by Kate Kneisel, B.A. and Robert Kitcher, M.A., RP.
This is the Extended Version of a Quinte Counselling Services Inc., Employee Assistance Program, Fall 2017 Newsletter article available in hard copy and on the Qxplore Group website at: www.qxplore.com/fall-2017. The Appendices can be accessed at www.qxplore.com/cannabis-appendices
Since marijuana, or more scientifically speaking, cannabis, has been approved for medical purposes and Canada moves toward legalizing and regulating its use and supply, the wide array of products available and the volume of information and misinformation may seem overwhelming.
If you are using or considering using cannabis either therapeutically or recreationally or you are working with people who are using cannabis, this primer may be a useful preliminary guide and source for more information on the subject.
As you read, you will find appendices that can be accessed on the Qxplore Group website at www.qxplore.com for more detailed information and links to reference documents and websites.
On the therapeutic side, you may find it helpful to know more about medical cannabis, the system that dispenses it, and Health Canada’s recommendations for healthcare professionals around managing this recent addition to approved medical therapies.
[Appendix A, Information for Health Care Professionals on Medical Cannabis from Health Canada]
First, an important cautionary note – combining use of cannabis with other prescribed medications or recreational drugs can lead to unpredictable and potentially dangerous effects.
The risks of cannabis use to both immediate and long-term health are described in the Lower-Risk Cannabis Use Guidelines (LRCUG) released in June 2017 by several Canadian medical groups.
[Appendix B, Information on Lower-Risk Cannabis Use from Centre for Addiction and Mental Health (CAMH)]
At the local level, Quinte Counselling Services and Quinte Assessment and Treatment Group provide Employee Assistance Program services, psychological assessment and psychotherapy services including assistance with abuse and addiction.
In its 2013 information on cannabis for healthcare professionals document, Health Canada notes:
The endocannabinoid system is an ancient, evolutionarily conserved, and ubiquitous lipid signaling system found in all vertebrates, and which appears to have important regulatory functions throughout the human body.
The body’s endocannabinoid system naturally produces chemicals like those found in the cannabis plant, which transmit signals between the brain and nerve cells throughout the body. In fact, cannabinoid receptors develop in humans before birth and naturally produced endocannabinoid compounds are even found in a mother’s breast milk.
Research suggests that the endocannabinoid system is involved in a wide range of human bodily functions and dysfunctions, including development of the nervous system, immune function, inflammation, digestion, psychiatric disease, memory, sleep, pain, and regulation of stress and emotions.
Some researchers have proposed that various illnesses such as fibromyalgia, migraine and irritable bowel syndrome may be part of a theoretical disorder known as clinical endocannabinoid deficiency (CEDC).
While the hemp plant and cannabis use have a history dating back thousands of years, cannabis research is still in its infancy – and already more than 85 different cannabinoids are said to have been identified within the cannabis plant.
[Appendix C, 2015 “High Times” article on the relevance of cannabis strain]
The two best known cannabinoids, tetrahydrocannabinol (THC) and cannabidiol (CBD), have been studied individually, and many of their specific properties have been identified although not necessarily confirmed in human or clinical studies.
However, increasing evidence suggests that use of isolated cannabinoids may provide less medicinal benefit than use of the whole plant. This synergistic activity, known as the entourage effect, was proposed by Israeli scientists in 1998 and there is growing support for the theory.
[Appendix D, Education on all aspects of cannabis from the MedicalJane website]
THC is psychoactive, meaning it affects mental functions such as thinking, mood, perception, and behavior. Research suggests that THC has properties that may help relieve pain, nausea and vomiting, and inflammation, and a variety of additional properties are being investigated.
CBD is not psychoactive; although most studies of CBD have been done in laboratory rather than in human beings, research suggests that CBD has properties that may help relieve inflammation, pain, nausea and vomiting, anxiety and symptoms of epilepsy.
Two factors are thought to help determine a cannabis plant’s specific effects – its THC and/or CBD content, and whether the plant strain is largely indica or sativa.
The relevance of strain is a subject of ongoing debate. It may be less important than previously thought, as cross-breeding has produced a variety of mixed strains or hybrids that account for most cannabis available today.
Emerging information about the numerous other compounds contained in cannabis, such as terpenes, has also complicated the task of isolating therapeutic and other effects.
Health Canada noted in February 2013 that there is insufficient support for claims that one strain of cannabis may be more beneficial than another for a particular medical condition.
Nevertheless, approved medical cannabis producers generally indicate the cannabis plant strain, proportions of THC-CBD for their products, and suggested timing of use. Their consultants will also assist patients and their physicians in selecting the most appropriate product for a given condition and patient health profile.
Cannabis is available in a variety of forms – it may be smoked, vapourized (“vaped”), or inhaled using an e-cigarette device, consumed as oil under the tongue or in food, juiced, or brewed as tea, or applied topically on the skin.
The original prescribed, pharmaceutically-developed cannabinoids are taken orally: Nabilone (Cesamet) is synthetically produced and taken in capsule form, and THC/CBD (Sativex) is a spray derived from cloned cannabis, also taken by mouth. Another synthetic oral product, dronabinol (Marinol), is no longer available due to adverse effects.
Another untested, non-pharmaceutical form of synthetic cannabinoids (e.g., K2 and Spice) are offered as “legal” forms of cannabis. These have more severe psychoactive effects and carry significant health risks, including cases of death.10
[Note: Access directly through an online search of Synthetic Cannabis Bulletin.]
A recent innovation, dabs, are a concentrated marijuana extract named accordingly as shatter or wax, butane hash oil (BHO) containing up to 70-90% THC.
The way a person takes cannabis will depend on their treatment requirements – such as how quickly they require it to take effect and how long they want the effect to last.
The effects of smoked/vaped cannabis begin within minutes, and last a shorter time compared to taking cannabis in foods. In contrast, the effects of ingested cannabis occur more slowly over several hours, and last longer. Although there is conflicting evidence regarding the carcinogenic potential of cannabis smoke, Health Canada notes that this route of administration can have negative effects on respiratory health and is best avoided.
While not entirely risk-free, vapourization or “vaping” and use of e-cigarette devices offer a lower-temperature alternative with less of the toxic by-products of smoking, and more efficient uptake of THC from the cannabis. Dabs are inhaled in very small quantities using a specially developed vaporizer called a dab rig.
Edible cannabis oils can be added to foods or taken under the tongue, which is the most efficient means of maximizing the bioavailability of the cannabinoids, and obtaining the effects as rapidly as would be provided by inhalation.
Those with a medical condition who are seeking access to medical cannabis should ideally broach the subject with their physician, since legal use requires a prescription.
[Appendix J, Basic regulatory information on medical marijuana for Canadian doctors from the Canadian Medical Protective Association]
Individuals who may not have a physician, are reluctant to make that request, or have had their physician refuse to prescribe medical cannabis may choose to pursue other avenues through medical cannabis clinics or an online medical provider such as Medical Marijuana Services, which lists potential indications.
[Appendix K, A patient navigation service to help people access medical cannabis]
Regulations vary provincially, although there many similarities, except for Quebec.
The College of Physicians and Surgeons of Ontario’s Policy Statement on Marijuana for Medical Purposes (March 2015) states that “physicians must weigh the available evidence in support of dried marijuana against other available treatment options,” and must not sign medical documents for marijuana for patients under the age of 25 unless all other conventional treatment has been attempted and failed to alleviate the patient’s symptoms. Doctors must also “advise patients about the material risks and benefits of dried marijuana.” The College recommends that physicians who suggest the use of dried marijuana first require patients to sign a written treatment agreement.
The Centre for Addiction and Mental Health (CAMH) advises abstinence for individuals with predisposition for, or a first-degree family history of, psychosis and substance use disorders, as well as pregnant women (primarily to avoid adverse effects on the fetus or newborn) are likely to be at higher risk for cannabis-related adverse effects.
Health Canada notes that tolerance to cannabis can develop.
There is evidence that cannabis dependence (physical and psychological) occurs especially with chronic, heavy use. Withdrawal symptoms associated with the abrupt cessation of cannabis use (oral or smoked) appear within the first one to two days following discontinuation; peak effects typically occur between days 2 and 6 and most symptoms resolve within 1 – 2 weeks.
The most common symptoms include anger or aggression, irritability, anxiety, nightmares/strange dreams, insomnia/sleep difficulties, craving, headache, restlessness, and decreased appetite or weight loss. Other symptoms appear to include depressed mood, chills, stomach pain, shakiness and sweating
The most significant interactions may occur when cannabis is taken with other CNS depressant drugs such as sedative-hypnotics or alcohol.
Cannabinoids may enhance the effects of opioids, thus allowing the opioid dose to be reduced, which in turn may lessen opioid-related side effects.
Health Canada provides information on the psychiatric effects of cannabis use in specific psychiatric subpopulations. [refer to Appendix A]
The Lower-Risk Cannabis Use Guidelines (LRCUG) released in June 2017 note that “cannabis use is common, especially among adolescents and young adults… and is associated with risks to both immediate and long-term health.”
As providers of mental health and Employee Assistance Program services, counselors will need to be vigilant for signs of cannabis abuse. The Centre for Addiction and Mental Health (CAMH) offers a brief version of the LRCUG guidelines intended for the public.
[Appendix L, Lower-Risk Cannabis Use Guidelines aimed at people who use cannabis]
They offer the following recommendations in their brochure for healthcare consumers:
Tips for parents about discussing cannabis with their children are also available from Drug Free Kids Canada, at www.drugfreekidscanada.org.
Individuals who are having difficulty with cannabis or any other substance should consult their physician, and/or seek psychotherapy through their Employee Assistance Program or other mental health and addiction services.
Kate Kneisel is an award-winning content producer – she has written hundreds of articles on health and medical topics, and also writes on topics of interest in the community. Kate graduated from Trent University with a BA in English. She recently moved back into Belleville from a farm in Prince Edward County. To find out what Kate has been writing over the last 25 years, visit www.yourmedicalcopywriter.com
Bob Kitcher M.A., RP is the Managing Director of the Qxplore Group of companies which includes Quinte Counselling Services, Quinte Assessment and Treatment Group, and Qxplore Inc.
Assessment, Psychological, Psychotherapy, Social Work, and Counselling services provided by Quinte Assessment and Treatment Group and Quinte Counselling Services are described at www.qxplore.com