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ROB O ER E T M. M GOL O DM DMAN, N MD MD, PhD, D DO, O FA F ASP S W rld Ch Wo C airman-In I te t rnational Me M dical Commis i sion Co-Fo F under & Ch C airman of o th t e Board r -A4M F under & Ch Fo C airman-In I ternational Sp S orts t Ha H ll of o Fa F me Co-Fo F under & Ch C airman-Wo W rld Academy m of o Anti-Aging n Me M dicine Pre r sident Emeritus-Na N tional Academy m of o Sp S orts t Me M dicine (N (NASM) M DR. RON ONALD KL K ATZ TZ, MD MD, DO, O is i the phy hysician fo f under and Pre r sident of o the American Academy m o Anti-Aging of n Me M dicine. In I 1984, Dr.r Klatz t was a pioneer in the clinical sp specialty t of of pre r ventative medicine: as a princip i al fo f under of o th t e Na N tional Academy m of o Sp S orts t Me M dicine and re r searc r her into cannabis i medicine elite human perf rformance and phy hysiolog og y. Dr.r Kl K atz t is i a best-selling n author,r and is i columnis i t or Senior Me M dical Editor to several inte t rnational medical journals l . He H is i the inventor,r develop oper,r or adminis i trator of o 100-p - lus scientifific patents, s including n those ffor technolog o ies fo f r brain re r suscitation, trauma and emerg rgency c medicine, e org rgan transp s lant and blood pre r servation. DAVI D VID B. MA M ND N EL E L, JD JD, MB MBA, is i a fo f rmer attorney e and author of o ten books fo f r clients t, including n Fo F r Doctors r Only l : A Guide to Wo W rk r ing n Less & Building Mo M re re, as well a number of o state books. He H is i a princip i al of o the fifnancial consulting fifrm OJ OJM Gro r up u. H has co-authore He r d the Categ egory r I CM CME Mo M nog o rap a h Ris i k Ma M nag agement fo f r th t e Practicing n Phy h sician which has go g ne thro r ug ugh 5 editions since 1998 & is i certifified fo f r 5-hour business of o medicine CM CME. MANO M NON PI PILON ON, Sp S eaker,r In I ternational Educator,r Me M dical SP SPA Sp S ecialist – Mrs r . Ma M non Pilon’s backg k ro r und sp s ans over thirty t -seven years r of o pro rofessional ex experience in M DICA ME C L SPA P op o eration and manag agement,t mark r eting strateg e ies, Me M dical Sp S a concep e t and develop o ment,t and motivation methods d . She is i holding senior manag agement positions in comp m anies such as Euro rope CosmÊtiques, CurA r ge g Me M d, d CurA r ge g Sp S a, and Euro ropelab.

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MON O TE T ZWA W NG N is a pprincip i al of o We W llness Cap apital Ma M nage g ment,t pro r viding cash fflow and fifnancial strateg e ies to businesses in the cannabis i &wellness industry r y. Mo M nte has been a consultant fo f r more r th t an 25 years r , teaching n entre repre r neurs r and comp m any n leaders r in health care re, r al estate, re e ffood and beverage ge, day a sp s a, re r sorts t and hote t ls l , and re r tail dis ispensary r y industries the strateg e ies oof cash flfow manag agement.t Mo M nte is i driven to the wellness industry r because of o a pers r onal passion fo f r healthy hy lififesty tyle choices, and a pro rofessional ppassion to work with t cannabis i wellness entre repre r neurs r as they e achieve their business go g als l by b hellping n peop o le live a healthy h lififesty t le. BREN E T A. BA B UE UER, M. M D. D as dire r ctor of o the Ma Mayo Clinic Comp m lementary r and Integ e rative M dicine Pro Me rogram, Bre r nt A. Bauer,r M. M D. D , has broad and varied re r searc r h intere r sts t . Dr.r Bauer's pers r onal go g al is i to ensure r that re r searc r h conducted under the ausp s ices of o th t e Comp m lementary r and I teg In e rative Me M dicine Pro rogram is i alway ays held to the same hig igh standard rds as all oth t er re r searc r h at Mayo Clinic. He Ma H broug ught re r al,l evidence-based knowledg dge to patients and phy hysicians try r ing to incorp r orate the best of o conventional and comp m lementary r medicine practices.

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History Pharma

MEDICINAL CANNABIS: HISTORY, PHARMACOLOGY, AND IMPLICATIONS FOR THE ACUTE CARE SETTING Medicinal cannabis, or medicinal marijuana, is a therapy that has garnered much national attention in recent years. Controversies surrounding legal, ethical, and societal implications associated with use; safe administration, packaging, and dispensing; adverse health consequences and deaths attributed to marijuana intoxication; and therapeutic indications based on limited clinical data represent some of the complexities associated with this treatment. Marijuana is currently recognized by the U.S. Drug Enforcement Agency’s (DEA’s) Comprehensive Drug Abuse Prevention and Control Act (Controlled Substances Act) of 1970 as a Schedule I controlled substance, defined as having a high potential for abuse, no currently accepted medicinal use in treatment in the United States, and a lack of accepted safety data for use of the treatment under medical supervision.1 7–9








13 10,19 14






MEDICINAL CANNABIS: HISTORY, Y PHARMACOLOGY, Y AND IMPLICAT A IONS FOR THE ACUTE CARE SETTING that standardization in potency or quantity of pharmacologically active constituents is absent; that adverse health eff ffects relate not only to smoking cannabis but to unmasking mental health disorders, impairing coordination, and aff ffecting judgment; that standardization does not exist fo f r product packaging and controls to prevent inadvertent use by minors or pets; that there is a potential fo f r dependence, addiction, and abuse; and that costs pose a potential burden.23–25 Regardless of personal views and perceptions, to deny n or disregard the implications of use of this substance on patient health and the infr f astructure of the health care system is irresponsible; clinicians must be aw a are of these implications and info f rmed about how this therapy may a inflfuence practice in a variety of health care settings, including acute care. PHARMACOLOGY Endocannabinoids (eCBs) and their receptors are fo f und throughout the human body: nervous system, internal organs, connective tissues, glands, and immune cells. The eCB system has a homeostatic role, having been characterized as “eat, sleep, relax, fo f rget, and protect.”26 It is known that eCBs hav a e a role in the pathology of many n disorders while also serving a protective fu f nction in certain medical conditions.27 It has been proposed that migraine, fi f bromyalgia, irritable bowel syndrome, and related conditions represent clinical eCB defi f ciency syndromes (CEDS). Defi f ciencies in eCB signaling could be also inv n olved in the pathogenesis of depression. In human studies, eCB system defifciencies hav a e been implicated in schizophrenia, multiple sclerosis (MS), Huntington’s disease, Parkinson’s disease, anorexia, chronic motion sickness, and fa f ilure to thrive in infa f nts.28

CB1 is also expressed in non-neuronal cells, such as adipocytes and hepatocytes, connective and musculoskeletal tissues, and the gonads. CB2 is principally associated with cells governing immune fu f nction, although it may a also be expressed in the central nervous system. The most well-known eCB ligands are N arachidonylethanolamide (anandamide or AEA) and sn-2arachidonoylglycerol (2-AG). AEA and 2-AG are released upon demand fr f om cell membrane phospholipid precursors. This “classic” eCB system has expanded with the discovery of secondary receptors, ligands, and ligand metabolic enzymes. For example, AEA, 2-AG, Narachidonoyl glycine (NA N Gly), and the phy h tocannabinoids Δ9-THC and CBD may a also serve, to diff fferent extents, as ligands at GPR55, GPR18, GPR119, and several transient receptor potential ion channels (e.g., TRPV1, TRPV2, TRPA P 1, TRPM8) that hav a e actions similar to capsaicin.28 The eff ffects of AEA and 2-AG can be enhanced by “entourage compounds” that inhibit their hydrolysis via substrate competition, and thereby prolong their action through synergy and augmentation. Entourage compounds include N-palmitylethanolamide (PEA), N-oleoylethanolamide (SEA), and cis-9-octadecenoamide (OEA or oleamide) and may a represent a novel route fo f r molecular regulation of endogenous cannabinoid activity. y 29

The eCB system represents a microcosm of psychoneuroimmunology or “mind–body” medicine. The eCB system consists of receptors, endogenous ligands, and ligand metabolic enzymes. A variety of physiological processes occur when cannabinoid receptors are stimulated. Cannabinoid receptor type 1 (CB1) is the most abundant G-protein–coupled receptor. It is expressed in the central nervous system, with particularly dense expression in (ranked in order): the substantia nigra, globus pallidus, hippocampus, cerebral cortex, putamen, caudate, cerebellum, and amyg y dala.


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MEDICINAL CANNABIS: HISTORY, Y PHARMACOLOGY, Y AND IMPLICAT A IONS FOR THE ACUTE CARE SETTING The time courses of plasma concentrations and clinical “high” h were of the same order fo f r intrav a enous injection and smoking, with prompt onset and steady decline over a fo f urhour period.Aft f er oral THC, the onset of clinical eff ffects was slower and lasted longer, but eff ffects occurred at much lower plasma concentrations than they did aft f er the other two methods of administration.38

Limited clinical trials quantify f ing the eff ffect of the exogenous cannabinoids on the metabolism of other medications exist; however, drug interaction data may a be gleaned fr f om the prescribing info f rmation fr f om cannabinoid-derived pharmaceutical products such as Sativex (GW Pharmaceuticals, United Kingdom) and dronabinol (Marinol, AbbVie [Un U ited States]).41,42

Cannabinoids are usually inhaled or taken orally; the rectal route, sublingual administration, transdermal delivery, y eye drops, and aerosols hav a e been used in only a fe f w studies and are of little relevance in practice today. y The pharmacokinetics of THC vary as a fu f nction of its route of administration. Inhalation of THC causes a maximum plasma concentration within minutes and psychotropic eff ffects within seconds to a fe f w minutes. These eff ffects reach their maximum aft f er 15 to 30 minutes and taper off f within two to three hours. Following oral ingestion, psychotropic eff ffects manife f st within 30 to 90 minutes, reach their maximum eff ffect aft f er two to three hours, and last fo f r about 39 f ur to 12 hours, depending on the dose. fo

Concomitant administration of ketoconazole with oromucosal cannabis extract containing THC and CBD resulted in an increase in the maximum serum concentration and area under the curve fo f r both THC and CBD by 1.2-fo f ld to 1.8-fo f ld and twofo f ld, respectively; coadministration of rifa f mpin is associated with a reduction in THC and CBD levels.40,41 In clinical trials, dronabinol use was not associated with clinically signifi f cant drug interactions, although additive pharmacodynamic eff ffects are possible when it is coadministered with other agents hav a ing similar phy h siological eff ffects (e.g., sedatives, alcohol, and antihistamines may increase sedation; tricyclic antidepressants, stimulants, and sympathomimetics may a increase tachy h cardia).41 Additionally, y smoking cannabis may a Within the shift f ing legal landscape of medical cannabis, increase theophy h lline metabolism, as is also seen aft f er diff fferent methods of cannabis administration have smoking tobacco.40,42 important public health implications. A survey using data f om Qualtrics and Facebook showed that individuals in ADVERSE EFFECTS fr states with medical cannabis law a s had a signifi f cantly higher Much of what is known about the adverse eff ffects of likelihood of ever hav a ing used the substance with a history medicinal cannabis comes fr f om studies of recreational users of vaporizing marijuana (odds ratio [OR], 2.04; 99% of marijuana.43 Short-term use of cannabis has led to confifdence interval [CI], 1.62–2.58) and a history of oral impaired short-term memory; impaired motor administration of edible marijuana (OR, 1.78; 99% CI, coordination; altered judgment; and paranoia or psychosis 1.39–2.26) than those in states without such law a s. Longer at high doses.44 Longterm or heavy use of cannabis, duration of medical cannabis status and higher dispensary especially in individuals who begin using as adolescents, has density were also signifi f cantly associated with use of lead to addiction; altered brain development; cognitive vaporized and edible fo f rms of marijiuana. Medical cannabis impairment; poor educational outcomes (e.g., dropping out law a s are related to state-level patterns of utilization of of school); and diminished life f satisfa f ction.45 Long-term or 34 heav a y use of cannabis is also associated with chronic alternative methods of cannabis administration. bronchitis and an increased risk of chronic psychosis related DRUG INTERACTIONS health disorders, including schizophrenia and variants of Metabolic and pharmacody d namic interactions may a exist depression, in persons with a predisposition to such between medical cannabis and other pharmaceuticals. disorders.46–48 Va V scular conditions, including myocardial Quantifi f cation of the in vitro metabolism of exogenous infa f rction, stroke, and transient ischemic attack, hav a e also cannabinoids, including THC, CBD, and cannabinol (CBN), been associated with cannabis use.49–51 The use of cannabis indicates hepatic cytochrome 450 (CYP450) isoenzymes fo f r management of symptoms in neurodegenerative 2C9 and 3A4 play a signifi f cant role in the primary diseases, such as Parkinson’s, Alzheimer’s, and MS, has metabolism of THC and CBN, whereas 2C19 and 3A4 and provided data related to impaired cognition in these may a be responsible fo f r metabolism of CBD.40 individuals.52,53


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MEDICINAL CANNABIS: HISTORY, Y PHARMACOLOGY, Y AND IMPLICAT A IONS FOR THE ACUTE CARE SETTING Cannabis-based medications may a be usefu f l fo f r treating chemotherapy-induced nausea and vomiting that responds poorly to conv n entional antiemetics. However, the trials produced low to moderate quality evidence and reflfected chemotherapy agents and antiemetics that were av a ailable in the 1980s and 1990s. With regard to the management of neurological disorders, including epilepsy and MS, a Cochrane review of fo f ur clinical trials that included 48 epileptic patients using CBD as an adj d unct treatment to other antiepileptic medications concluded that there were no serious adverse eff ffects associated with CBD use but that no reliable conclusions on the eff fficacy and safe f ty of the therapy can be draw a n fr f om this limited evidence.57 The American Academy of Neurology (AAN) has issued a Summary of Systematic Reviews fo f r Clinicians that indicates oral cannabis extract is eff ffective fo f r reducing patient-reported spasticity scores and central pain or painfu f l spasms when used fo f r MS.58 THC is probably eff ffective fo f r reducing patient-reported spasticity scores but is likely ineff ffective fo f r reducing objective measures of spasticity at 15 weeks, the AAN f und; there is limited evidence to support the use of fo cannabis extracts fo f r treatment of Huntington’s disease, levodopa-induced dy d skinesias in patients with Parkinson’s disease, or reducing tic severity in To T urette’s.58 In older patients, medical cannabinoids hav a e shown no eff fficacy on dyskinesia, breathlessness, and chemotherapyinduced nausea and vomiting. Some evidence has shown that THC might be usefu f l in treatment of anorexia and behav a ioral symptoms in patients with dementia. The most common adverse events reported during cannabinoid treatment in older adults were sedation-like symptoms.59 Despite limited clinical evidence, a number of medical conditions and associated symptoms hav a e been approved by state legislatures as qualify f ing conditions fo f r medicinal cannabis use. TABLE 1 contains a summary of medicinal cannabis indications by state, including select disease states and qualify f ing debilitating medical conditions or symptoms.10,60,61 The most common conditions accepted by states that allow medicinal cannabis relate to relief of the symptoms of cancer, glaucoma, human immunodefifciency virus/acquired immunodefifciency syndrome, and MS.

A total of 28 states, the District of Columbia, Guam, and Puerto Rico now allow comprehensive public medical marijiuana and cannabis programs.10 The National Confe f rence of State Legislatures uses the f llowing criteria to determine if a program is fo comprehensive: f om criminal penalties fo f r using 1. Protection fr marijiuana fo f r a medical purpose; 2. Access to marijiuana through home cultivation, dispensaries, or some other system that is likely to be implemented; 3. Allows a variety of strains, including more than those labeled as “low THC;” and 4. Allows either smoking or vaporization of some kind of marijiuana products, plant material, or extract. Some of the most common policy questions regarding medical cannabis now include how to regulate its recommendation and indications fo f r use; dispensing, including quality and standardization of cultivars or strains, labeling, packaging, and role of the pharmacist or health care profe f ssional in education or administration; and registration of approved patients and providers.


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MEDICINAL CANNABIS: HISTORY, Y PHARMACOLOGY, Y AND IMPLICAT A IONS FOR THE ACUTE CARE SETTING In 2009, U.S. At A torney General Eric Holder recommended that enfo f rcement of fe f deral marijiuana law a s not be a priority in states that hav a e enacted medicinal cannabis programs and are enfo f rcing the rules and regulations of such a program; despite this, concerns persist. The argument fo f r or against the use of medicinal cannabis in the acute care setting encompasses both legal and ethical considerations, with the argument against use perhaps seeming obvious on its surfa f ce. States adopting medical cannabis law a s may a advise patients to utilize the therapy only in their own residence and not to transport the substances unless absolutely necessary. y 66 Further,r many acute care institutions hav a e policies prohibiting smoking on f cility grounds, thus restricting the smoking of cannabis, fa regardless of purpose or indication. Of note, several Canadian hospitals, including Montreal’s Jewish General Hospital and Quebec’s Centre Hospitalier U Universitaire de Sherbrooke, hav a e permitted inpatient cannabis use via vaporization; the pharmacy departments of the respective institutions control and dispense cannabis much like opioids fo f r pain. Canada has adopted national regulations to control and standardize dried cannabis fo f r medical use.67,68 There are complicated logistics ffor selff administration of medicinal cannabis by the patient or caregiver; in particular, many hospitals have policies on selff administration of medicines that permit patients to use their own medications only aft f er identififcation and labeling by pharmacy personnel. The argument can be made that an herb- or plant-based entity cannot be identifi f ed by pharmacy personnel as is commonly done ffor traditional medicines, although medicinal cannabis dispensed through state programs must be labeled in accordance with state a s. law

The therapy cannot be prescribed, and states may a require phy h sicians authorizing patient use to be registered with local programs. In a transition into the acute care setting fr f om the community setting, a diff fferent clinician who is not registered could be responsible fo f r the patient’s care; that clinician would be restricted in ordering continuation of therapy. y Despite the complexities in the logistics of continuing medicinal cannabis in the acute care setting, proponents of palliative care and continuity of care argue that prohibiting medicinal cannabis use disrupts treatment of chronic and debilitating medical conditions. Patients hav a e been denied this therapy during acute care hospitalizations fo f r reasons 69 stated above. Permission to use medicinal cannabis in the acute care setting may a be dependent on state legislation and restrictions imposed by such law a s. Legislation in Minnesota, as one example, has been amended to permit hospitals as f cilities that can dispense and control cannabis use; similar fa legislative actions protecting nurses fr f om criminal, civil, or disciplinary action when administering medical cannabis to qualififed patients hav a e been enacted in Connecticut and Maine.70–73 Proposed legislation to remove restrictions on the certififcation of patients to receive medicinal cannabis by doctors at the Department of Ve V terans Aff ffairs was struck down in June; prohibitions continue on the use of this therapy even in fa f cilities located in states permitting medicinal cannabis use.74

Dispensing and storage concerns, including an evaluation of where and how this product should be stored (e.g., within the pharmacy department and treated as a controlled substance, by security personnel, or with the patient); who should administer it, and implications or violations of f deral law by those administering treatment; what fe pharmaceutical preparations should be permitted (e.g., smoked, vaporized, edible); and how it should be charted in the medical record represent other logistical concerns. Inpatient use of medicinal cannabis also carries implications fo f r nursing and medical staff f members.


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MEDICINAL CANNABIS: HISTORY, Y PHARMACOLOGY, Y AND IMPLICAT A IONS FOR THE ACUTE CARE SETTING 11. Food and Drug Administration. FDA D and marijuana. July 7, 2016. Av A ailable at: www. w fd f E ents/PublicHealthFocus/ ucm421163.htm. Accessed August 5, 2016. 12. Throckmorton DC. FDA work on medical products containing marijiuana. Food and Drug Administration. March 2015. Av A ailable at: www. w fd f ffices/Off fficeof -MedicalProductsandTo T bacco/CDER/UCM438966.pdf.f Accessed August 5, 2016. 13. Bennett C. Early/ancient history. y In: Holland J, ed. T e Pot Book: A Comp Th m lete t Guide to Cannabis. Rochester,r Ve V rmont: Park Street Press; 2010. 14. Zias J, Stark H, Sellgman J, et al. Early medical use of cannabis. Na N ture r 1993;363:215. 15. Malmo-Levine D. Recent history. y In: Holland J, ed. T e Pot Book: A Comp Th m lete t Guide to Cannabis. Rochester,r Ve V rmont: Park Street Press; 2010. 16. Musto DF. F The Marihuana Ta T x Act of 1937. Arc r h Gen Ps Psychiatry r 1972;26:101–108. 17. Giancaspro GI, Kim N-C, Ve V nema J, et al. The advisability and fe f asibility of developing USP standards f r medical cannabis. U.S. Pharmacopeial Conv fo n ention. A ailable at: Av www. w f ult/fifles/usp_pdf/ f EN/USPNF/usp-nf notices/usp_stim_article_ medical_cannabis.pdf.f Accessed August 5, 2016. 18. Cameron JM, Dillinger RJ. Narcotic Control Act. In: Kleiman MAR, Haw a don JE, eds. Ency c clop o edia of o Drug u Policy cy. Thousand Oaks, Califo f rnia: SAGE Publications, Inc.; 2011:543–545. 19. State marijiuana law a s in 2016 map. Governing ng. November 11, 2016. Av A ailable at: www. w a smap-medical-recreational.html. Accessed November 29, 2016. 20. Sidney S. Comparing cannabis with tobacco–again. BMJ M .2003;327:635–636.

21. Norml. Ab A out marijuana. A ailable at: Av Accessed August 9, 2016. 22. Clark PA P , Capuzzi K, Fick C. Medical marijuana: medical necessity versus political agenda. M d Sci Mo Me M nit 2011;17:RA249–RA261. 23. National Institute on Drug Ab A use. Drug fa f cts: is marijuana medicine? July 2015. Av A ailable at: www. w f cts/marijuanamedicine. Accessed February 11, 2016. 24. Should marijiuana be a medical option? December 28, 2016. Av A ailable at: Accessed February 11, 2016. 25. MacDonald K, Pappas K. Why h not pot? Innov Clin Ne N urosci 2016;13:13–22.


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MEDICINAL CANNABIS: HISTORY, Y PHARMACOLOGY, Y AND IMPLICAT A IONS FOR THE ACUTE CARE SETTING 47. Blanco C, Hasin DS,Wa W ll MM, et al. Cannabis use and risk of psychiatric disorders: prospective evidence fr f om a U.S. national longitudinal study dy. J MA JA M Ps Psychiatry r 2016;73:388–395. 48. de Graaf R, Radovanovic M, van Laar M, et al. Early cannabis use and estimated risk of later onset of depression spells: Epidemiologic evidence fr f om the population-based W rld Health Organization Wo Wo W rld Mental Health Survey Initiative. Am J Ep E idemiol 2010;172:149–159. 49. Hackam DG. Cannabis and stroke: systematic appraisal of case reports. Stroke 2015;46:852–856. 50. Barber PA P , Pridmore HM, Krishnamurthy h V, V et al. Cannabis, ischemic stroke, and transient ischemic attack: a case-control study. y Stroke 2013;44:2327–2329. 51. Barber PA P , Roberts S, Spriggs DA, et al. Adverse cardiovascular, cerebrovascular, and peripheral vascular eff ffects of marijiuana: what cardiologists need to know. w Am J Card r iol 2014;113:1086. 52. Karila L, Roux P, P Rolland B, et al. Acute and long-term eff ffects of cannabis use: a review. w Curr Pharm Des 2014;20:4112–4118. 53. Tu T rcotte D, Le Dorze JA, Esfa f hani F, F et al. Examining the roles of cannabinoids in pain and other therapeutic indications: a review. w Expert Op Ex O in Pharmacoth t er 2010;11:17–31. 54. Wa W ng T, T Collet JP, P Shapiro S, Wa W re MA. Adverse eff ffects of medical cannabinoids: a systematic review. w CMAJ 2008;178:1669–1678. CM

58. American Academy of Neurology. y Eff fficacy and safe f ty of the therapeutic use of medical marijiuana (cannabis) in selected neurologic disorders. Av A ailable at: www. w Accessed Au A gust 16, 2016. 59. van den Elsen GA, Ahmed AI, Lammers M, et al. Eff fficacy and safe f ty of medical cannabinoids in older subjects: a systematic review. w Age g ing n Res Rev 2014;14:56– 64. 60. Marijiuana Policy Project. State-by-state medical marijiuana law a s 2015. Av A ailable at: www. w statemedical-marijuana-law a s/state-by-state-medicalmarijiuanalaw a s- report. Accessed August 10, 2016. 61. 25 legal medical marijiuana states and DC: law a s, fe f es, and possession limits. Av A ailable at: w resource.php?re sourceID=000881#DC. Accessed Au A gust 10, 2016. 62. Cole JM. Guidance regarding marijiuana enfo f rcement. August 29, 2013. w A ailable at: www. Av 3052013829132756857467.pdf.f Accessed Au A gust 8, 2016. 63. DEA Diversion Control Division. DEA Form 225— New application fo f r registration. Av A ailable at: www. w t.htm. Accessed Au A gust 10, 2016.

55. Ly L nch ME, Campbell F. F Cannabinoids fo f r treatment of chronic noncancer pain: a systematic review of randomized trials. Br J Clin Pharmacol 2011;72:735–744. 56. Smith LA, Azariah F, F Lav a ender VTC, et al. Cannabinoids f r nausea and vomiting in adults with cancer receiving fo chemotherapy. y Cochrane Database Sy Syst Rev 2015 Nov 12;(11):CD009464. 57. Gloss D, Vickrey B. Cannabinoids fo f r epilepsy. y Cochrane Database Sy Syst Rev 2014 Mar 5;(3):CD009270.


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Cannabis Tourism


Longtime marijuana advocate Neev Tapiero is ready for the cannabis-driven tourists to come, and he has not waited for legalization to roll out the welcome mat. The former dispensary owner anticipates an influx of visitors eager to try Canadian weed, and is already courting foreign travellers through his Toronto-based tour company Canadian Kush Tours.


ut while he prep e ares to hit the ground

Charlotte Bell, president of the To T urism Industry

running ng, he say ays he's ' disap appointe t d by b a lack

Association of Canada, points to a lack of clarity fr f om

o sup of upport fr f om go g vernment to back

f deral, provincial and municipal governments on fe

entre repre r neurs r like him:

what will and will not be allowed, and the likelihood

" eally "R l none of o th t e inf nfrastructure r is pre repare r d fo f r

that what is already known could very well be undone

leg egaliz i ation in te t rms of o th t ing ngs like hote t ls l (a ( nd) d

by upcoming provincial elections.

park r s." She notes that Ontario just reversed course on a plan to E actly Ex l how th t e to t urism industry r could be re reshap a ed

sell cannabis under its liquor control board when a

b leg by egal weed is still very r hazy z fo f r many n hop o ing n to t

June election turned the province To T ry blue fr f om

cap a italize

Liberal red. The province said that it now plans to




gre r en-f -focused ge g ta t way ays.

o of


oversee online sales to allow private retail. • CANNABIS JOURNAL OF MEDICINE

Neev Ta Tapiero r is photo tograp a hed in T ro To r nto t.

CANNABIS Journal of Medicine

Cannabis Tourism

HOW THE TOURISM INDUSTRY COULD BE RESHAPED BY LEGAL WEED Online-only sales would almost certainly quash the ambitions of some imaginative tour operators env n isioning winery-style tastings at grow fa f rms and 4:20 "happy hours" in a hotel lounge. Bell's organization -- whose members include attractions, concert halls, conv n ention centres, f stivals, restaurants, arenas, transportation fe and travel services -- say a s the prospect of pot-driven tourists will be discussed at an upcoming congress. "There will defi f nitely be opportunities," is pretty much all she fe f els comfo f rtable say a ing now. w "It's still early day a s." Uncertainty over weed is especially high in the U hospitality world, where a myriad of regulations on related sectors could make-or-break their pot potential. Bell notes that rules vary widely across the country on where cannabis can be sold, with some municipalities taking a harder line than others. The ski town of Whistler, B.C., has notably banned retail fr f om its picturesque, chalet-dotted community, y with Mayor Nancy Wilhelm-Morden explaining: "Whistler is prioritizing health, safe f ty and the resort experience in developing and considering its regulations related to recreational cannabis." "If the municipality decides to permit retail, it will do so with adequate public input and time to consider the best approach to regulating retail," she adds in a statement. Back in Ontario, To T ny n Elenis, president and CEO of the Ontario Restaurant Hotel and Motel Association, wants clarity on whether a trav a eller would be able to smoke cannabis in the province's hotel rooms, as recently greenlit by Prince Edward Island.


Ontario's previous Liberal government quietly allowed f r the consumption of cannabis in a guest room of a fo hotel, motel or inn under certain conditions, but it's unclear if that, too, will be undone by the new To T ry government. Businesses in both provinces would still have to abide by their respective smoke-fr f ee laws, and since demand f r smoking rooms is generally on the decline, Elenis fo doesn't expect it to be off ffset by legal pot-smoking. Given the uncertainties, he doubts much will change once legalization hits: "It's not as wild and fr f ee as it may a sound to be." Canadians are already welcoming weed-smoking tourists by renting their homes through the Airbnblike website, budandbreakfa f The site's CEO and fo f under Sean Roby estimates that about 30 Canucks advertise on the site and that the number will grow. w

CANNABIS Journal of Medicine

CAPITA T LIZE ON PROVIDING GREEN-FOCUSED GETWA WAYS "A guest who comes here and decides to a have a beer with their lunch befo f re their golf game is no diff fferent than a person who says, 'Oh, I'm hoping there's a place where I can light up befo f re my golf game.' There's no reason why h one of them should be treated any n diff fferently, y " he say a s, of the dilemma he's grappling with. While many n outlets suggest they are taking a wait-and-see approach, others fe f el pressure to be fifrst out of the gate. Natalie Koshowski, the spa director at Ste. Anne's Spa east of To T ronto, say a s the luxury retreat wants to off ffer a massage and aromatherapy treatment infused with "hemp CBD" in the coming weeks, as well as But the more restrictions there are around cannabis, sell balms, oils and body butters containing the less likely cannabis-driven tourism can thrive, he cannabidiol. suggests, noting "the whole point is cannabis." She say a s they can pre-empt the legislation because the "If a place is listed on our site as a bud-and-breakfa f st products derive CBD fr f om the same type and part of and they say: 'Oh, we're fi f ne with you smoking the cannabis plant that makes hemp rather than bud, cannabis and there's a dispensary down the way ay,' ... which results in products that contain no THC or they'll get booked out every now and then," Roby says tetrahy h drocannabinol, the psychoactive ingredient in f om Boulder, Colo. fr cannabis. "But if a place says: 'We W are all-inclusive (and) we have a cannabis yo y ga class, we have a CBD-infu f sed meal, we have a 4:20-happy hour that has a bud bar, the whole thing -- they're booked out fo f r six months in advance, every day. y "' For Jesse Hamilton, the general manager of the Deerhurst Resort in Ontario's Muskoka region, more practical concerns loom large: How to accommodate recreational users while still respecting non-smokers? "How diff fferently can you treat a cannabis smoker than a tobacco smoker?" asks Hamilton, whose resort currently bans smoking in all rooms, patios and trails.

Tapiero, who previously challenged the laws with his T f rmer dispensary CALM, is reluctant to wait too long fo befo f re legalization hits. His early clients include a bachelor party fr f om South Carolina and Te T xas, and a solo traveller fr f om Te T xas who recently came into town fo f r a Radiohead concert. Tapiero hopes more will be clear by the time April 19 T rolls around, lest the potential fo f r pot tourism dies befo f re it even begins. " could see trave "I v llers r coming n to Canada being n totally l unsure r of of: Can I consume it? W ere Wh r can I consume it?" • CANNABIS JOURNAL OF MEDICINE

Cannabis Tourism




By Larry Banegas,

The report “World Analgesics Market - Opportunities and Forecasts, 2015-2022” projects that the world analgesics market would reach $26.4 billion by 20221. Pain suff fferers have long regarded plant botanicals as a source of healing; there are more than 100 plants known to have pain relieving properties2. Consumers have sought retail brands of topical pain relief with menthol as an active ingredient3. There is a “new” botanical that consumers need to be aware a of for pain relief:f cannabidiol.

In a study published by the National Institutes of Health4, it is stated that, “The nonpsychoactive cannabinoid, cannabidiol (CBD), has great potential fo f r the treatment of chronic and 'breakthrough’ pain..” The study also states, “Chronic pain relief can be best achieved through the transdermal route.” Today, the Un U ited States fa f ces a health epidemic: prescription opioid addiction. To T address this problem, manufa f cturers are producing a new topical combination of CBD with menthol. These non-habit for f ming ingredients are a welcome solution fo f r consumers who do not wish to pursue prescription opioid pain medications or are looking fo f r an alternative to prescription pain medicine. n is that CBD is anything but “new”. CBD is a naturally occurring component of the hemp plant. Hemp is The irony from the cannabis genus and cannabis fo f r medicinal use dates back to the ancient Chinese emperor, Shen-Nung (c.2700 B.C.). Having compiled the medical encyclopedia called, Pen Ts T 'ao,5 Shen-Nung is regarded as the Father of

Chinese Medicine. Cannabis or“Ma”was used by the Chinese to treat weaknesses (menstruation), gout, rheumatism, malaria, beri-beri, constipation, and absentmindedness. During the second century A.D., the Chinese surgeon, Hua T'o, began to use cannabis as an anesthesia.

a a role in antinociception, CBD is activated in the body through CB2 receptors located in the skin. CB2 receptors play or the relief of pain.6 Menthol is a known active ingredient with cooling properties. Working similar to ice, menthol

binds with temperature-sensitive receptors in the skin and is thought to modulate pain signals within the body’s natural pain relieving systems. CBD, known to be hydrophobi h c and lipophilic, does not dissolve or emulsify f readily in water, but will dissolve in fa f t. Bioavailability of CBD depends on the way a that the cannabinoid is delivered into the human body. Today, a science has enabled CBD to be water soluble as well as time-release.

The new topical pain cream, RapidCBD™, delivers a powerful combination of micro-encapsulated time-released CBD called Cebidiol™. In Cebidiol™, consumers will benefift fro f m menthol plus eight additional homeopathic ingredients including lavender and rosemary essential oils to relieve pain. The RapidCBD™ Cooling Pain Cream is ideal after strenuous activity and has been proven to be as eff ffective and work as fa f st as an FDA approved OTC topical pain relief solution. The immediate availabilit a y of RapidCBD™ is welcome news fo f r consumers who are seeking a non-opioid solution fo f r muscle aches, strains and joint pain. 1 -http t :/://www. w m/news-relea r ses/ s/analgesics-market-is-exp x ected-to t -reac r h-264 6 -billion-glo g bally l -by b -202 0 2-57568892 9 1.html 2 -http t :/://www. w motherearthliving. g com/ m/health t -and-wellness/ s th t e-best-herbs-f -forr-pain-relief r f asp s x 3 -http t :/://health t / ealth t -p - roducts ts/top-re r c-topica t l-analgesics-arthritis-j - oint-p - ain-135 4 -http t :/://www. w ncbi.nlm.nih.go g v/ v/pubmed/ d/20545522 5 -http t s:/://www. w psychologytoday m/blog og/the-te t enage g -mind/ d/201105/ 5/history r -cannabis-in-ancient-china 6 -http t s:/://en.wikip i rg/wiki/i/Cannabinoid_receptor r


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CANNABIS Journal of Medicine  

MEDICINAL CANNABIS-History, Pharmacology, and Implications for the Acute Care Setting _THE MEDICINAL CANNABIS DEBATE

CANNABIS Journal of Medicine  

MEDICINAL CANNABIS-History, Pharmacology, and Implications for the Acute Care Setting _THE MEDICINAL CANNABIS DEBATE