Personalising Cannabis Care

Important Aspects of History Taking

Eligibility

Eligibility — condition >3 months, non-responsive to conventional medicines or experienced intolerable side effects from other treatments. Note: previous treatments can include OTC treatments or lifestyle, dietary and behavioural modifications. It is important to clarify that the patient did not have to have tried all available treatments, but should have considered them.

Primary Condition / Presenting Complaint

Make sure of appropriate diagnostic work up as we don't want to mask symptoms of something sinister that needs timely intervention. Don't want cannabis to take the place of more appropriate medication.

• Timing / duration
• Severity
• Location
• Character
• Associated features
• What makes it better
• What makes it worse
• Progression of symptoms
• Diagnosis
• Current treatments
• Previously trialled treatments
• Other members of healthcare team
• Hardest parts of condition to deal with
• Impact on ADLs, relationships, work, sense of self

Medications and natural therapies: Length of time that the failed treatment options were trialled. Reasons for ceasing the treatment options that have failed.

Secondary features: Sleep, stress, digestion, mood, motivation, infections. Looking for ECS dysfunction.

Comorbid Health Conditions / Past Medical History of Significance

Looking for contraindications, interactions and cautions:

• Cardiovascular disease or other severe cardiac conditions
• Falls risk
• Drug dependency issue
• Pregnant / breastfeeding / planning on becoming pregnant
• End organ disease
• Family history of significant mental illness
• Suspected or confirmed personal history with mental illness, specifically schizophrenia
• Drug / ETOH use disorders

Current medications and supplements: keeping in mind potential interactions.

Past Cannabis Experience

• Experience
• Type, duration, effects
• Sensitivity to THC?

Social History: Roles, responsibilities, dependents.

Objectives and Consent

• Expectations
• Goals
• Question: “What does being unencumbered by their condition look like to them?”

Goal setting: Realistic, patient driven, functional (not about the symptom).

Understanding around cannabis as a medicine: Assess baseline knowledge and provide appropriate education.

Consent: Understand driving, unapproved nature of medicine, costs, follow up, potential side effects.

Contraindications, Interactions and Warnings

Allergy to Cannabis or Constituents in Formulations

Rare but can happen. Can have reactions to carrier oil especially sesame oil in a few products. Some particular terpenes can cause side effects for individuals.

Schizophrenia or Previous Psychosis

*Note: this is relevant to THC, not CBD. CBD itself is being studied for its potential application as an antipsychotic medication.

Anxiety Disorders (excluding PTSD)

The right dose of THC can have significant anxiolytic effects. The wrong dose can worsen anxiety in susceptible individuals. This is due to the bidirectional nature of THC. In the case of anxiety disorders, slower titration protocols are recommended and pairing THC with CBD can widen the therapeutic window and reduce anxiogenic properties of THC.

Unstable Heart Disease

Increased risk of MI after having high dose THC due to the potential induction of tachycardia and subsequent drop in blood pressure, however the actual size of the infarct is reduced due to the cardioprotective nature of cannabinoids.

Extreme caution is recommended for patients with:

• Unstable angina
• Difficulty walking up two flights of stairs without experiencing chest pain or significant SOB
• Ejection fraction <20%
• Dangerous arrhythmia

Falls Risk

Due to THC's potential to cause motor or cognitive dysfunction, especially with high dose. THC can also cause hypotension so beware patients with postural hypotension. Advise at risk patients to be extra cautious during nocturnal waking to go to bathroom etc.

Previous Drug Use Disorder (Addictive Potential of Cannabis)

THC predominant medications do have low addictive potential. Reported levels of addiction are between 7–9% in recreational uses. This is much lower than caffeine, alcohol, cigarettes, benzodiazepines and opioids but still needs to be considered when choosing therapies.

Addiction is much more likely to occur in adolescents as the brain is still maturing and in those using concentrates or high percentage THC whole flower via the inhaled route. The inhaled route is more likely to cause addiction due to the instant gratification consumers get which can activate reward pathways. If addiction does occur then withdrawals are unpleasant but mild compared to many other drugs, often quoted as being similar physical symptoms to withdrawing from caffeine.

When used appropriately, with intentions aimed at managing symptoms rather than intoxication, cannabis has very low likelihood of addiction and abuse especially in more mature patients. The Sativex (1:1 ratio CBD:THC) trials which are the largest cumulative trials using cannabis to date showed no evidence of abuse or addiction in any of the patients being treated.

Layering of Medications

Patient needs vary through the day with significant variations between day and night functional goals. Also for most people with chronic conditions they can have large variations naturally in the intensity of their symptoms. I often use multiple products within the one patient to use the most appropriate formulation for the patient's needs for a particular time of day.

In general I will use more CBD predominant or balanced products during the day. If sleep disturbance is a major issue I will often use more THC predominant treatments at night time. For background symptoms I will use oral or sublingual medications for their longer duration of action. If a patient has an acute flair or breakthrough symptoms I will use the inhaled route on top of their background SR medications to get on top of symptoms quickly.

Administering Cannabis Medications

Tincture and Softgels

• Having with fat containing food can increase absorption by 5 times e.g. few nuts, teaspoon of peanut butter, avocado etc
• Hold medicine under the tongue for few minutes for added sublingual absorption (tincture only). Limited evidence to show that normal oil based tinctures are absorbed effectively through SL route.
• Takes 30–60mins before having some effect, can take up to 2 hrs or longer if having on a full stomach.
• Peak effect 2–3hrs
• Depending on speed of metabolism effects last 6–12hrs

Flower

• To be used with vaporiser e.g. Volcano, Mighty Medic, Arizer
• Vaporiser takes a minute to heat up, use this time to set positive intentions and reflect on what you are wanting to achieve while using cannabis
• Vaporisers can be set between 160–220 degrees. A good place to start is 190 degrees
• Start with 1 medium inhalation, wait 10 mins before repeating
• Continue until therapeutic effect, once you know your therapeutic dose you can start next time just below this e.g. 4 inhalations without waiting 10 mins between inhalations
• Onset 2–10 mins
• Peak effect 30mins
• Effects wane after 2–4hrs

Oromucosal Sprays

• Each spray contains around 2–2.5mg cannabinoids depending on product
• Spray solution to inside of cheek
• Having small amount of fat containing food after use can help absorption
• Onset 20–40mins
• Peak effect 1–2hrs
• Effects wane 4–8hrs

Topical

• For pain apply directly to the area up to 4x daily as required
• For skin conditions use 2–3x daily
• Nil significant systemic absorption with topical use

Storage

• Light and heat will degrade cannabis products
• Store all cannabis products in a cool dark place below 25 degrees Celsius
• Some tinctures can become more concentrated towards the bottom of the product, it is worth inverting and gently agitating to reduce the chance of this occurring

Managing Side Effects and Adverse Reactions

• Reassurance: no one has ever died from THC overdose. The amount of THC required to cause toxicity would be impossible to self-administer
• Calm space, gentle music and chamomile tea
• If you also have CBD taking 20–40mg stat dose can help
• Concentrated limonene found in lemon rind can help reduce anxiety associated with THC overdose
• α-Pinene in pine nuts can help reduce side effects of THC
• Calamus root can also improve anxiety, dry mouth, conjunctival erythema and memory impairment associated with THC

Prescribing Cannabis to Self-Medicating Patients

Mankind has had significant and longstanding cultural, spiritual and medicinal relationships with the cannabis plant. The last 90 odd years however have lead to significant changes in that relationship; both in the ways it's used, and in the way we think about its use.

Despite prohibition cannabis has remained an integral component in many people's personal medicinal and/or recreational toolkit. However, without the guidance and clarity gleaned through tangible research, clinical insights and pharmacological understanding, that relationship is often sub optimal.

As a cannabis practitioner, you will undoubtably come across people with previous cannabis relationships who are looking to legitimise their access. These interactions are an opportunity to re-establish and co-create healthy, sustainable and beneficial relationships between ‘self-medicating’ patients and their go to medicine, cannabis. To do so involves providing education and meaningful support free from judgement to a group of people used to being perceived through a lens of criminality or shame.

Most patients with prior cannabis experience haven't learned how to use cannabis appropriately but how could they when they have been without guidance. Similar to our European counterparts, Australians have generally mixed their cannabis with tobacco for use in either joints or water pipes. The effects experienced under that particular combination, at uncontrolled and often uninformed dosages, may have contributed to a fairly singular idea of what cannabis and its constituents can actually do. Moreover, the inclusion of tobacco within cannabis preparations may also present the challenge of a concurrent nicotine addiction.

Education around the benefits of vaporisation, activating the ‘full spectrum’ of constituents, eliciting deliberate effects, setting intentions, engaging in mindful dosage and administration, understanding that more intoxicating doesn't mean more effective, understanding potential risks and practicing regular tolerance breaks are all key components in establishing these healthy relationships. These patients can be some of the most engaged and excited by the newfound knowledge they are presented with.