1. A Review of the Evidence for Medical Cannabis Based on Approved Conditions in Iowa
Authors: Ryan Molander, Sarah Kadura, spencer smythe, and nickolas Scott
Preceptor: Ronald herman

2. Background
Medical Marijuana was first approved in the United States by the state of California in the year of  
Since then, many states have followed (28 to be exact) but each state's’ laws are slightly different, and they vary based on the medical conditions it is approved for and whether Cannabidiol or Tetrahydrocannabinol can be used in the formulation.  
While marijuana is still currently classified as a Schedule 1 substance under Federal Law, the government has chosen not to enforce it.
On May 12, 2017, Governor Branstad signed a new Medical Cannabidiol Act, House File 524 from the Iowa legislature.

3. Background (continued)
The Iowa Department of Public Health is responsible for implementing the new Medical Cannabidiol Act.
The current Act will approve medical cannabis for patients with these list of conditions:
Cancer, if the underlying condition or treatment produces one or more of the following
Severe or chronic pain
Nausea or severe vomiting
Cachexia or severe wasting
Multiple sclerosis with severe and persistent muscle spasms
Seizures, including those characteristic of epilepsy
AIDS or HIV
Crohn’s disease
Amyotrophic lateral sclerosis
Any terminal illness, with a probable life expectancy of under one year, if the illness or its treatment produces one or more of the following
Severe or chronic pain
Nausea or severe vomiting
Cachexia or severe wasting
Parkinson's disease
Untreatable pain

4. Introduction
Many prescribers are still hesitant of prescribing marijuana to their patients due to the lack of education on the subject.
The purpose of this project is to review studies that determine the safety and efficacy of medical marijuana use for the different disease states as specified by Iowa's state law.
Our evaluations of current and past studies of medical marijuana in various dosage forms and strengths will help guide prescriber's decision-making for patients with these conditions
NASEM (2017) is currently the most comprehensive study of scientific literature on the health effects of cannabis use

5. Methods
Use the databases PubMed, Embase, CINAHL, and IPA to find articles demonstrating high quality evidence for the use of cannabidiol in each of the approved indications from the new Medical Cannabidiol Act.
Our search strategy includes splitting the conditions into “cachexia/wasting”, “nausea/vomiting”, “pain”, and “neurological” and reviewing literature that addresses CBD’s ability to treat these symptoms.

6. Methods: search criteria
English-only publications
Published between
Human trials
Randomized control trials
Systematic reviews
Controlled clinical trials

7. Results: Nausea/vomiting
PubMed
Embase
IPA
CINAHL
Total
Abstracts 67
149 26 27
269
Included Abstracts 18 25 4 8 55
Excluded Abstracts 49
124 22 19
214
NASEM Recommendation: There is conclusive evidence that oral cannabinoids are effective antiemetics in the treatment of chemotherapy-induced nausea and vomiting.
51 additional studies not included in NASEM showing evidence for medical marijuana as an antiemetic 

8. Results: analgesia PubMed Embase IPA CINAHL Cochrane Other Total
Abstracts
199
109 21 69 4 1
403
Included Abstracts 74 10 86
Excluded Abstracts
125 99 68
317
According to NASEM, all the reviews were widely consistent in suggesting that cannabinoids demonstrate a modest effect on pain. Studies mainly used inhaled cannabis or an oral mucosal spray (Sativex)
48 other studies not included in the NASEM demonstrated a modest effect on pain
Currently there is one promising study that is still in the recruiting phase comparing THC vs CBD vs placebo using different dosages to treat chronic pain

9. Muscular & Neurologic Disorders
PubMed
Embase
IPA
CINAHL
Total
Abstracts
107 10 6
123
Included Abstracts 37 2 41
Excluded Abstracts 70 8 4 82
NASEM Recommendation for muscular and neurologic disorders:
Epilepsy - insufficient evidence
MS - substantial evidence that oral cannabinoids are an effective treatment for improving patient-reported multiple sclerosis spasticity symptoms, but limited evidence for an effect on clinician-measured spasticity.    
Paralysis due to spinal cord injury - insufficient evidence
ALS - insufficient evidence 
Parkinson's Disease - insufficient evidence

10. Results: Cachexia and wasting
The NASEM report identified 2 good systematic reviews that examined use for cachexia in HIV/AIDS.
Whiting et al. (2015) assessed four randomized controlled trials involving 255 patients
All four studies included dronabinol, with one investigating inhaled cannabis as well. Three trials were placebo-controlled, and one used the progestational agent megestrol acetate as the comparator.
A second systematic review (Lutge et al., 2013) focused on morbidity and mortality in HIV/AIDS as the primary outcomes, with changes in appetite and weight as secondary endpoints
Seven RCTs conducted between 1993 and 2009 were included in the qualitative analysis. The trials compared dronabinol or inhaled cannabis with a placebo or with each other.
There were no good or fair systematic reviews that reported on cannabis or cannabinoids as effective treatments for cancer-associated anorexia-cachexia syndrome or for anorexia nervosa.  
There were no studies identified in the database search for evidence of the treatment of cachexia and wasting outside of those that were included in the NASEM report.

11. Conclusions Nausea/Vomiting: Analgesia:
There is conclusive evidence for oral cannabinoids as effective anti-emetics in treatment of chemotherapy induced nausea and vomiting.
Analgesia:
There is consistent evidence that suggests that cannabinoids demonstrate a modest effect on chronic pain

12. Conclusions (Continued)
Muscular & Neurologic Disorders:
With the exception of MS, there was insufficient evidence to support or refute use of cannabinoids for treatment of muscular and neurologic disorders.
Cachexia & Wasting:
There is some evidence for oral cannabinoids being able to increase weight in patients with HIV-associated wasting syndrome and anorexia nervosa 
No benefit has been demonstrated in cancer-associated anorexia-cachexia syndrome

13. References
National Academies of Sciences, Engineering, and Medicine The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press.
Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA. 2015