Cannabinoids

Cannabinoids

What are cannabinoids?

• Cannabinoids are a class of drug found in cannabis (marijuana).
• Marijuana and cannabis are words that describe the same thing. We will use cannabis.
• There are over 100 active cannabinoids found in cannabis.
  • The two most common and best-studied cannabinoids are Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD).
  • THC and CBD have different effects on the body.
• THC is responsible for the cannabis “high.”
  • THC is responsible for the abuse and addiction potential of cannabis.
  • THC can be used to stimulate appetite in chemotherapy-induced nausea and vomiting.
  • It can also help manage chronic pain.
  • THC can reduce muscle spasticity for people with multiple sclerosis.
• CBD is non-intoxicating and has very little abuse potential.
• CBD can be used to reduce seizures in kids with rare epileptic conditions, like Dravet syndrome.
• There has been a lot of excitement about the CBD’s potential to help with pain.
• There are no published clinical trials showing that CBD alone is effective at treating pain.

Are cannabinoids legal?

The Drug Enforcement Agency (DEA) classifies drugs based on:

• Having known medical uses.
• Potential for abuse.

Cannabis is currently classified as a Schedule I substance under the Controlled Substances Act.

• This means that as far as the DEA is concerned:
  • It has a high potential for abuse.
  • It does not have any accepted medical uses.
• Currently, cannabis products with more than 0.3% THC are illegal under federal law.
• Many states have made medical and adult-use cannabis legal at the state level.
  • Some states only allow for medicinal use of cannabis.
  • Some states allow for medicinal and recreational use of cannabis.
  • It is legal purchase and use cannabis products in these states.
  • Each state has its own laws and restrictions.
• Cannabis products are still considered illegal at the federal level.

Hemp is a type of cannabis that contains less than 0.3% THC.

• Hemp was removed from the Controlled Substances Act in 2018.
• CBD that comes from hemp became more widely available after 2018.
• There is still debate about how these products should be regulated.

There are some FDA-approved cannabinoid medications.

• All FDA-approved medications with THC are made in labs.
  • They do not come from the cannabis plant.

How do cannabinoids work?

Our bodies have a system called the endogenous cannabinoid system.

• It helps regulate pain, memory, appetite, sleep, and mood.
• Cannabinoids work by interacting with the part of the endogenous cannabinoid system.
• The exact mechanisms of how THC and CBD work to reduce pain are not clear.

THC appears to reduce pain and cause cannabis intoxication by binding to cannabinoid receptor 1 (CB1) in the brain.

• There is not good understanding about exactly how CBD works.
• We do know that it interacts with the endogenous cannabinoid system and many other body systems.
• Scientists study animals before they can study how something works in people.
• Studies with non-human animals show promise:
  • CBD has been shown to reduce inflammation, pain, and anxiety.
  • These findings have not been replicated in people.
  • CBD may also enhance the therapeutic effects of THC.
  • Clinical trials have shown that using CBD and THC together helps with pain relief.

Note: There are some cannabinoid medications that have been approved by the FDA (see below). These medications have a single active ingredient.

• Most medical cannabis products sold at dispensaries have more than just THC and CBD.
  • Most cannabis products have THC, CBD, and other cannabinoids.
  • They usually have other ingredients that have the potential to be therapeutic.
  • For example, cannabis flower also contains terpenes and flavonoids.
  • These contribute to the different tastes, smells, and colors found in cannabis.
  • How these compounds all interact together is unknown and remains an open area of research.

What are the names of some cannabinoid medications?

FDA-approved cannabinoids:

• Syndros (synthetic THC)
• Dronabinol (synthetic THC)
• Cesamet (nabilone, a THC analog)
• Epidiolex (plant-derived CBD)

Cannabis products that are not FDA-approved

CBD that comes from hemp:

• CBD:
  • CBD products that come from hemp are available online and in brick-and-mortar stores.
  • The quality and accuracy of labeling varies greatly based on product and store.
  • Use caution and do your homework on the company selling the product before buying.
  • Make sure you look for products that have independent third-party testing for contaminants (such as heavy metals and pesticides) and potency.

Medical Cannabis:

• Medicinal cannabis can be purchased in states where it is legal.
  • It does not go through the same kind of testing that is required for other prescription medications.
  • There is federal regulation of prescription medications.
  • Each state makes its own laws about whether and how cannabis should be regulated.
• Some states require a prescription or special license to purchase cannabis.
• Other states do not require any special license or prescription.
  • Medicinal cannabis can be purchased at cannabis dispensaries in these states.
• If you live in a state where recreational cannabis use is not legal:
  • You may be able to obtain a prescription or medical cannabis license.
  • This allows people to purchase cannabis products from medical cannabis dispensaries.

If you choose to go this route, there are three important things to keep in mind:

Administration route: The effects of cannabis differ by how you use it.

• The experience of cannabis use is partly dependent on the administration route.
  • Smoking or vaporizing
    • The effects are felt in 5-15 minutes
    • The effects last for 2-4 hours
    • Using in this way can damage the lungs.
  • Eating (edibles)
    • Foods or candies can be infused with cannabis oil.
    • Edibles can take effect as fast as 30 minutes, or may take 3 hours to be felt.
    • The effects of edibles last between 6-8 hours.
    • Wait 3 hours before taking more so you do not overdose.
    • It is important to keep edibles away from children because kids may think that it is candy.
  • Tinctures
    • These are infused cannabis oils or alcohol-based products.
    • The tincture is held under the tongue for 1-2 minutes.
    • The effects are felt in about 15-30 minutes.
    • Effects last for 4-6 hours.
  • Topicals (creams)
    • There are many different types of topicals.
    • How long it takes to feel effects depends on what type of topical is used.
    • It is not known how topicals penetrate the skin.
    • They should be used directly over the painful area.
    • Topicals do not generally cause a whole-body effect.

Dosing: “Start low, go slow”.

People have different responses to cannabis.

• Each person is unique.
• Past experience with cannabis influences how someone responds.
• Start with a low dose.
  • Lower doses may be medically effective.
  • Starting low can help avoid unwanted side effects.
  • Using a low dose to start can avoid building tolerance.

CBD to THC ratio

Since CBD has fewer side effects than THC and is non-intoxicating, you may want to start with CBD alone.

• Another option is to use a product that is mostly CBD.
• If you choose to take THC, make sure you take it with CBD.
  • CBD may enhance THC’s analgesic effects.
  • CBD can reduce some THC-related negative effects.

Summary:

Medication doses are tested before they can be prescribed by healthcare providers.

• This does not happen for medical cannabis products.
  • There is no dosing information that has been rigorously tested for cannabis.
• Consider using edibles in the same way that extended-release pain medications are used.
  • Edibles can help with pain for 6-8 hours.
  • Tinctures can be added for breakthrough pain.
• You may want to start with CBD alone.
  • Try it for one week.
  • Consider increasing the dose after one week if it does not provide adequate relief.
• If CBD alone is not helpful, it is possible that you may want to add in a THC-containing product.
  • Add in THC products slowly.

Medical risks

• People should not drive or operate heavy machinery after using products with THC.
• Special care should be used when considering cannabinoids for people who have a family or personal history of mental health issues or heart conditions.
• Because many CBD products are poorly regulated, people choosing to use hemp-derived CBD products should be cautious about which products to buy.
  • Edibles with THC and CBD are regulated as food products by the FDA.
  • Each state is responsible for regulating cannabis products sold at dispensaries.
    • There are different requirements based on state laws.
    • Some states have more rigorous regulations than others.
  • Not all products are accurately labeled.
  • Some products may contain contaminants like pesticides, heavy metals, or mold.

Some common side effects of THC include the following:

• Confusion
• Intoxication
• Dizziness
• Nausea
• Sleepiness

Some common side effects of CBD include the following:

• Malaise
• Diarrhea
• Sleepiness
• Poor sleep quality
• Fatigue
• Decreased appetite

You should consult your healthcare provider if you want to use cannabinoids.

• This will allow you to develop goals for treatment.
• Working with your healthcare provider can help you tracking your progress.
• Helps you and your healthcare provider to be on the same page about how you are using it.

Other risks

Many employers test for THC.

• Drug screens are used even in states where cannabis is legal.
• Using cannabis can risk employment if your employer tests for it.

Resources:

Medical cannabis and CBD laws from the National Conference of State Legislatures Website: https://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx

Arthritis Foundation CBD guidance Website: https://www.arthritis.org/living-with-arthritis/pain-management/chronic-pain/arthritis-foundation-cbd-guidance-for-adults.php

Inaccurate labeling in CBD products: Website: https://jamanetwork.com/journals/jama/article-abstract/2661569