1. Marijuana as Medicine: Current Understanding and Trends
Penelope P. Ziegler, M.D.
Medical Director
Professionals Resource Network (PRN)

2. Disclosures
None

3. Primary Psychoactive Ingredient- Tetrahydrocannabinol

4. THC Mimics Neurotransmitter Anandamide in the Brain’s Endocannabinoid System

5. Cannabis Is a Plant 484 known biological compounds
Flowers, seeds, leaves and stems are consumed
Smoking
Vaporization
Concentrated oils
Infused “teas”
Edibles, plant usually cooked into foods
At least 84 brain-active cannabinoids
THC
Cannabidiol (CBD)
Cannabinol (CBN)
Many others with unclear or unknown effects

8. Edibles

11. Marijuana Has Been Used As Medicine Throughout History
Ancient History
Used in Chinese medicine dating back 10,000 years; still a basic herbal in Traditional Chinese Medicine
Ancient Egypt- hemorrhoids and other inflammatory conditions
India- used for insomnia, pain, digestive problems
Ancient Greece- extensive veterinary uses, also in humans (nosebleeds, tapeworms, etc.)
Middle East- used as antiemetic, diuretic, antiepileptic, anti-inflammatory
Western Medicine
Europe- used for muscle spasms, stomach cramps
America- widespread use in “patent medicines”
Modern times- Advocates Support Use for Many Conditions
Insomnia
Pain
Nausea and vomiting
Decreased appetite with weight loss
Muscle spasms
Epilepsy
Glaucoma

12. American Patent Medicines

13. In Recent Times, Medications Are Subject to Scientific Standards
Purity
Indications
Dosage
Research to determine medication’s:
Efficacy
Safety
Adverse effects

14. What Is the Evidence for Cannabis as a Medication?
Nausea and vomiting in cancer chemotherapy (CINV)
2010 Cochran review- “probably effective” in children but with high incidence of side effects; inadequate evidence for effectiveness in adults
European meta-analysis of synthetic cannabinoids showed superior anti-emetic effects but higher side effects
Additional concern- cannabis induced hyperemesis
Glaucoma- probably not effective in reasonable doses
Wasting syndrome in AIDS- inadequate evidence, studies flawed
Muscle spasms, spasticity- variable results with MS, small studies
Insomnia- small study showed improvement in sleep patterns in fibromyalgia patients
Pain- reviews show some benefits but studies are hard to compare

15. Recent Review of Medical Marijuana in Neurological Disorders Koppel BS, Brust JCM, Fife T et al Neurology. 82:
Spasticity
Oral cannabis extract (OCE) effective, nabiximols and THC probably effective for reducing patient-centered measures
OCE and THC possibly effective for both patient-centered and objective measures at 1 year
Central pain, painful spasms
OCE effective
THC and nabiximols probably effective
Urinary dysfunction
Nabiximols probably effective for reducing voids/day
THC and OCE probably ineffective for reducing all bladder complaints
Tremor
THC and OCE probably ineffective
Nabiximols possibly ineffective
Other conditions
Unknown efficacy in Huntington’s disease, Tourette syndrome, cervical dystonia, epilepsy
Probably ineffective in Parkinson disease
High incidence of serious adverse reactions (almost 1%) and side effects

16. What Are Risks, Adverse Effects
Side effects
Addiction
Impaired motor skills
Cognitive impairment
Motivational impairment
Risks associated with method of consumption
Special risks for adolescents
Impact on brain development
Psychotic syndromes
Cyclic vomiting syndrome

17. What Is “Charlotte’s Web”
“Charlotte’s Web” or “Realm Oil” is extracted from a strain of marijuana bred by crossing Cannabis sativa (marijuana) and Cannabis indica (hemp) that has low levels of THC and high levels of CBD (cannabidiol)
Developed by the Stanley brothers, major marijuana growers in Colorado
Named after Charlotte Figi, a seven year old diagnosed with Dravet Syndrome or SMEI, who had intractable seizures until tried on Realm Oil
This strain of cannabis is not associated with a “high” because of its low THC level and, if imported, would be classified as hemp.
Originally called “Hippie’s Disappointment”
The Stanleys plan to move their Realm Oil operations to Uruguay and import the oil to the U.S. as hemp oil
Hemp oil is legal in all 50 states but most lacks the high levels of CBD

19. FDA- Approved Cannabinoids Are Already Available in U.S.
Dronabinol (Marinol®)- Schedule III, approved for CINV, wasting syndrome in AIDS
Nabilone (Cesamet®)- Schedule II, approved for CINV
Nabiximols (Sativex®)- oral mucosal spray, not approved in U.S., used in Canada and Europe. Currently in Phase III trials in US for MS, cancer pain, CINV

20. Status of “Charlotte’s Web” in Florida
The Compassionate Medicinal Cannabis Act of 2014 has been tied up in hearings and lawsuits since it was signed in 6/14.
A 2015 effort to fix some of the problems with the original law was unsuccessful when legislature adjourned early.
Major concerns that are blocking the implementation of the “Charlotte’s Web” law include:
Levels of THC allowed in the plants
Approval of growers
Rules for inspection, manufacture, distribution and prescription of the product

21. Recent References
Degenhardt L, Lintzeris N, Campbell G, et al. Experience of adjunctive cannabis use for chronic non-cancer pain: Findings from the Pain and Opioids IN Treatment (POINT) study. Drug Alcohol Depend. 2015;147:
Koppel BS, Brust JC, Fife T, et al. Systematic review: efficacy and safety of medical marijuana in selected neurologic disorders: report of the Guideline Development Subcommittee of the American Academy of Neurology Neurology. 2014;82:
Kahan M, Srivastava A, Spithoff S, Bromley L. Prescribing smoked cannabis for chronic noncancer pain: Preliminary recommendations. Can Fam Physician. 2014;60:
Borgelt LM1, Franson KL, Nussbaum AM, Wang GS. The pharmacologic and clinical effects of medical cannabis. Pharmacotherapy. 2013;33:
Cooper ZD, Comer SD, Haney M. Comparison of the analgesic effects of dronabinol and smoked marijuana in daily marijuana smokers. Neuropsychopharmacology :  
Bostwick M. Blurred boundaries: the therapeutics and politics of medical marijuana. Mayo Clin Proc. February (2):
Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA (24):