Understanding Cannabis: Clinical Considerations

The use of cannabis for medicinal purposes and recreational use across all age groups continues to increase across the United States. Cannabis is reported to be the most commonly used illicit drug in the United States. In recent years, more states have legalized cannabis for both medicinal and recreational use. With the growing public acceptance and prevalence of cannabis use, advanced practice nurses will encounter more patients seeking guidance on the use of cannabis for a variety of conditions. Providers need to be armed with a basic level of knowledge concerning cannabis use, potential side effects, adverse reactions, legal issues, and drug interactions.     

Role of the Endocannabinoid System and Medical Cannabis

Our bodies produce complex substrates called endocannabinoids, which attach to the endocannabinoid system (ECS) receptors and impact many physiologic processes. Current research on the ECS and cannabis-based medications is accelerating in the presence of continued conflict between federal and state laws. In this article we present a summary of the latest information on the ECS, its receptors, and current research on the cannabis-based medicines and their potential to treat various disease pathologies and medical conditions. Our study includes the latest information on the continued legal ramifications nurse practitioners face in treating patients with these medications.     

Cannabidiol for Epilepsy: New Hope on the Horizon?

Epilepsy is a common neurologic disorder; it is estimated that ～50million people are affected worldwide. About one third of those patients are drug resistant, defined as failure to stop all seizures despite adequate trials of at least 2 appropriate medications. There has been an enormous interest in developing antiepileptic drugs with novel mechanisms of action. This review discusses the evidence supporting the anticonvulsant properties of cannabis in humans, focusing on cannabidiol. We begin by exploring the early and somewhat anecdotal evidence that was recently replaced by high-quality data from randomized controlled studies, which subsequently led to the US Food and Drug Administration approval of a purified cannabidiol extract for the treatment of 2 highly refractory pediatric epilepsy syndromes (Dravet and Lennox-Gastaut).     

Medical Cannabis and Chronic Opioid Therapy

ABSTRACT

Fourteen states and the District of Columbia have legalized the use of cannabis for medical purposes. A small, high-quality literature supports the efficacy of medical cannabis for the treatment of neuropathic pain. The smoked botanical product, however, is associated with a number of adverse medical and psychiatric consequences. Furthermore, experimental data indicate that acute use of cannabis results in impairment of every important metric related to the safe operation of a motor vehicle. Epidemiological data show associations between recent cannabis use and both psychomotor impairment and motor vehicle crashes, associations that are strengthened by the concomitant use of alcohol and other central nervous system depressants. Finally, data from pain clinics reveals an unusually high prevalence of cannabis use in nearly all age groups and an association between cannabis use and opioid and other substance misuse. Based on available data and expert opinion, concomitant use of cannabis and opioids is an absolute contraindication to the operation of a motor vehicle. In patients who use cannabis and are prescribed opioids, heightened vigilance for opioid- and other substance-related problems is warranted. It is appropriate to refrain from prescribing opioids to individuals using medical cannabis if there is reasonable suspicion that the combination will pose a risk to the patient or others.     

Medical Cannabis

Medicolegal realities surrounding “medical marijuana” or “medical cannabis” are rapidly evolving in the United States. Clinicians are increasingly being asked by patients to share information about or certify them for medical cannabis. In order to engage in informed discussions with patients or be comfortable certifying them in states with medical cannabis laws, clinicians may benefit from an understanding of the current state of medical knowledge about medical cannabis. Intended for the generalist and subspecialist, this review provides an overview of the legal status, pharmacology, benefits, risks, and abuse liability of medical cannabis along with a general framework for counseling patients.     

Cannabinoid Hyperemesis Syndrome: An Update for Primary Care Providers

Cannabis is the most commonly used recreational drug worldwide. Crossbreeding and genetic modification techniques have dramatically increased the delta-9-tetrahydrocannabinol content, with resultant increased rates of cannabis use disorders and other toxic effects among users. Cannabinoid hyperemesis syndrome (CHS) is a recently identified disorder and should be considered as a differential diagnosis in patients exhibiting recurrent symptoms of abdominal pain, weight loss, intractable vomiting, and compulsive bathing. Treatment includes vigorous rehydration with intravenous fluids, antiemetics, proton pump inhibitor administration, weight monitoring, and cannabis use cessation. Awareness of CHS symptomology and clinical management strategies can prevent extensive diagnostic workups and unnecessary hospitalizations.     

Cannabis and driving: A new perspective

Cannabis and driving is an emerging injury‐prevention concern. The incidence of driving while affected by cannabis is rising in parallel with increased cannabis use in the community. Younger drivers are at particular risk. Improvements in research methodology, technology and laboratory testing methods have occurred in the last 10 years. These cast doubt on earlier results and conclusions. Studies now show that cannabis has a significant impairing effect on driving when used alone and that this effect is exaggerated when combined with alcohol. Of particular concern is the presence of cannabis as the sole psychoactive drug in an increasing number of road fatalities and the lack of any structural response to this problem. A review of testing methods, laboratory and real driving studies, and recent epidemiological studies is presented. Suggestions for methods of further data collection and future public policy are made.     

The Psychiatric Consequences of Cannabinoids

With rising rates of cannabis use in the general population and an increasing number of US states legalizing both recreational and medical cannabis use, it is important to be informed about the adverse consequences of cannabinoids. This Commentary provides an overview of the psychiatric effects of plant-based and synthetic cannabinoids, differentiating acute effects from effects associated with persistent use. Cannabinoids produce multiphasic and dose-dependent effects on anxiety, mood, and perception, in addition to impairing cognition and psychomotor function. Generally, in healthy individuals, the acute negative psychiatric effects of cannabinoids are rated as milder in severity compared with those in individuals with pre-existing psychiatric disorders. With chronic exposure to cannabinoids, the probability of developing tolerance and dependence can increase. A problematic pattern of cannabis use can lead to clinically significant impairment and distress. Cessation of cannabis use in individuals who are tolerant and dependent can lead to a withdrawal syndrome. Studies report long-term cannabis exposure has been linked to psychiatric disorders, such as anxiety, psychotic and mood disorders. Limitations to the existing evidence notwithstanding, the plausibility of a causal relationship between cannabinoid exposure and persistent negative psychiatric outcomes, and the potential for long-term brain changes by regular exposure, especially for adolescents, are sufficient to warrant discussions with clinicians and the public. Implications for clinicians who certify, prescribe, or care for patients receiving cannabinoids are discussed, and a case is made for further research to better understand the impact of legalization on public mental health.     

Cannabis and anticancer drugs: societal usage and expected pharmacological interactions – a review

Cannabis is a plant that has been used for centuries to relieve a wide range of symptoms. Since the 1960s, interest in medical research into this plant has grown steadily. Already very popular for recreational use, a growing number of consumers not accustomed to using cannabis for psychoactive purposes have begun to use it as an alternative or complement to mainstream pharmaceutical medicines. The principal unsubstantiated or ‘social’ uses of cannabis are based mainly on data that is at best controversial, but usually not scientifically proven. The aim of this review was to identify the scientific basis and reasons that lead patients with cancer to consume cannabis, and also to identify whether there is a risk of interaction between cannabis and anticancer medicines through drug transporters (P‐glycoprotein and other ATP‐binding cassette superfamily members) Cytochromes P450 (3A, 1A, 2B, 2C, 2D families…) and glucuronyl transferases.     

Cannabis Use: Change in Screening for Primary Care Preoperative Clearance

Patients are required to obtain preoperative screening 30 days before elective surgery with an emphasis on testing and screening tools to identify patients at risk for perioperative, intraoperative, and postoperative complications. Surgical complications are being reported in patients who have recently consumed cannabis before surgery. As cannabis use becomes more prevalent for both medicinal and recreational reasons, the lack of evidence-based guidelines for preoperative screening in the primary care setting and surgical setting is problematic. To prevent surgical complications, advanced practice registered nurses must obtain a thorough cannabis history with education on abstaining from use before elective surgery.     

Pediatric Cannabis Single-Substance Exposures Reported to the Michigan Poison Center From 2008–2019 After Medical Marijuana Legalization

BackgroundLegalization of medical and recreational cannabis is a major contributor to pediatric cannabis exposures. The trends and magnitude of pediatric cannabis exposures in Michigan after medical cannabis legalization in 2008 have not been assessed.ObjectiveTo describe the temporal trends of pediatric cannabis exposures reported to the Michigan Poison Center (MiPC) after medical cannabis was legalized in 2008 and 1 year after legalization of recreational cannabis in 2018.MethodsRetrospective electronic chart review of pediatric (<18 years old) single-substance cannabis exposures reported to the MiPC from January 1, 2008 to December 31, 2019. Routes of cannabis exposure were reported as ingestion, inhalation, and unknown. Types of ingested cannabis products were also documented.ResultsBetween 2008 and 2019, 426 pediatric cannabis single exposures were reported. The median patient age was 6.0 years (interquartile range 2–15 years). Age distribution was bimodal. A total of 327 (76.8%) exposures were from cannabis ingestion, 79 (18.5%) from inhalation, 2 (0.5%) from both ingestion and inhalation, and 18 (4.2%) from unknown route. The doubling time for number of cases was 2.1 years, and the total number of annual reported cases increased after 2016. Teenagers (13–17 years) had the highest number of inhalational exposures, whereas young children (0–5 years) had the highest number of ingestions.ConclusionSingle-substance pediatric cannabis exposures reported to the Michigan Poison Center increased after medical cannabis was legalized in 2008 through recreational legalization in 2018.     

Resolution of cannabis hyperemesis syndrome with topical capsaicin in the emergency department: a case series

Background: Cannabinoid hyperemesis syndrome (CHS) is characterized by symptoms of cyclic abdominal pain, nausea, and vomiting in the setting of prolonged cannabis use. The transient receptor potential vanilloid 1 (TRPV1) receptor may be involved in this syndrome. Topical capsaicin is a proposed treatment for CHS; it binds TRPV1 with high specificity, impairing substance P signaling in the area postrema and nucleus tractus solitarius via overstimulation of TRPV1. This may explain its apparent antiemetic effect in this syndrome.

Purpose: We describe a series of thirteen cases of suspected cannabis hyperemesis syndrome treated with capsaicin in the emergency departments of two academic medical centers.

Methods: A query of the electronic health record at both centers identified thirteen patients with documented daily cannabis use and symptoms consistent with CHS who were administered topical capsaicin cream for symptom management.

Results: All 13 patients experienced symptom relief after administration of capsaicin cream.

Conclusion: Topical capsaicin was associated with improvement in symptoms of CHS after other treatments failed.     

Cluster Attacks Responsive to Recreational Cannabis and Dronabinol

Pharmacological preparations of cannabinoid compounds have a variety of therapeutic uses in medicine, including different pain syndromes, but have not been previously reported as beneficial for cluster headache. We present a patient with cluster headache who was refractory to multiple acute and preventive medications but successfully aborted his attacks with recreational marijuana use; subsequent use of dronabinol provided equally effective pain relief. The beneficial effect may be related to the high concentration of cannabinoid receptors in the hypothalamus, which has been implicated as a site of dysfunction in neuroimaging studies of patients with cluster headache.     

Medical Marijuana: A 2014-2016 Update on Law and Policy for Nurse Practitioners

In October 2014, the article, “Medical Marijuana: A Primer on Ethics, Evidence and Politics,” was published in this journal. The focus of that review was the controversy in the United States surrounding access to marijuana, or cannabis, for the relief of intractable patient symptoms, especially pain. In this article we provide an update on the changing US law and policy in the since that report. We also focus on scope-of-practice and advocacy implications for advanced practice registered nurses.     

Oral health implications of increased cannabis use among older adults: Another public health concern?

Prevalence of cannabis use among older Americans (aged ≥ 65) appears to be rising, and emerging evidence associates cannabis use with several oral diseases. The burden of oral diseases among older Americans is great, but literature discussing potential implications of increasing rates of cannabis use and the oral health of older persons is lacking. This paper explores the latest trends in prevalence of cannabis use among older Americans and summarizes the literature on the oral health status of older adults and oral effects of cannabis use, and considers broad implications for oral health and public health policy and future research. Further studies on the effects cannabis use on the oral health of older adults are needed. Future research should investigate older subjects’ susceptibility to cannabis-related oral diseases, as well as the proportions that develop disease. Policymakers may wish to tackle barriers to access of dental services for the older population, or target subsets of the population that suffer from comparably higher rates of oral diseases, while dental professionals may require training on managing underlying substance use behaviors in addition to clinical oral manifestations.     

Safety and pharmacokinetics of medical cannabis preparation in a monocentric series of young patients with drug resistant epilepsy

ObjectivesTo evaluate safety and pharmacokinetic parameters (PK) of medical cannabis in add-on for children and young adults with drug-resistant epilepsy.Design, settingTen patients (4 females, 6 males, age 2.5–23.2 years) were enrolled in a prospective open trial with a galenic preparation (decoction) of Italian cannabis (FM2, ratio THC:CBD = 3:5, range THC 5.2–7.2 %; CBD 8.2–11.1 %). Patients received the first dose in Hospital, progressively augmented by CBD dose titration (from 1 to 4 mg/kg/day).Outcome measuresIn order to assess safety, blood parameters, heart rates and electrocardiograms (ECGs) were evaluated before the enrollment and during the follow up. The PK study was performed measuring THC and CBD concentrations by UHPLC–MS/MS in plasma samples collected during the first administration and at each follow-up visit.ResultsTwo out of ten patients stopped the treatment for adverse events (detected in 6/10: gastroenteric, sleep or behavioral disorders) and difficulties in drug supply. We observed minor ECG alterations in two patients and asymptomatic transient reductions of fibrinogen after 6 months of therapy. The PK study during follow-up revealed statistically significant correlations between THC-CBD blood concentrations and: volumes of decoction, FM2 and THC-CBD daily dosages.ConclusionsThe present study, although with some limitations, shows a good safety profile of medical cannabis in children and young patients with drug-resistant epilepsy and encourages the possibility of further studies with oral cannabis-based drugs. The correlations between THC-CBD plasma concentrations and their administered dosages underline the need of a therapeutic drug monitoring for cannabinoids therapy.     

Cannabidiol for the treatment of cannabis withdrawal syndrome: a case report

What is known and Objective:  Cannabis withdrawal in heavy users is commonly followed by increased anxiety, insomnia, loss of appetite, migraine, irritability, restlessness and other physical and psychological signs. Tolerance to cannabis and cannabis withdrawal symptoms are believed to be the result of the desensitization of CB₁ receptors by THC. Case summary:  This report describes the case of a 19‐year‐old woman with cannabis withdrawal syndrome treated with cannabidiol (CBD) for 10 days. Daily symptom assessments demonstrated the absence of significant withdrawal, anxiety and dissociative symptoms during the treatment. What is new and Conclusion:  CBD can be effective for the treatment of cannabis withdrawal syndrome.