings from the currently available research suggest that the safety profile of the short-term use of medical cannabis is acceptable. Case studies Neuropathic low-back pain A year-old, single male patient reporting chronic lower back pain due to diagnoses of spinal stenosis, degenerative disc disease, and neuropathic pain including sciatica for over 20 years presented at our clinic. Fibromyalgia — widespread neuropathic pain A year-old, married male patient reporting fibromyalgia for 5 years, and osteoarthritis, torn shoulder tendon, and spinal stenosis for over 20 years was referred to our clinic.
MS-related neuropathic pain A year-old, single female patient reporting neuropathic pain secondary to MS diagnosis of over 20 years was referred to our clinic by her pain intervention physician. Conclusion This review documents some of the relevant history and current research literature on medical cannabis.
Footnotes Disclosure The authors report no conflicts of interest in this work. History of cannabis as a medicine: Examining the roles of cannabinoids in pain and other therapeutic indications: Pharmacology and potential therapeutic uses of cannabis.
History of therapeutic cannabis.
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