Cutting Through the Haze Magdalena Casagrande, PGY-5 Psychiatry - PowerPoint PPT Presentation

Cutting Through the Haze Magdalena Casagrande, PGY-5 Psychiatry Resident Island Schizophrenia Conference November 18, 2016

 Presenter : Magdalena Casagrande  Relationships with commercial interests :  Grants / Research Supports : None  Speakers Bureau / Honoraria : None  Consulting Fees : None  Other : Employee of Vancouver Island Health Authority

 This program has received financial support from Otsuka / Lundbeck, Janssen and Mylan in the form of unrestricted educational grants.  This program has received in-kind support from Lundbeck Inc, BMS in the form of logistical support.  Potential for conflict(s) of interest :  I have no actual or potential conflict of interest in relation to this presentation

 There has been no influence from the funders on the content of my presentation  I will present information that is evidence-based rather than reporting on personal clinical experiences  I will be using generic names when discussing medications

 New cannabis regulations in Canada  “Health Canada today announced the Access to Cannabis for Medical Purposes Regulations. Under the ACMPR, Canadians [ …] will be able to produce a limited amount of cannabis for their own medical purposes, or designate someone to produce it for them. They will also have the option of purchasing [...] cannabis from one of the 34 producers licensed by Health Canada. ”  Statement from Health Canada concerning access to cannabis for medical purposes, August 11 th 2016  Emotionally-charged topic fueled by a myriad of political, legal & philosophical interests & opinions

 Recognize the ubiquity of marijuana use  Review the psychobiology of cannabis  Consider the medical uses of marijuana  Explore the link between mental illness & marijuana  Have a joint discussion on the medical implications of changing social policy

 Cannabis is the most commonly used illegal drug in Canada  Younger Canadians are the biggest consumers CADUMS 2008 – 2012, CTADS 2013

9% of South Vancouver Island youth used marijuana the previous Saturday McCreary Centre Society, BC Adolescent Health Survey 2013

>60% of South Vancouver Island youth tried marijuana for the first time at 14 years or younger McCreary Centre Society, BC Adolescent Health Survey 2013

 Mixture of dried flowers, leaves & stems from the common hemp plant  Contains > 100 cannabinoids, chemically related compounds that mimic effects of endocannabinoids  Principal cannabinoids in marijuana  Δ 9 -tetrahydrocannabinol (THC) – psychoactive ingredient  Cannabidiol (CBD) – virtually no psychoactive effects, may have beneficial medical properties National Institute on Drug Abuse, www.drugabuse.gov , updated Mar 2016

% THC / CBD content National Institute on Drug Abuse, Potency Monitoring Program 2014 Mehmedic Z et al. J Forensic Sci 2010

 Ancient & recently discovered lipid signaling system implicated in regulatory processes aimed at maintaining body homeostasis  Metabolism, sleep / wake cycle, immune function, neural development, memory, emotinal state...  Composed of:  Lipids called endocannabinoids - anandamide & 2-AG*  CB1 & CB2 receptors, metabolic enzymes  There is much research interest in the role of the endocannabinoid system in neurological, psychiatric & inflammatory diseases * 2-arachidonoyl-glycerol Health Canada, Information for Health Care Professionals: Cannabis and the Cannabinoids, 2013

 Physiological  Increased HR / BP / RR, conjunctival injection, increased appetite, dry mouth, slowed reaction time  Psychological  Sense of well-being, euphoria, relaxation, altered perception of time, impaired short-term memory, anxiety, paranoia, frank psychosis  When ingested, psychoactive effects are often delayed  Inadvertent consumption of more THC than intended, leading to increased risk of adverse effects like psychosis & panic National Institute on Drug Abuse, www.drugabuse.gov , updated Mar 2016

 THC & CBD are the primary cannabinoids found in marijuana  The potency of marijuana has significantly increased over the last few decades  Endocannabinoids mediate a variety of bodily functions in a manner that is not yet fully understood  THC & CBD interact in a complex manner with the endocannabinoid system to produce psychotropic & potentially therapeutic effects, respectively

 Since landmark court decision R. v. Parker (2000), Health Canada has regulated access to cannabis for medical purposes  Under MMPR* program, people were not able to grow their own marijuana, relying on federally licensed producers  Allard et al. v. Canada (Feb 2016)  ‘Allard decision’  MMPR* regulations were deemed to violate charter rights to reasonable access  Today, Health Canada regulates production & distribution of marijuana for medical purposes through ACMPR*  Eligible clients can now access cannabis by registering with licensed producers, growing their own or designating someone else to grow it for them * Marihuana for Medical Purposes Regulations * Access to Cannabis for Medical Purposes Regulations Health Canada Understanding the New ACMPR Aug 2016

 Completed by a physician or nurse practitioner  No need to cite a specific indication  No requirement to monitor outcome Health Canada, www.hc-sc.gc.ca/dhp-mps/marihuana/info/med-eng.php , updated Aug 2016

 College of Physicians & Surgeons of BC (July 2015)  ‘Physicians are advised that they should not prescribe any substance for their patients without knowing the risks, benefits, potential complications and drug interactions associated with the use of that agent.’  ‘Physicians may be the subject of […] liability if the use of marijuana produces unforeseen or unidentified negative effects.’  Outlines for whom cannabis would not be appropriate  Under the age of 25, personal / family hx psychosis, substance use disorder, cardiovascular / respiratory disease, pregnant  Recommends steps that physicians, who chooses to prescribe marijuana, should abide by

 College of Family Physicians of Canada (Feb 2013)  ‘Physicians cannot be expected to prescribe a drug without the safeguards in place as for other medications – solid evidence supporting the effectiveness and safety of the medication, and a clear set of indications, dosing guidelines and precautions .’  ‘The CFPC recommends the “declaration” approach in lieu of “prescribing”. A “declaration” [ …] states only that the patient meets Health Canada criteria allowing access to marijuana for medical use. [ …] a declaration does not give doses or directions, and does not imply that the physician recommends or advises the patient to smoke or ingest marijuana.’

 8 federally licensed producers in BC, 4 of which are on Vancouver Island  Dried marijuana & oils are shipped directly to clients  35 dispensaries in Victoria (all illegal)  Dried marijuana, oils, edibles, marijuana paraphernalia  City of Victoria regulations require each dispensary to submit a rezoning application & to obtain an annual business license fee  Sept 2016: 82,000 Canadians registered with licensed producers  Registration is not condition-specific so no available data on this Cleverley B Times Columnist Jul 23, 2016 City of Victoria Medical Cannabis Businesses www.victoria.ca/medicalcannabis Sept 23, 2016 Health Canada news.gc.ca/web/article-en.do?nid=1127659 Sept 21, 2016

 Recent meta-analysis found:  Moderate-quality evidence to support use of cannabinoids for treatment of spasticity & pain related to cancer or neuropathy  Low-quality evidence suggesting that cannabinoids were associated with improvements in nausea & vomiting due to chemotherapy, weight gain in HIV, & sleep disorders  Other: Epilepsy, cancer, glaucoma, neurodegenerative diseases, arthritis, inflammatory bowel disease, ALS... Whiting P et al. JAMA 2015 Alexander SPH et al. Prog Neuropsychopharmacol Biol Psychiatry 2016 Reddy DS et al. J Pharm Exp Ther 2016

Medical Marijuana Prescription Cannabinoids Plant species Pharmaceutical product Regulated by ACMPR* Program Regulated by Health Canada Patient pays Government pays Individual has a ‘medical need’ Specific indications Recommendation by physician Standard prescribing procedures * Access to Cannabis for Medical Purposes Regulations  Prescription cannabinoids approved by Health Canada  Nabilone – synthetic derivative of THC in pill form  Nabiximols – oral sprary containing equal proportions of THC & CBD Health Canada, Information for Health Care Professionals: Cannabis and the Cannabinoids 2013

 Medical marijuana has been legal in Canada since 2001; however, there is a lack of standardized, evidence-based guidelines for prescribing & monitoring practices  Prescription cannabinoids are regulated as pharmaceutical agents by Health Canada while medical marijuana is regulated by the ACMPR* Program  Research provides evidence for potential therapeutic effects of cannabinoids  There are many local dispensaries in Victoria offering easy access to a variety of illegal marijuana products * Access to Cannabis for Medical Purposes Regulations