1. Dr. Nick Salamie PharmD, RPh
Cannabis & Pain
Dr. Nick Salamie PharmD, RPh

2. Pain Complex interaction Nerves Spinal Cord Brain Subjective
Acute Pain
Sudden/Severe
Resolves
Chronic Pain
Persistent
Health Condition
-Pain involves a complex interaction between nerves, the spinal cord and brain.
-Pain is very subjective. What may be a 10/10 on a pain scale for one person may be a 4/10 for another person.
-Pain can be classified into two different categories. Acute and Chronic Pain. Acute pain is sudden or severe pain that usually resolves over time. May be due to an illness, injury or surgery.
- Chronic pain is persistent and can last a long time and it is considered a health condition by it self, but its not currently one of the qualifying conditions.

3. Causes Stimulation of nerve endings Tissue Damage Sensory nerve cells
Peripheral nervous system
Spinal Cord
Nerve Damage
Misfires
Other Factors
Genetics
Gender
Chronic Health Issues
Mental Health
-From a physiological standpoint pain starts when certain nerve endings are stimulated.
Pain from tissue damage is perceived through sensory nerve cells and can be seen as a survival mechanism. Its essentially an alert mechanism when there is a disruption in a normal functioning body. Like when you get burned. If that pain wasn’t there you may not see excessive heat as a threat to survival.
These nerve cells that respond to pain are part of the peripheral nervous system. These are all the nerves in the body that are not part of the spinal cord or brain. They carry messages in the form of electrical currents and chemical interactions to the spinal cord and brain.
Cells in the spinal cord will prioritize these messages. Severe pain will be processed as an urgent warning. Lesser pain like a scratch is processed more slowly or with less strength.
Damage to one or more peripheral or spinal nerves may cause pain.
These damaged nerves may misfire and send inappropriate pain signals randomly. Rather than in response to a stimulus.
Other factors at play that can influence how sensitive you are to pain and how you respond to it may include:
Genetics.
Gender. Women report more frequent pain, more severe levels of pain and longer-lasting pain. But who knows if this is due to biological differences or just underreporting by stubborn men.
Chronic health issues can definitely play a factor, fibromyalgia, migraines and ibs just a to name a few.
And finally mental health, pain is more prevalent in individuals with depression, anxiety or low self-esteem. An exaggerated pessimism of pain can make it worse.

4. The Endocannabinoid System and Pain
Multifaceted pain relieving mechanisms
Pain signaling mediation by ECS
THC/CBD activate or block signaling
Pain modulation
Analgesic and Anti-Inflammatory properties
Bodies own natural opioids
Endocannabinoid Deficiencies?
Cannabis as treatment
-Many of you may be familiar with the endocannabinoid system. Just a brief primer for those who are not its basically a complex regulatory system found in all mammals. It regulates many of the bodys functions including pain. Our body makes our own cannabinoids on demand and these endocannabinoids play an important role in maintain a balance in the body, but we can also use phytocannabinoids like THC and CBD as treatment when our endocannabinoid system is deficient or out of wack.
-Cannabinoids are multifaceted and work in more than one way to address pain
-the actual communication of pain throughout the body, like the messages we spoke about on the last slide is mediated by endocannabinoids interacting with cannabinoids and other receptor- based signaling systems. THC and CBD work by activating or blocking the signaling through CB1 and CB2 receptors.
-Also, background pain levels appear to modulated by the endocannabinoid system.
-Phytocannabinoids like THC can also relieve pain through its analgesic and anti-inflammatory effects.
-phytocannabinoids can also stimulate the release of the bodys own natural opioids that can contribute to pain relief.
-Lastly there is some growing throught painful conditions like fibromyalgia and migraines may be the direct result of an endocannabinoid deficiency. More research needs to be done, but if this is the case many patients may benefit from a daily cannabis regimen.

5. First PDI Visit Control Pain Drug Interactions
Assess Patients Cannabis Experience
No or little cannabis experience
Intermediate cannabis experience
Advanced Cannabis Experience
Tapering Strategy if Necessary
Product selection and initial strategy
Minimum Effective Dose
Follow Up
When a patient experiencing pain first comes into PDI ideally they will have a brief conversation with me or another healthcare professional to devise a game plan. PDI is the only dispensary in Illinois to have a health care professional available at most times.
The goal with most of these patients will be to alleve symptoms of pain with out any unwanted side effects.
Initial Dosing Strategies with patients are typically based off the patients experience and comfort with cannabis.
Patients with no or little cannabis experience I will take a way different approach than someone with Advanced Cannabis Experience. Patients with no or little cannabis experience I typically recommend starting out with CBD Rich cannabis products and/or microdosing of a THC rich product. This conservative approach reduces the chances of any unwanted side effects and allows patients to find their sweet spot in a comfortable fashion.
A patient with intermediate cannabis experience can be defined as someone who is familiar with the effects of THC on their body and have somewhat of an idea how well they tolerate cannabis. Typically they are also able to share some of their previous cannabis experiences with clarity. I typically will recommend either a 1:1 cbd to thc product and/or thc rich products at low to moderate doses for these types of patients.
A patient with advanced cannabis experience can be defined as someone who has been self medicating for quite some time and knows exactly how well and the amount of cannabis they can tolerate. These patients are the easiest to dose since you don’t have to worry as much about adverse effects.
If the patient is currently coming off of opioids a sound tapering strategy should be discussed. Each tapering approach will be unique from patient to patient. A patient who has been on extended release and intermediate release oxycontin for years may have a completely different approach than a patient who has been taking norco twice a day for 1 month.
-Initial product selection and strategy is going to be based on the patients current cannabis use and any limitations, like if the patient cant inhale and so forth.
The idea is to get the patient to the minimum effective dose, also known as the sweet spot, which is the dose where they are getting sufficient relief without any adverse effects.
Following up is important because it may take multiple visits to find the best possible regimen.

6. Dosage Forms Inhalation Ingestible Sublingual/Buccal/Oromucosal
Combustion
Vaporization
Ingestible
Edibles
Oils (RSO)
Tablets/Capsules
Sublingual/Buccal/Oromucosal
Topical
Transdermal
We have quite a few dosage forms to work with in the state of Illinois to achieve this “sweet spot.”
Starting with inhalation we have a couple of different methods we can use. We have the old tried and true combustion method with either a pipe, joint, bong, or steamroller just name a few different ways. We prefer patients to inhale using vaporization over combustion to avoid any possible harmful by products. Every cannabis patient should have some sort of inhalation product unless they have some limitation that deters them from inhalation. The reasoning behind that is that inhalation is the fastest way to get the medicine into the body and is superior for acute nerve pain or flare ups. You can think of inhalation as your rapid or break through cannabis medicine.
The downside to inhalation is that it wears off very quickly with relief really lasting only 1 to 3 hours. That’s were other dosage forms come into play like ingestible products as these products can last anywhere from 4-8 hours. But the downside is that there is a high variability as far as the onset of effect goes, anywhere from 30 minutes to 2 hours. I am a big proponent of rick simpson oil when it comes to addressing any type of pain with cannabis. I recommend patients with chronic pain issues to take at least one to two doses of a CBD rich cannabis oil daily. RSOs are a good way to keep a constant baseline of cannabinoids in the body.
Sublingual forms like tinctures are excellent for new patients when we want to take a microdosing approach. Tinctures allow us to go drop by drop if need be in patients who are more comfortable with a conservative approach. RSOs can also be taking sublingually.
Topicals are a nice add on to any cannabis regimen when one part of the body is hurting more than another. We get localized action with topicals so patients don’t have to worry about any psychoactivity. I recommend patients who experience pain in localized areas to give a topical a shot.
Transdermal dosage forms such as a patch are very convenient, but are by far the most expensive dosage form per dose.

7. Cannabis Oils/RSOs Best medical dosage form
Whole Plant/Full Spectrum Extract/Herbal Shotgun
Varying Cannabinoid Profiles
Different CBD:THC ratios
Acidic Cannabinoids: THCa, CBDa, CBGa
“Varin” Cannabinoids: THCV, CBDV
Less abundant Cannabinoids: CBN, CBG, CBC
Terpenes Captured
Beta-Caryophyllene
Lets discuss Cannabis Oils also known as Rick Simpson Oils, RSO for short, even though Rick Simpson doesn’t like his name being used in commericialized cannabis products. And that’s Rick Simpson in the picture.
In my opinion and experience Rick Simpson Oils are the best medical cannabis dosage form currently available.
The way the extract process works is that it literally extracts everything from the plant including the cholorphyll when ethanol is used as the main solvent.
Luckily medical cannabis patients in Illinois have access to a wide variety of RSOs ranging from all THC to nearly all CBD and everything in between. There are some with very unique cannabinoid profiles you can find offered from Shelby county. For instance when the traditional THC and CBD rich medicines don’t provide much relief we may look at using a RSO that’s rich in acidic cannabinoids since THCa shows promise in neurological problems. Or we can find one with a decent amount of the varin cannabinoids like CBDV. Typically the varin cannabinoids are found more in Oils that use Carbon dioxide as a solvent like Shelby uses. Also, you will find the less abundant cannabinoids listed here in some of these RSOs. RSOs are the best way to get as many cannabinoids and terpenes into the body as possible per dose size and we may be getting a better synergistic effect than just a typical thc dominant edible.
RSOs are typically rich in terpenes. The specific terpene profile or entourage will really be dependent on the strain. It best to look for Oils rich in Beta-Caryophyllene since this particular terpene also acts as an anti-inflammatory agent.

8. Beyond THC and CBD for Pain
CBG (cannabigerol)
Analgesic
CBC (cannabichromene)
THC potentiation
THCa (tetrahydrocannabinolic acid)
Anti-inflammatory
Neuroprotective
CBDV (cannabidivarin)
More studies needed
-A total in depth discussion about these less abdunant cannabinoids on the previous slide will have to be reserved for a later date, but the Main ones to look for when pain isn't controlled by THC and CBD alone are:
-CBG also know as cannabigerol for its analgesic properties
CBC also known as cannabichromene for its ability to enhance the analgesic effects of THC
THCa which is THC in acidic or raw form is anti-inflammatory and neuroprotective.
- More studies are needed, but Im including CBDV on here also known as cannabidivarin. CBDv has been shown to have significant anticolvusant properties. Like I said more studies will be needed in regards to nerve pain, but the line of thinking here is that if other anticolvsuant drugs have helped nerve pain CBDV may prove to be very beneficial in a cannabis regimen for patients with pain.

9. Further Assistance Contact PDI or Compassionate Care
Dispensary Transfer
Only Dispensary with Health Care Professionals
For further assistance you can contact PDI or Compassionate Care. Staff members can assist you with application questions and submission for both the OAPP and the MCPP.
Also, if you are currently a patient at a different dispensary PDI can help you transfer over and schedule a one on one consult with a Pharmacist.
PDI is currently the only dispensary in Illinois that has registered pharmacist on duty at nearly all times.

10. References
Backes, Michael, et al. Cannabis Pharmacy: the Practical Guide to Medical Marijuana. Black Dog & Leventhal Publishers, 2017.
Russo, Ethan B., and Jahan Marcu. “Cannabis Pharmacology: The Usual Suspects and a Few Promising Leads.” Cannabinoid Pharmacology Advances in Pharmacology, 2017, pp. 67–134., doi: /bs.apha
Salamie, Nicholas PharmD, RPh. “Alzheimer’s Disease and the Alternative to Opioids Act.” Powerpoint File.
“Understanding Pain.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 26 July 2016,

11. Questions