Medical Cannabis Q&A

Cannabis is a plant. Under the scientific classification and definition of cannabis, the cannabis plant is part of the Cannabaceae family and has been further classified as Cannabis sativa L.

Cannabis plants can be divided into three basic varieties: sativa, indica and ruderalis. These varieties originally grew in different climate zones and differ in appearance, growth pattern and effects. Because of its long-term use in medical applications, most of the Cannabis plant genetics used today are hybrids between sativa, indica and ruderalis strains, also known as ‘cultivars.’ All are routinely recognized and accepted as Cannabis sativa L.

It is a botanical, phytomedicine, or plant medicine also commonly known as Medical Marijuana. It is the medical use of the Cannabis plant to relieve symptoms of, or treat diseases, conditions, and disorders. The Cannabis plant was used medically for centuries around the world, including within the United States until the early 1930’s. Cannabis was the most widely prescribed drug in the US Pharmacopeia until its official prohibition in 1937 with the passing of the ‘Marihuana Tax Act.’

Cannabis produces cannabinoids that mimic compounds produced in the human body. These plant-based cannabinoids, or phytocannabinoids, can work in place of the body's endogenous cannabinoids, or endocannabinoids, when the body experiences a deficiency in its endocannabinoid system (ECS).

Medical Cannabis is standardized to ensure batch-to-batch consistency and has strict manufacturing standards for safety and consistency. Medical Cannabis is subject to strict quality control measures that are validated through Lab Testing to ensure quality and safety. Medical Cannabis products contain purified products through extraction, distillation, and reformulation of specific cannabinoid profiles to target specific conditions, disease states, and disorders.

Cannabidiol (CBD) and tetrahydrocannabinol (THC), are two natural compounds, known as cannabinoids, found in the Cannabis Sativa plant. Both compounds interact with your body’s endocannabinoid system but have different effects.

Molecular Structure - Both CBD and THC have the exact same molecular structure: 21 carbon atoms, 30 hydrogen atoms, and 2 oxygen atoms. A slight difference in how the atoms are arranged accounts for the differing effects on your body. Receptor Systems and Effects - THC binds to the CB1 receptor within our body’s endocannabinoid system located primarily in the brain and spinal cord, and sparsely throughout our organs controlled by our peripheral nervous system. When THC binds to the CB1 receptor, it can produce a psychoactive or euphoric effect. However, CBD, by itself, cannot bind to the CB1 receptor, but naturally binds to the CB2 receptor located throughout the organs governed by our peripheral nervous system. CBD can only bind to the CB1 receptor by attaching itself to the THC molecule. CBD will bind to THC and the THC molecule binds with the CB1 receptor. CBD does not have psychoactive properties, and very minimal side effects if any. When CBD and THC together bind with the CB1 receptor the psychoactive effects are reduced, and the medicinal properties of THC are enhanced significantly. THC by itself is not well tolerated and not recommended to take as an isolate.

Both CBD and THC are chemically similar to your body’s endocannabinoids. This allows them to interact with your CB1 and CB2 cannabinoid receptors, among others. This interaction affects the release of neurotransmitters in your brain. Neurotransmitters are chemicals responsible for relaying messages between cells and have roles in pain, immune function, stress, sleep, and every other function within the human body.

CBD is well tolerated, even in large doses. Research suggests any side effects that occur with CBD use are likely the result of drug-to-drug interactions between CBD and other medications you may be taking. Neither compound affects breathing modulation, like alcohol, opiods, and other pharmaceuticals, therefore, neither can be fatal.

The list of conditions CBD may help with is ever expanding. CBD is popularly used to manage the following symptoms and conditions:
• Epilepsy
• Seizure Disorders
• PTSD
• Anxiety
• Crohn’s Disease
• Multiple Sclerosis
• Opioid withdrawal

A Certificate of Analysis (CoA) is a document provided by a third-party lab that analyses the various compounds found in your medical cannabis. This can include outlining a strain or cultivar’s cannabinoid and terpene profile, as well as testing for other crucial factors like pesticide, residues or heavy metals. You can also find other information in a CoA such as manufacturer information, testing method used, and batch data.

There are acceptable limits that agencies have set for each compound and they are all listed in a medical cannabis product's Certificate of Analysis (CoA). This allows patients to ensure the products they consume are free of unwanted residual solvents, microbiological contaminants, mycotoxins, heavy metals, and pesticides that can compromise a person's immune system.

Transparency and Impartiality. The ultimate function of a CoA is to ensure a product’s content matches what was advertised. As such the first element to consider when reading a CoA is who the test was conducted by. This information can be found at the top of the first page. You should always check to ensure the company who performed the test is not the original manufacturer.

The CoA of all medical cannabis products can be viewed through the information provided on the packaging.

Hemp - In the United States, the term “hemp” is used to describe a cannabis plant that produces no more than 0.3% THC, which is the molecule that causes the euphoric and intoxicating effects associated with medicinal and adult-use cannabis. The classification does not take into consideration any other cannabinoids. Therefore, if a plant produces 20% CBD and only 0.29% THC, it's still legally considered hemp. There is a staggering diversity of molecules that plants in this legal category are capable of producing. Among these are cannabidiol (CBD), cannabigerol (CBG), and cannabichromene (CBC), cannabinoids which are valued for their medicinal properties.

Many laws have been created based on this percentage-based definition of hemp. It's the level of THC the plant variety produces that differentiates it from cannabis' intoxicating variety, “marijuana,” and allows for its legal classification as a commodity crop.

Inhalation
• Dried Flower
• Vaporization
• Atomizer
Orally
• Tinctures
• Oils
• Edibles
• Salves
Topicals
• Lotions
• Bath bombs
Rectally
• Suppositories

Pharmacokinetics is how the active compounds of a medication are released once a product has been incorporated into our body. This includes how it is absorbed, how it is distributed around the body, and how they are inactivated and excreted.

Bioavailability indicates the percentage of active compound from a medicine that reaches the bloodstream, which is the system for transporting of nutrients, oxygen, medicines, etc. in our body.

When selecting a product and the route of administration, the pharmacokinetics and bioavailability differ with the various routes of consumption. The active cannabinoid content incorporated into our bodies, length of time before the patient feels the effects, and the duration of the effects of the medication are the 3 primary questions a patient should consider when making this decision.

Through this method, cannabinoids reach their maximum concentration in the blood and brain a few minutes after consumption, which represents 3 important advantages compared to other forms of administration: 1. First, the therapeutic benefit is almost immediate, which is very important when suffering from acute crises in certain pathologies (peaks of post-traumatic stress, pain, nausea, outbreaks in inflammatory bowel disease, etc.). 2. The speed of the effect allows avoiding ‘couch-lock’ episodes. 3. Bioavailability of the major cannabinoids consumed by this method is very high (around 25%)

The endocannabinoid system (ECS) is a complex cell-signaling system that governs homeostatic balance within the human body. The ECS ensures and maintains physiological and neurological balance within and between your body’s internal organs. The Endocannabinoid system was not discovered until the early 1990’s by research exploring the molecular properties of THC and its interactions within the human body. The Endocannabinoid System exists and is active in your body even if you do not use cannabis.

Cannabinoids are naturally occurring compounds found in the Cannabis Sativa plant that play a critical role in regulating a range of functions and processes, including sleep, mood, appetite, memory, reproduction, fertility, and more. With 480 different compounds present in the plant, only around 66 are termed cannabinoids. The most well-known among these compounds is the delta-9-tetrahydrocannabinol (Δ9-THC), which is the main psychoactive ingredient in cannabis. Cannabidiol (CBD) is another important component, which makes up about 40% of the plant resin extract.

The primary function of the Endocannabinoid System is to maintain Homeostatic Balance. If homeostasis is disrupted, the imbalance will lead to disease states, medical conditions, and disorders unless remediated or controlled. Human physiological systems work together to maintain neurological and physiological balance. The ECS is a complex signaling molecule system that ensures and maintains physiological and neurological balance within and between your body’s internal organs. If that balance is shifted or disrupted and homeostasis is not maintained, the results may not allow normal functioning of the human body and results in diseases, medical conditions, and disorders.

•Appetite and Digestion
• Metabolism
• Chronic Pain
• Inflammation and Immune System Responses
• Mood
• Learning and Memory
• Motor Control
• Sleep
• Cardiovascular System Function
• Muscle Formation
• Bone Remodeling and Growth
• Liver Function
• Reproductive System Function
• Stress
• Skin and Nerve function
These functions all contribute to homeostasis, which refers to the stability of your internal environment. For example, if an outside force, such as pain from an injury or a fever, throws off your body’s homeostasis, your ECS kicks in to help your body return to its ideal operation by signaling the organs necessary to implement the healing process. Maintaining homeostasis is the primary role of our Endocannabinoid System.

Tetrahydrocannabinol (THC) is one of the main cannabinoids found in cannabis. It’s the psychoactive compound that gets you “high.” Once in your body, THC interacts with your ECS by binding to our CB1 and CB2 receptors in our Central and Peripheral Nervous systems, just like our own internal naturally occurring endocannabinoids such as Anandamide and 2-AG. This allows it to have a range of effects on your physiological and neurological systems.

This theory suggests that low endocannabinoid levels in your body or ECS dysfunction can contribute to the development of certain conditions. Over 10 years of research on the subject suggests the theory could explain why some people develop migraine, fibromyalgia, and irritable bowel syndrome. None of these conditions have a clear underlying cause and are commonly ‘diagnosed by exclusion.’ These conditions are also often resistant to treatment and sometimes occur alongside each other. If CECD does play any kind of role in these conditions, targeting the ECS or endocannabinoid production could be the missing key to treatment.

Our body and brain maintain their normal functioning (homeostasis) through the delicate and precise interactions between many systems. Human physiological systems work together to maintain neurological and physiological balance. If that balance is shifted or disrupted and homeostasis is not maintained, the results may not allow normal functioning of the human body and results in diseases, medical conditions, and disorders.

The primary function of the Endocannabinoid System is to maintain Homeostatic Balance. If homeostasis is disrupted, the imbalance will lead to disease states, medical conditions, and disorders unless remediated or controlled. Human physiological systems work together to maintain neurological and physiological balance. The ECS is a complex signaling molecule system that ensures and maintains physiological and neurological balance within and between your body’s internal organs. If that balance is shifted or disrupted and homeostasis is not maintained, the results may not allow normal functioning of the human body and results in diseases, medical conditions, and disorders.

Trauma is an emotionally charged event with a negative outcome. Traumatic experiences often involve a threat to life or safety, but any situation that leaves you feeling overwhelmed and isolated can result in trauma, even if it does not involve physical harm. It is not the objective circumstances that determine whether an event is traumatic, but your subjective emotional experience (perspective) of theevent. The more frightened and helpless you feel, the more likely you are to be traumatized.

Post-traumatic stress disorder (PTSD) is characterized by debilitating trauma-related intrusive thoughts, avoidance behaviors, hyperarousal, insomnia, depressed moods, and anxiety.

• Reduces hyperarousal
• Reduces hypervigilance
• Allows you to sit in the emotion and approach painful memories with logic
• Restores Homestatic Balance
• Promotes Neuroplasticity

A Holistic Approach means to provide support for the whole person, not just their physical health needs. The support, when considering our overall health and well-being, should take into account all aspects of our being to include the physical, mental, emotional, social, and spiritual well-being.

America defines health only as the absence of disease, and does not take into account the mental, emotional, social, and spiritual aspects that encompass a person’s total well-being. This definition has and continues to drive a profitable pharmaceutical healthcare model that is continuing to create a significant gap b/w the patient’s and physicians entrusted with their care.

The variation of MMLs across the USA largely dictates patterns of access, prescription, dispensation, and permissible use of medical marijuana. Additional factors such as income, race/ethnic background, stigma, and physician participation have emerged as the social determinants that dictate access to medical marijuana. Large-scale social forces and sometimes the very policies that address them often determine who falls ill, who has access to care, and the type of care they receive. “Structural violence” in the form of constrained access to medication impedes individuals from obtaining the necessary provisions for their health and well-being.

Structural Violence, a term coined by John Galtung in the 1960’s, describes social structures – economic, political, legal, religious, and cultural – that stop individuals, groups, and societies from reaching their full potential. In its general usage, the word violence often conveys a physical image; however, according to Glatung, it is the “avoidable impairment of fundamental human needs or…the impairment of human life, which lowers the actual degree to which someone is able to meet their needs below that which would otherwise be possible.” Structural violence is often embedded in longstanding “ubiquitous social structures, normalized by stable institutions and regular experience.” Because they seem so ordinary in our ways of understanding the world, they appear almost invisible. Disparate access to resources, political power, education, healthcare, and legal standing are just a few examples.

Medical marijuana use is predominant among white Americans. The association between race/ethnicity and levels of disposable income is consistently cited as an underlying reason for why ethnic minorities in general might be less likely to use medical marijuana. Marijuana possession remains a federal crime, and ethnic minorities continue to be charged significantly more frequently than whites for marijuana-related offenses. Therefore, the higher likelihood of ethnic minorities, such as Latinos and African Americans, being targeted by law enforcement or facing legal consequences for involvement with marijuana could also deter their use of medical marijuana.

Medical Cannabis use is more common among individuals who are employed, have health insurance, and earn high incomes. For example, California residents earning over $60,000 annually are most likely to use medical marijuana. Similarly, a major proportion (64.8%) of medical cannabis patients in medical cannabis assessment clinics across California reported being employed while almost three quarters (73.4%) of them had private health insurance. Issuance of medical marijuana cards across all states has a financial cost. In certain cases, states may provide a cost subsidy for medical cannabis users who also qualify for federal assistance programs such as Medicaid or the Supplemental Nutrition Assistance Program (SNAP), as seen in Arizona. Neither the cost of receiving a medical provider referral nor the state registration fee is covered by health insurance. Thus, without sufficient disposable income, health insurance, or subsidies, individuals with qualifying medical conditions may be unable to participate in the medical marijuana program offered by their jurisdiction. (Great example of Structural Violence).

The Stigma associated with possessing and using marijuana could further deter individuals from considering medical cannabis. For instance, the fear of labels such as “junkie” or “stoner” may dissuade patients with qualifying medical conditions from discussing medical marijuana use with their healthcare provider. This fear could also prevent qualifying patients from visiting a licensed dispensary to purchase cannabis. Statutes legalizing medical cannabis could reduce the stigma associated its use due to the sheer increase in its availability and resulting social acceptability.

Another predictor of medical marijuana initiation and continuous use is physician attitudes. Under many state medical marijuana programs, a licensed physician must certify that a patient has a qualifying medical condition before that patient can access medical marijuana. Depending on their source of information, physicians can be ambivalent about making these recommendations. In fact, many physicians cite the physical and mental health risks of medical marijuana as deterrents to recommending qualified patients. Two further significant drawbacks to recommending medical marijuana are its classification as a “schedule I illegal drug” by the U.S. Drug Enforcement Administration and its unapproved status by the Federal Drug Administration. The potential for physicians to resist recommending medical cannabis has also created obstacles to access. For example, 39% of specialists and 34% of primary care physicians in Delaware reported being “very unlikely” to authorize eligible patients for medical cannabis. In addition, it has been found that patients do not initiate medical marijuana-related conversations with their primary care provider because of anticipated negative responses.

There are two kinds of stress. Acute stress is a normal part of everyday life and helps our stress response system stay on the ball. Problems arise when we are repeatedly exposed to the same stressor or many different stressors for an extended period of time. When this happens, we can fall prey to the effects of chronic stress and PTSD.

Novelty – Something new you have not experienced before
Unpredictability – Something you had no way of knowing it would occur
Threat to the Ego – Your competence as a person is called into question
Sense of Control – You have little to no control over the situation

The stress response begins in the brain. When a person is confronted with danger, the eyes or ears (or both) send the information to the amygdala, an area of the brain that contributes to emotional processing. The amygdala interprets the images and sounds. When it perceives danger, it instantly sends a distress signal to the hypothalamus, an area of the brain that functions like a command center, communicating with the rest of the body through the nervous system so that the person has the energy to fight or flee.

After the amygdala sends a distress signal, the hypothalamus activates the sympathetic nervous system by sending signals through the autonomic nerves to the adrenal glands. These glands respond by pumping the hormone epinephrine (also known as adrenaline) into the bloodstream. As epinephrine circulates through the body, it brings on a number of physiological changes. The heart beats faster than normal, pushing blood to the muscles, heart, and other vital organs. Pulse rate and blood pressure go up. The person undergoing these changes also starts to breathe more rapidly. Small airways in the lungs open wide so the lungs can take in as much oxygen as possible with each breath. Extra oxygen is sent to the brain causing our senses, sight, hearing, and other senses become sharper. Meanwhile, epinephrine triggers the release of blood sugar (glucose) and fats from temporary storage sites in the body. These nutrients flood into the bloodstream, supplying energy to all parts of the body.

As the initial surge of epinephrine subsides, the hypothalamus activates the second component of the stress response system — known as the HPA axis. This network consists of the hypothalamus, the pituitary gland, and the adrenal glands. The HPA axis relies on a series of hormonal signals to keep the sympathetic nervous system — the "gas pedal" — pressed down. If the brain continues to perceive something as dangerous, the hypothalamus, through the pituitary and adrenal glands, prompts them to release cortisol. The body thus stays revved up and on high alert. When the threat passes, cortisol levels fall. The parasympathetic nervous system — the "brake" — then dampens the stress response.

The ‘Fight or Flight’ response evolved as a survival mechanism, enabling people and other mammals to react quickly to life-threatening situations. This carefully orchestrated yet near-instantaneous sequence of hormonal changes and physiological responses helps humans and mammals to fight the threat off or flee to safety.Neither compound affects breathing modulation, like alcohol, opiods, and other pharmaceuticals, therefore, neither can be fatal.

a. This is stress resulting from repeated exposure to situations that lead to the release of stress hormones. This type of stress can cause wear and tear on your mind and body. It is unhealthy for our stress response systems to be constantly activated. This overuse contributes to the breakdown of many bodily systems. Chronic stress has been linked to heart disease, high blood pressure, high cholesterol, type II diabetes, depression and many other disorders, conditions, and inflammatory diseases.

a. Chronic low-level stress keeps the HPA axis activated, much like a motor that is idling too high for too long. The HPA axis or network consists of the hypothalamus, the pituitary gland, and the adrenal glands. Over time, repeated activation of the stress response takes a toll on the human mind, body, and spirit. Chronic stress contributes to high blood pressure, promotes the formation of artery-clogging deposits and causes neurological changes in the brain that lead to anxiety, depression, addiction and long-term inflammatory diseases among others. Also, chronic increases in adrenaline and cortisol shrink the hippocampus and prefrontal cortex areas of the brain, which negatively affects stress tolerance and the formation of new memories.

Homeostatic Balance and Neuroplasticity. Homeostatic balance and neuroplasticity are the keys to recovery, stability, and continued functionality. Cannabis facilitates the process by providing the necessary physiological balance while enhancing the neuroplastic properties of the brain.

Homeostatic Balance or Homeostasis is the state of steady internal, physical, and chemical conditions maintained by living systems. This is the condition of optimal functioning for the organism and includes many variables, such as body temperature and fluid balance, being kept within certain pre-set limits (homeostatic range).

Neuroplasticity is the ability of the brain to form new connections and pathways and change how its circuits are wired.

Three symptom categories characterize the disorder:
1. Re-Experiencing - Persistent re-experience of the traumatic event
2. Hyperarousal - Persistent symptoms of increased arousal
3. Avoidance - Persistent avoidance of stimuli associated with the trauma

Symptoms of PTSD fall into four categories. Specific symptoms can vary in severity:
1. Re-experiencing or Intrusion:
• Intrusive thoughts such as repeated, involuntary memories
• Distressing dreams
• Vivid flashbacks (feeling like the trauma is happening right now)
• Panic Attacks or Intense distress at real or symbolic reminders of the trauma
• Physical sensations such as pain, sweating, nausea or trembling

2. Avoidance: Avoiding reminders of the traumatic event may include:
• Avoiding people, places, activities, objects and situations that may trigger distressing memories.
• People may try to avoid remembering or thinking about the traumatic event.
• They may resist talking about what happened or how they feel about it.
• Feeling like you have to keep busy
• Avoiding anything that reminds you of the trauma
• Being unable to remember details of what happened
• Feeling emotionally numb or cut off from your feelings
• Feeling physically numb or detached from your body
• Being unable to or have trouble expressing affection
• Using alcohol or drugs to avoid memories

3. Alterations in cognition and mood:
• Irritability or aggressive behavior
• Finding it hard to concentrate – including on simple, everyday tasks
• Being jumpy or easily startled, also sometimes called hypervigilance
• Self-destructive behavior and recklessness
• Sudden mood changes
• Substance Abuse
• Inability to remember important aspects of the traumatic evet
• Negative thoughts and feelings about oneself or others (e.g., “I am bad,” “No one can be trusted”)
• Distorted thoughts about the cause or consequences of the event leading to wrongly blaming self or other
• Ongoing fear, horror, anger, guilt or shame
• Much less interested in activities previously enjoyed
• Feeling detached or estranged from others
• Unable to experience positive emotions (a void of happiness or satisfaction).
• Panic Attacks - Panicking when reminded of the trauma
• Being easily upset or angry
• Disturbed sleep, lack of sleep, or the inability to sleep

4. Alterations in arousal and reactivity - Arousal and reactive symptoms may include:
• Being irritable and having angry outbursts
• Behaving recklessly or in a self-destructive way
• Being overly watchful of one's surroundings in a suspecting way
• Being easily startled
• Having problems concentrating or sleeping.
• Extreme alertness, also called ‘Hypervigilance
• Memory problems

Many people who are exposed to a traumatic event experience symptoms similar to those described above in the days following the event. For a person to be diagnosed with PTSD, however, symptoms must last for more than a month and must cause significant distress or problems in the individual's daily functioning. Any aspect of the following symptoms above that endure longer than a month after they started. These symptoms can be a result of:

• Re-experiencing or intrusion
• Avoidance
• Alterations in cognition and mood
• Hyperarousal

Many individuals develop symptoms within three months of the trauma, but symptoms may appear later, months or years, and often persist for months and sometimes years.

If not treated properly, trauma effects the long-term psychiatric and physical health of survivors. These changes can also lead to chronic inflammation of organs and the failure of adaptive systems. This can lead to behavior and quality of life changes, sleep disturbances, metabolic disturbances, and cardiovascular disturbances. These disturbances lead to inflammatory diseases, decreased quality of life, and death.

It reduces the hyperarousal symptoms that lead to avoidance of the painful emotions. In order to begin the recovery process, we must begin turning the trauma into words. In order to convert the painful memories, we must sit within them. Using cannabis allows us to sit in the painful emotions and confront with logic, rather than avoid the emotion. Avoiding the emotions lead to maladaptive behaviors that create a negative close-loop thought process. This closed-loop thought process becomes very difficult to unravel the more it is repeated. Cannabis allows us to be in the absolute present, which is the necessary stage for neuroplasticity. The ‘Therapeutic’ approach through talk therapy aims to achieve just this. Cannabis incorporated with a structured therapeutic approach will expedite stability, recovery, and continued functionality.

Initial:
• Your heart rate and breathing increases
• Your blood sugar levels and blood pressure increase
• Your digestion stops
• After a few days of interrupted digestion, you may start to experience heartburn, diarrhea and/or constipation.
• You may also experience some of the following:
Emotional distress: Irritability, resentment, anger, anxiety, and a depressed state
Muscular problems: Tension headache, back pain, jaw pain, etc.
Intermediary: Here, things are getting a little out of control and are somewhat chaotic. One stressor follows the other. The stress response system is constantly activated and constantly extracting stored energy.
• You abound with nervous energy
• You take on too much and are always rushing and are often late
• You feel overwhelmed and overworked
• You feel over-aroused and short-tempered
• You feel anxious, and/or tense most of the time
• You cannot turn off your mind when you go to bed
• You are constantly worrying and expecting the worst
• You increase your intake of tobacco, alcohol, and unhealthy foods
• Your memory starts to fail you
• You often get colds and the flu
When the brain is constantly bombarded it screams out for rewards and release. Too often, this release comes in the form of more alcohol, tobacco, illicit and over the counter drug use and high fat and high sugar foods.
Chronic: Here, the repeated activation of the stress response system leads to increased pharmaceutical used to mask the symptoms. Our personalities can change dramatically and judgement declines. Some of the most common health problems linked to chronic stress are:
• Heart disease (high blood pressure, high cholesterol)
• Insomnia
• Depression
• Burnout
When the stress response system is activated, energy is mobilized. Overall, what ends up happening is wear and tear on our stress response system and all the other body systems that work with it to ensure a healthy balance.