Cannabis Use Medicine, Malady, or Neither? Christy Soran, MD, MPH - - PDF document

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Cannabis Use Medicine, Malady, or Neither?

Christy Soran, MD, MPH UCSF Primary Care Addiction Medicine Fellow

No Disclosures

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Harvest https://recreationaldispensariesnearme.com/the-10-best-marijuana-dispensaries-in-san-francisco/ Harvest https://recreationaldispensariesnearme.com/the-10-best-marijuana-dispensaries-in-san-francisco/

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Plant Derived (THC and CBD) Synthetic (THC)

Photo : https://www.cnn.com/2015/04/16/opinions/medical-marijuana-revolution-sanjay-gupta/index.html Photo: http://www.milwaukeeindependent.com/articles/public-health-alert-issued-result-synthetic-marijuana-hospitalizations/ Source: https://www.mayoclinicproceedings.org/article/S0025-6196(18)30352-5/fulltext Graph Source: https://www.leafly.com/news/cannabis-101/understanding-marijuana-thc-cbd-levels

THC CBD

Agonist CB1 receptors CNS Activity High Modulates activity CB1 and CB2 Modulates THC action

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Colorado Department of Public Health: https://www.colorado.gov/pacific/sites/default/files/MJ_RMEP_Factsheet-Methods-of-Use.pdf Colorado Department of Public Health: https://www.colorado.gov/pacific/sites/default/files/MJ_RMEP_Factsheet-Methods-of-Use.pdf

Tinctures

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Science is behind commercial Industry

Graph: Volkow, N. Adverse Health Effects of Marijuana Use. NEJM, 2014. Photo Source: https://apnews.com/2cb04323f9074c1ca28001693f6e2a8a

Schizophrenia or psychosis Mania in bipolar disorder Depression, SI, suicidal completion Social Anxiety Disorder Impaired Performance: Memory, Learning, Attention Cough, phlegm

Source: National Academies of Sciences, Engineering, and Medicine, 2017

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Schizophrenia or psychosis Mania in bipolar disorder Depression, SI, suicidal completion Social Anxiety Disorder Impaired Performance: Memory, Learning, Attention  lung, head, and neck cancers Cough, phlegm Motor Vehicle Accidents Overuse injuries

Source: National Academies of Sciences, Engineering, and Medicine, 2017

Low birth weight

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Evidence for Cannabis as Medicine

Conclusive or Substantial Evidence

• Chronic pain in adults (cannabis)
• Chemotherapy induced nausea or

vomiting (oral cannabinoids)

• Patient reported MS spasticity (oral

cannabinoids) Moderate Evidence

• Short‐term sleep (oral cannabinoids)

Source: National Academies of Sciences, Engineering, and Medicine, 2017

But what about….

Limited evidence

• Cachexia related to HIV/AIDS
• Clinician‐measure MS spasticity
• Tourette syndrome
• Anxiety
• PTSD
• Post‐TBI outcomes

Limited evidence of ineffectiveness

• Dementia
• Glaucoma
• Depressive symptoms

https://marijuanapatients.org/top-10-benefits/

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Medical Marijuana Cards in California

• AIDS
• Anorexia
• Cachexia
• Cancer
• Chronic Pain
• Glaucoma
• Migraine
• Severe Nausea
• MS spasms
• Disabling Symptoms

Source: https://www.cdph.ca.gov/Programs/DO/letstalkcannabis/CDPH%20Document%20Library/October%202017%20Update/CDPH-Medicinal.pdf Photo: https://www.laweekly.com/news/california-officials-move-to-phase-out-medical-marijuana-id-cards-8189346

FDA Approved Medications

Name Approved Indication Dronabinol (Marinol, Syndros) Anorexia in patients with AIDS Chemotherapy induced nausea and vomiting Nabilone (Cesamet) Chemotherapy induced nausea and vomiting Cannabidiol (Epidiolex) Lennox‐Gaustat Dravet Syndrome Sativex (Nabiximols) (not FDA approved, approved in Canada and UK) Spasticity or neuropathic pain related to MS

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DSM‐5 Criteria for Cannabis Use Disorder

• 1. More use than intended
• 2. Inability to cut down
• 3. Great amounts of time spent dedicated to

substance

• 4. Cravings
• 5. Continued use despite physical or psychological

problems caused

• 6. Role failure
• 7. Social or interpersonal problems
• 8. Recurrent use in situations where it is physically

hazardous

• 9. Giving up activities

10.Tolerance 11.Withdrawal

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DSM‐5 Criteria for Cannabis Use Disorder

• 1. More use than intended
• 2. Inability to cut down
• 3. Great amounts of time spent dedicated to

substance

• 4. Cravings
• 5. Continued use despite physical or psychological

problems caused

• 6. Role failure
• 7. Social or interpersonal problems
• 8. Recurrent use in situations where it is physically

hazardous

• 9. Giving up activities

10.Tolerance 11.Withdrawal

22 million people used marijuana in the last month

(8.5% of US population >12 years)

~4 million people use disorder

Prevalence of Cannabis Use Disorder

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Risk factors for cannabis use disorder

• Younger age
• Male sex
• Native American or Black
• Urban dwelling
• Divorced or widowed
• Lower education
• Lower income
• Mood disorders
• Anxiety disorders
• Personality disorders
• Conduct disorder
• ADHD
• Other substance use disorders

Source: https://www.hiv.uw.edu/go/basic‐primary‐care/substance‐use‐disorders/core‐concept/all https://www‐ncbi‐nlm‐nih‐gov.ucsf.idm.oclc.org/pmc/articles/PMC3069146/ Center for Behavioral Health Statistics and Quality, 2016 National Survey on Drug Use and Health: Detailed Tables, Substance Abuse and Mental Health Services Administration, Rockville 2017

Lower‐risk cannabis use guidelines

• 1. Most effective: not using
• 2. Avoid starting young
• 3. Choose low‐potency THC or

balanced THC:CBD products

• 4. Don’t use synthetic cannabinoids
• 5. Avoid combusted inhalation
• 6. Avoid deep or risky inhalation

practices

• 7. Avoid high‐frequency use
• 8. Refrain from cannabis‐impaired

driving

• 9. Populations at risk for cannabis‐

related health problems should avoid use

• 10. Avoid combining risk behaviors

Resource: Fischer, et al. AJPH 2017. https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.303818

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Monday ‐ Thursday Once a month Friday ‐ Sunday

Key Points

Medicine? – Yes

• There are a few evidence based conditions and FDA approved indications
• There may be more indications in the future

Malady? – Yes

• Cannabis use disorder can be diagnosed with the DSM‐V

Neither? – Yes

• Cannabis use is common and not always harmful
• There are ways to reduce risks of recreational cannabis use

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Thank You