Medical Marijuana Essay
As additional states continue to pass laws that allow for the use of medical and recreational marijuana, it is important for us as providers to be able to answer basic questions that patients will inevitably have. Being blindsided by inquiries about potential benefits of medical marijuana and CBD related products can be thwarted with fundamental fact-based information. As the CBD market is projected to reach $20 billion in sales over the next 5 years (BDS Analytics), we would seemingly have our heads in the sand if we think that the absence of these products on a patient profile list tells a complete story. Our patients are using these products, and it is our responsibility to know how these products work and influence our patient’s health and wellbeing.
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The 1970 Controlled Substances Act set the tone for marijuana and hemp. This lumped them in with heroin and LSD as Schedule 1 drugs that are characterized as having a “high potential for abuse” and are of no medical use or value. Despite the federal prohibition, individual states were emboldened by a Department of Justice memo in the 2009 that provided states with basic guidelines for legalizing medical marijuana and a later memo in 2013 outlined the same for recreational marijuana. These memos laid the foundation for states to set up marijuana regulatory structures.
The 2018 Farm Bill passed by President Trump officially removed hemp from the federal list of controlled substances making it an ordinary agricultural commodity. However, marijuana remained on the list and it remains there today. This has created confusion for many of us as individual states are left to wrestle with their own decisions about the use and legal status of marijuana. Our nation is faced with an entire spectrum of legality. Certain states like Alabama and South Carolina have deemed medical and recreational marijuana fully illegal while other states like California and Maine have made it fully legal.
Other states such as Arkansas and Oklahoma have made recreational use illegal but have approved the use of medical marijuana. To muddy the water even further, some states like Georgia have approved medical marijuana but only in the form of low THC oil. In total, 16 states have recreational marijuana laws and 38 have approved varying medical marijuana laws. Additionally, each state that has approved medical marijuana laws has laid out specific conditions that must be verified by a physician before a prescription is signed and treatment can begin. The amounts and places to obtain medical marijuana are also state specific.
As confusion exists among state laws, it is important there not be any when considering the differences between marijuana and hemp. The two primary classifications within the cannabis family are indica (marijuana) and sativa (hemp). The leaves are similar in appearance, and this likeness contributed to hemp’s inclusion with marijuana as a Schedule 1 drug under the 1970 Controlled Substances Act. Two naturally occurring compounds, tetrahydrocannabinol (THC) and cannabidiol (CBD), are found in cannabis but they have significant differences in the levels of THC and CBD. THC is the primary chemical compound in marijuana that gives the high sensation, and although natural potency can vary, the average strain of marijuana contains approximately 12% THC. This is an important distinction since marijuana is cannabis that includes more than 0.3% THC and hemp is cannabis that has less than 0.3% THC (by dry weight). This distinction is the basis for legal medical marijuana and CBD products derived from hemp versus illegal medical marijuana and CBD products derived from marijuana.
THC and CBD both interact with the Endocannabinoid System (ECS) found throughout the body. The THC and CBD from cannabis interact with the CB1 and CB2 cannabinoid receptors and induce particular effects that may or may not be beneficial to patients. Manipulation of this system opens the pharmaceutical door. This could be achieved synthetically from pharmaceutical companies or naturally from hemp or marijuana. There are four currently FDA-approved cannabinoid medicines available in the United States. These include Marinol, Syndros, Cesamet and Epidiolex. Since these medications’ costs range from $700 to $32K, it is not hard to see why patients would be willing to try natural cannabis alternatives.
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THC binds to CB1 and CB2 receptors to induce the mind-altering euphoric effect. Additionally, antiemetic effects and influences on appetite occur with this binding. Conversely, CBD inhibits binding to the receptors. It also inhibits enzymes that break down endogenous cannabinoids. These combined actions are thought to elicit the desired effects that patients are seeking. These effects influence stress- response, inflammation, immunity, pain, mood, and more. Although CBD is tolerated well in large doses, the World Health Organization research shows any side effects tend to arise from drug to drug interactions with medications that might already be in the system.
Dosing and delivery methods vary, and the condition patients are looking to influence should direct the delivery method. When considering the immune system, mood and pain management, patients should use vaporizers and orals. Oral products like CBD oils, tinctures, edibles, capsules, and powder deliver a sustained and steady level of CBD throughout the day. If conditions are localized, topical products should be considered. Inhaled delivery methods such as dabs, smoking, or vaporizers provide immediate short-term relief, and it takes about 10 minutes to obtain the highest bloodstream levels using these methods. Added benefits have been shown when combining delivery methods.
There presently is not an FDA Recommended Daily Intake (RDI) or universal guide for CBD, so patients are often left to seek guidance on their own. CBD Origin authors recommend taking 1–6MG of CBD for every 10 pounds of body weight when consuming edibles such as gummies. Dosing with tinctures and oils requires some math, as the total CBD in the bottle must be divided by the number of milliliters in the bottle. As therapy begins, low dosing is recommended, and a general rule of thumb is to wait approximately 6 hours for oral delivery methods and 1 hour for vaporizers before repeating any dosage. An important note when using other medications in conjunction with CBD is that it inhibits cytochrome p450 which, like grapefruit, will interfere with the ability to process certain pharmaceutical drugs.
Clearly, CBD and medical marijuana are the trendy choices for many individuals that are seeking relief for their conditions, and research is ongoing. Often those choices are the last stop on the option train when they have not received the expected relief from other pharmaceuticals. Other times it is the first stop because of the “natural” appeal of CBD versus the manufactured synthetic options. Either way, having a basic knowledge of medical marijuana and CBD establishes trust with our patients, and this helps prepare us for the inevitable questions that will come sooner than later.
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