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Medical Marijuana in Ohio

Medical Marijuana in Ohio. Amol Soin , MD Medical Board Member Medical Marijuana Member. Medical Marijuana Gains Momentum Politically. Background. Medical Marijuana begins to be used in other states Some States adopt Marijuana for recreational use

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Medical Marijuana in Ohio

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  1. Medical Marijuana in Ohio AmolSoin, MD Medical Board Member Medical Marijuana Member

  2. Medical Marijuana Gains Momentum Politically

  3. Background • Medical Marijuana begins to be used in other states • Some States adopt Marijuana for recreational use • Ohio debates medicinal and recreational use initiatives

  4. Background • House Bill 523, effective on September 8, 2016, legalizes medical marijuana in Ohio • The Ohio Medical Marijuana Control Program will allow people with certain medical conditions, upon the recommendation of an Ohio-licensed physician certified by the State Medical Board, to purchase and use medical marijuana.

  5. Background • While the legislation set a basic framework for the program, it left the task of establishing specific rules and guidelines for the cultivation, processing, testing, dispensing and medical use of marijuana to different state agencies. • Medicalmarijuana.ohio.gov

  6. The “Science” • The Science behind medical marijuana remains somewhat controversial • The use of cannabis as medicine has not been rigorously tested due to production restrictions and other governmental regulations • Limited evidence suggests cannabis can: reduce nausea and vomiting during chemotherapy, improve appetite in people with HIV/AIDS, and reduce chronic pain and muscle spasms

  7. Short-term use increases the risk of both minor and major adverse effects • Common side effects include dizziness, feeling tired, vomiting, and hallucinations. Long-term effects of cannabis are not clear.[ • Concerns include memory and cognition problems, risk of addiction, schizophrenia in young people, and the risk of children taking it by accident

  8. Forms of Medical Marijuana • Medical cannabis can be administered using a variety of methods, including liquid tinctures, vaporizing or smoking dried buds, eating cannabis edibles, taking capsules, using lozenges, dermal patches, or oral/dermal sprays • Similar to what we can expect in Ohio

  9. A Cannabis plant includes more than 400 different chemicals, of which about 70 are cannabinoids • In comparison, typical government-approved medications contain only one or two chemicals.Thenumber of active chemicals in cannabis is one reason why treatment with cannabis is difficult to classify and study • A 2014 review stated that the variations in ratio of CBD-to-THC in botanical and pharmaceutical preparations determines the therapeutic vs psychoactive effects (CBD attenuates THC's psychoactive effects) of cannabis products

  10. Evidence is moderate that it helps in chronic pain and muscle spasms. • Low quality evidence suggests its use for reducing nausea during chemotherapy, improving appetite in HIV/AIDS, improving sleep, and improving tics in Tourette syndrome • When usual treatments are ineffective, cannabinoids have also been recommended for anorexia, arthritis, migraine, and glaucoma

  11. Nausea and Vomiting • Medical cannabis is somewhat effective in chemotherapy-induced nausea and vomiting (CINV)and may be a reasonable option in those who do not improve following preferential treatment. • Comparative studies have found cannabinoids to be more effective than some conventional antiemetics such as prochlorperazine, promethazine, and metoclopramide in controlling CINV but these are used less frequently because of side effects including dizziness, dysphoria, and hallucinations. • Long-term cannabis use may cause nausea and vomiting, a condition known as cannabinoid hyperemesis syndrome

  12. Nausea and Vomiting • A 2016 Cochrane review said that cannabinoids were "probably effective" in treating chemotherapy-induced nausea in children, but with a high side effect profile (mainly drowsiness, dizziness, altered moods, and increased appetite). Less common side effects were "occular problems, orthostatic hypotension, muscle twitching, pruritis, vagueness, hallucinations, lightheadedness and dry mouth"

  13. HIV/AIDS • Evidence is lacking for both efficacy and safety of cannabis and cannabinoids in treating patients with HIV/AIDS or for anorexia associated with AIDS. As of 2013, current studies suffer from effects of bias, small sample size, and lack of long-term data

  14. Pain • A 2017 review found moderate to high quality evidence for effectiveness of cannabis in relieving chronic pain in several conditions, particularly when inhaled. • Another review found tentative evidence for use of cannabis in treating peripheral neuropathy, but little evidence of benefit for other types of long term pain

  15. Pain • When cannabis is inhaled to relieve pain, blood levels of cannabinoids rise faster than when oral products are used, peaking within three minutes and attaining an analgesic effect in seven minutes.[ • A 2014 review found limited and weak evidence that smoked cannabis was effective for chronic non-cancer pain. • A 2015 meta-analysis found that inhaled medical cannabis was effective in reducing neuropathic pain in the short term for one in five to six patients. • Another 2015 review found limited evidence that medical cannabis was effective for neuropathic pain when combined with traditional analgesics

  16. Neurological Problems • The efficacy of cannabis in treating neurological problems, including multiple sclerosis (MS), epilepsy, and movement problems, is not clear. • Studies of the efficacy of cannabis for treating multiple sclerosis have produced varying results. • The combination of Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) extracts give subjective relief of spasticity, though objective post-treatment assessments do not reveal significant changes.

  17. Neurological Problems • Evidence also suggests that oral cannabis extract is effective for reducing patient-centered measures of spasticity. • A trial of cannabis is deemed to be a reasonable option if other treatments have not been effective. • Its use for MS is approved in ten countries. • A 2012 review found no problems with tolerance, abuse or addiction.

  18. Pharmacology

  19. Pharmacology • The genusCannabis contains two species which produce useful amounts of psychoactive cannabinoids: Cannabis indica and Cannabis sativa, which are listed as Schedule I medicinal plants in the US • a third species, Cannabis ruderalis, has few psychogenic properties. • Cannabis contains more than 460 compounds;atleast 80 of these are cannabinoids– chemical compounds that interact with cannabinoid receptors in the brain. • As of 2012, more than 20 cannabinoids were being studied by the U.S. FDA

  20. Pharmacology • The most psychoactive cannabinoid found in the cannabis plant is tetrahydrocannabinol (or delta-9-tetrahydrocannabinol, commonly known as THC). • Other cannabinoids include delta-8-tetrahydrocannabinol, cannabidiol (CBD), cannabinol (CBN), cannabicyclol (CBL), cannabichromene (CBC) and cannabigerol (CBG); they have less psychotropic effects than THC, but may play a role in the overall effect of cannabis. • The most studied are THC, CBD and CBN

  21. Pharmacology • CB1 and CB2 are the primary cannabinoid receptors responsible for several of the effects of cannabinoids, although other receptors may play a role as well. Both belong to a group of receptors called G protein-coupled receptors (GPCRs). • CB1 receptors are found in very high levels in the brain and are thought to be responsible for psychoactive effects.[ • CB2 receptors are found peripherally throughout the body and are thought to modulate pain and inflammation

  22. Absorption • Cannabinoid absorption is dependent on its route of administration. • Smoking is by far the most common form of administration. Inhalation of the smoke quickly and efficiently delivers the drug from the lungs to the brain. Smoked THC has a bioavailability of approximately 25% and a rapid time to peak plasma levels of 6 to 10 minutes. • Bioavailability varies between individuals depending on the number, duration and spacing of puffs, hold time, and inhalation volume. Inhaled and vaporized THC have similar absorption profiles to smoked THC, with a bioavailability ranging from 10 to 35%.

  23. Absorption • Oral administration has the lowest bioavailability of approximately 6%, variable absorption depending on the vehicle used, and the longest time to peak plasma levels (2 to 6 hours) compared to smoked or vaporized THC • Similar to THC, CBD has poor oral bioavailability, approximately 6%. The low bioavailability is largely attributed to significant first-pass metabolism in the liver and erratic absorption from the gastrointestinal tract. However, oral administration of CBD has a faster time to peak concentrations (2 hours) than THC

  24. Absorption • Due to the poor bioavailability of oral preparations, alternative routes of administration have been studied, including sublingual and rectal. These alternative formulations maximize bioavailability and reduce first-pass metabolism. Sublingual administration in rabbits yielded bioavailability of 16% and time to peak concentration of 4 hours. • Rectal administration in monkeys doubled bioavailability to 13.5% and achieved peak blood concentrations within 1 to 8 hours after administration

  25. Distribution • Like cannabinoid absorption, distribution is also dependent on route of administration. Smoking and inhalation of vaporized cannabis have better absorption than do other routes of administration, and therefore also have more predictable distribution. • THC is highly protein bound once absorbed, with only 3% found unbound in the plasma. It distributes rapidly to highly vascularized organs such as the heart, lungs, liver, spleen, and kidneys, as well as to various glands. • Low levels can be detected in the brain, testes, and unborn fetuses, all of which are protected from systemic circulation via barriers

  26. Distribution • THC further distributes into fatty tissues a few days after administration due to its high lipophilicity, and is found deposited in the spleen and fat after redistribution

  27. Metabolism • Delta-9-THC is the primary molecule responsible for the effects of cannabis. Delta-9-THC is metabolized in the liver and turns into 11-OH-THC. • 11-OH-THC is the first metabolic product in this pathway. Both Delta-9-THC and 11-OH-THC are psychoactive. • The metabolism of THC into 11-OH-THC plays a part in the heightened psychoactive effects of edible cannabis

  28. Metabolism • Next, 11-OH-THC is metabolized in the liver into 11-COOH-THC, which is the second metabolic product of THC. •  11-COOH-THC is not psychoactive. • Ingestion of edible cannabis products lead to a slower onset of effect than the inhalation of it because the THC travels to the liver first through the blood before it travels to the rest of the body.

  29. Metabolism • Inhaled cannabis can result in THC going directly to the brain, where it then travels from the brain back to the liver in recirculation for metabolism. • Eventually, both routes of metabolism result in the metabolism of psychoactive THC to inactive 11-COOH-THC.

  30. Excretion • Due to the large propensity of THC and CBD being hepatically metabolized, a majority of their metabolites are excreted via feces than in the urine • After delta-9-THC is hydroxylated into 11-OH-THC via CYP2C9, CYP2C19, and CYP3A4, it undergoes phase II metabolism into more than 30 metabolites. A majority of these metabolites are products of glucuronidation. • Approximately 65% is excreted in feces and 25% in the urine, while the remaining 10% is excreted by other means. The terminal half-life is approximately 25–36 hours

  31. Excretion • CBD is hydroxylated by P450 liver enzymes into 7-OH-CBD. Its metabolites are products of primarily CYP2C19 and CYP3A4 activity, with potential activity of CYP1A1, CYP1A2, CYP2C9, and CYP2D6. • Similar to delta-9-THC, a majority of CBD is excreted in feces and some in the urine. • The terminal half-life is approximately 18–32 hours.

  32. Adverse Events • A 2011 systematic review evaluated published studies of the acute and long-term cognitive effects of cannabis. THC intoxication is well established to impair cognitive functioning on an acute basis, including effects on the ability to plan, organize, solve problems, make decisions, and control impulses. • The extent of this impact may be greater in novice users, and paradoxically, those habituated to high-level ingestion may have reduced cognition during withdrawal. • Studies of long-term effects on cognition have provided conflicting results, with some studies finding no difference between long-term abstainers and never-users and others finding long-term deficits.

  33. Adverse Events • The discrepancies between studies may reflect greater long-term effects among heavier users relative to occasional users, and greater duration of effect among those with heavy use as adolescents compared to later in life.[ • A second systematic review focused on neuroimaging studies found little evidence supporting an effect of cannabis use on brain structure and function. • A 2003 meta-analysis concluded that any long-term cognitive effects were relatively modest in magnitude and limited to certain aspects of learning and memory

  34. Impact on Psychosis • Exposure to THC can cause acute transient psychotic symptoms in healthy individuals and people with schizophrenia. • A 2007 meta analysis concluded that cannabis use reduced the average age of onset of psychosis by 2.7 years relative to non-cannabis use. • A 2005 meta analysis concluded that adolescent use of cannabis increases the risk of psychosis, and that the risk is dose-related.

  35. Impact on Psychosis • Exposure to THC can cause acute transient psychotic symptoms in healthy individuals and people with schizophrenia. • A 2007 meta analysis concluded that cannabis use reduced the average age of onset of psychosis by 2.7 years relative to non-cannabis use. • A 2005 meta analysis concluded that adolescent use of cannabis increases the risk of psychosis, and that the risk is dose-related.

  36. Other Side Effects • A 2008 National Institutes of Health study of 19 chronic heavy marijuana users with cardiac and cerebral abnormalities (averaging 28 g to 272 g (1 to 9+ oz) weekly) and 24 controls found elevated levels of apolipoprotein C-III (apoC-III) in the chronic smokers. • An increase in apoC-III levels induces the development of hypertriglyceridemia. • Synergistic Sedation when used with other medications • Gateway Drug?

  37. Ohio Medical Marijuana Law • Medicalmarijuana.ohio.gov • Cultivation • Processing • Testing • Dispensaries • Physicians • Patients and Caregivers

  38. Cultivation • Level 1 • Score - 179.28 Buckeye Relief LLC (Eastlake, Lake County) • Score - 173.44 Grow Ohio Pharmaceuticals LLC (Newton Township, Muskingum County) • Score - 173.28 OPC Cultivation LLC (Huron, Erie County) • Level II • Score - 178.92 Fire Rock Ltd. (Columbus, Franklin County) • Score - 178.92 Fire Rock Ltd. (Canton, Stark County) • Score - 178.92 Fire Rock Ltd. (Arkon, Summit County)

  39. Processing and Testing • Information available at the website • Examples include university centers

  40. Dispensaries • Application process • Information on the website • Application fee (other applicants have fees as well like cultivators) • Many locations • Only able to serve medical marijuana. Must be open at specific minimum time hours

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