MEDICAL MARIJUANA and MS Is it for YOU? Amos Katz MD Medical Director Linda E. Cardinale MS center Centrastate Medical Center Freehold,NJ

Flowering marijuana plant-Cannabis sativa

History of marijuana Also known as Cannabis and many other slang terms such as weed, maryjane, pot, grass among 200 others names. Indigenous to south and central Asia Earliest recorded use seen in seeds and leaf fragments found next to mummies from China and Egypt Can be used recreationally or as a medicinal drug.

History of marijuana continued Legally restricted in most countries since the early 20 th century Controlled Substance Act of 1970 made marijuana possession criminal and a schedule 1 drug. The state of Washington was the first to legalize marijuana in Dec quickly followed by Colorado. California legalized medical marijuana in 1996 Medical marijuana is currently legal in 23 states and Wash. DC

Medical marijuana legal in green states Marijuana illegal in orange states

Marijuana usage statistics UN estimates that marijuana is the world’s most produced, trafficked and consumed illegal drug. Up to 224 million users world wide. Cannabis is the number 4 value crop cash wise pound for pound in the US. Current market estimate yearly of $36 billion in the US. Street retail prices vary from $40 to $400 depending on quality and availability at the time.

Marijuana usage stats continued 100 million Americans have tried cannabis at least once and 25 million have smoked it in the past year. Every day 6000 Americans try marijuana for the first time according to some surveys. 20 % of high school students report using marijuana regularly. After alcohol, marijuana is the most popular recreational drug in the world.

Chemistry of marijuana The marijuana plant contains at least 483 known compounds of which 83 are cannabinoids. Effects of the drug begin within minutes when smoked and 30 minutes when eaten. The effects last between 2 and 6 hours depending on dosage. Cannabinoids are fat soluble and therefore persist in the body for a long time. Detectable levels can be found by testing weeks later. Cannabinoids and particularly THC act on receptors in the brain called CB1 and CB2.

Marijuana chemistry continued These receptors are found in the brain and in peripheral tissues and when activated by marijuana, increase dopamine and other neurotransmitters causing its effects on the brain and body. The main active ingredients studied have been Tetrahydrocannabinol (THC), Cannabinol (CBN), Cannabidol (CBD) and Tetrahydrocannabivarin (THCV). Different marijuana strains contain differing amounts of each chemical that can be tailored for appropriate medical use or otherwise.

Marijuana chemistry continued Cannabis is available in many forms including the flower and leaves (up to 20% THC content), resin (20% THC content in hashish) and hash oil (60% THC content). THC content of seized marijuana has been noted to be more potent over the last 20 years. Most common form consumed are the dried flowers, leaves and stems of the female Cannabis plant containing from 3% to 20% THC rolled up and smoked.

Marijuana chemistry continued Other available smoked forms of Cannabis besides paper wrapped joints include small pipes, bongs (using a water chamber) or roach clips among others. Cannabis can be vaporized using a vaporizer to heat the cannabis and inhale the vapor containing the active ingredients. Vaporization avoids the tar, odor, carcinogens found in smoke and more med. available (90%) Edibles where Cannabis is one of the ingredients for instance in Brownies.

Marijuana chemistry continued Marijuana plants can be Sativa (tall), Indica (short) or hybrid of both. In general (with exceptions) Sativa has more THC than Indica and is more helpful for restoring energy and reducing depression. Indica has more CBD and aids in anxiety and sleep. It is more sedating. Different strains are grown with differing amounts of each cannabinoid tailored to each person.

Uses of Marijuana Recreational use. Cannabis has psychoactive effects. Relaxation and a euphoric feeling “stoned” or “high” sensation. Changes mood and perception as well as many side effects to be discussed later. Spiritual use. Used in religion in India and Nepal since 2000 BCE and more recently by the Rastafarian movement for sacramental and meditation use. Medical uses such as to improve appetite in people with HIV or undergoing chemotherapy. Also to reduce nausea in patients undergoing chemotherapy, reduce epileptic seizures, reduce pain from various causes.

Marijuana and Multiple Sclerosis In 2014 The American Academy of Neurology issued a position paper in the efficacy of medical marijuana in several neurologic conditions. The title of the review was “Systemic review: Efficacy and safety of medical marijuana in selected neurologic disorders”. The review was of 34 different studies regarding uses of medical marijuana.

Medical Marijuana and MS The conclusions were : For SPASTICITY with MS, oral cannabis extract is effective. Nabiximols (Sativex mouth spray) is probably effective and tetrahydrocannabinol (marinol) is probably effective for spasticity as well. For centrally mediated PAIN, oral cannabis extract and was rated as effective and THC as probably effective. For bladder dysfunction and tremor, both were rated as ineffective.

Medical Marijuana and MS Dronabinol (Marinol) is THC in a pill available for many years under prescription in the US and other countries. It is a schedule 3 drug considered to be a non-narcotic. Approved for anorexia in AIDS patients, and for nausea and vomiting after chemotherapy. A similar drug, Nabilone(Cesamet) is also approved in Canada and the US but is less used. These 2 drugs only contain THC but no CBD or CBC which help with overactive nerves and pain.

Medical Marijuana and MS I have found in my personal experience as a prescriber that these pills are much less effective than smoked cannabis for patients’ symptoms. Nabiximols (Sativex) is a prescription mouth spray developed by a British company containing both THC and CBD. It is available in 28 countries including Canada but refused by the FDA. It works best to reduce muscle spasms associated with MS.

Side effects of Marijuana Dosages of active ingredients vary with each preparation. It is not standardized. Psychoactive “high” may not be wanted by some patients and can interfere with driving and operating machinery. Worries that marijuana is a “gateway” drug to later uses of illicit drugs. Studies regarding it have limited statistical evidence because they are of people using cannabis as a recreational drug not as a medicine.

Side effects of marijuana continued Some evidence of adverse long term side effects of cannabis use. Chronic heavy use may be associated with decline in decision making ability and planning abilities. A decline in long term memories have been noted in studies as well. No long term decline in lung function seen.

Medical marijuana in New Jersey On his last day in office Jan.18, 2010 Gov. Jon Corzine signed into law the Compassionate Use Medical Marijuana Act. First dispensary for medical marijuana opened in Montclair Dec Second dispensary opened in Oct There are now 5 MMP dispensaries in New Jersey.

Medical Marijuana in NJ The location of the 5 dispensaries are Montclair, Woodbridge, Cranbury, Little Egg Harbor and Bellmawr. A sixth one is planned for Bergen County. There are currently 5500 patients enrolled in the MMP and 350 NJ doctors have signed on as well. The largest dispensary is in Woodbridge. It is called the Garden State Dispensary and serves over 3000 patients.

Medical Marijuana in NJ Medical conditions that qualify patients to receive marijuana include ALS, MS, terminal cancer, muscular dystrophy, AIDS, inflammatory bowel disease and under certain conditions also seizures, glaucoma and intractable muscle spasms. You must be a New Jersey resident and have a bona fide relationship with a physician who has registered for the MMP.

Medical marijuana in NJ

Medical Marijuana in NJ It is difficult and confusing to register for the MMP both for providers and patients. The bureaucracy is stifling. Let’s go through the steps required. Your doctor must be registered with the state of NJ as a provider in the MMP and agrees that marijuana will be helpful to you. The physician’s office fills out the Attending Physician statement online. It is valid for 3 months and the amount of marijuana up to 2 ounces per month is filled into the form.

Medical Marijuana in NJ As soon as the form is submitted online a unique Patient Reference Number is generated which is given to the patient along with the Attending Physician Statement. The patient then goes online at home (must have a computer) to the website to complete the next steps.

Medical Marijuana in NJ Pick Patient Registration on the website on the left side of the screen and fill in all the required information including the reference number given to you by the physician’s office. Select “submit” to take you to the patient registration page. Complete more information on this page and acknowledge patient certification. Save and continue.

Medical Marijuana in NJ Next you must have a scanner to upload documents such as proof of NJ residency, driver’s license, passport photo and Social Security Award letter for any discount. The above documents are reviewed by the “STATE” and if correct, the patient is contacted by or regular mail to pay up. Registration costs $200 or if you have government assistance and can prove it then only $20 payable by credit card.

Medical Marijuana in NJ Finally, you receive a card entitling you to pick up your hard fought for marijuana at a dispensary near you. There are counselors at each dispensary that will help you pick out which marijuana strain with a colorful name is right for you and how to get it into your body. The final shock is the cost of the product. They vary by a few dollars from dispensary to dispensary. For instance, at Garden state dispensary the cost is $ for half an ounce and $535 per ounce.

Medical Marijuana in NJ The cost is at least $100 per ounce higher than in Colorado. Higher CBD strains are better for pain and spasticity caused by MS. Street marijuana is cheaper but you don’t know what you are getting. It can have pesticides, mold, mildew or other ingredients that can be harmful to you or are inert. I would not suggest it.

Medical Marijuana in NJ Don’t stray too far from your doctor because you have to re-register (can be done electronically) every 3 months. THANK YOU.