Medicinal Cannabis

August 29, 2009

Patient Experience with Cannabis Use & Side Effects – check blood pressure & pulse

Don’t forget to check blood pressure and pulse before and after each dose

Please add your comments at end – they will be kept confidential – and check back later as more patient experiences and comments are added.

I understand that tolerance develops to the psychoactive side effects. It would help to hear from others. If that is true, how long does it take?

The potential for pain and symptom management:

1. CBD causes no psychoactive symptoms and is much more helpful for symptom relief. We need more help finding clones using GC/MS assay. Any leads?

2. Cannabis may be an affordable alternative to FDA approved medications

3. Partial opioid substitution may help to relieve cumulative side effects of the opioid such as daytime sleepiness.

4. Substituting cannabis instead of an opioid at bedtime or at least part of the 24 hour day, will lower the 24 hour dose of opioid.

5. Cannabis may be better than the opioid both for relieving pain and insomnia.

6. Opioids create pain and relieve pain. Using less opioid may be an advantage.

7. Opioids may cause central apnea in sleep. That is untreatable and interferes with the ability to treat obstructive sleep apnea which increases risk of stroke, heart attack, weight gain, and daytime sleepiness due to sleep apnea.


Patient DJ:

Patient with progressive painful peripheral neuropathy, now no longer relieved for several months by opioid prescription and too sedated at a dose that partially relieves pain. Unable to wear closed shoes due to pain. If dose is not taken every 6 hours, side effects of nausea and “icky feeling” are intolerable.  Must set alarm to waken for dose or be very uncomfortable for hours after waking. At the very least, the hope is that the patient may be able at the very least to use cannabis at bedtime and accomplish above goals# 3 ,4, 5 and 6, and avoid developing #7.

–Tried cannabis in a sublingual glycerin liquid using one eye dropper full.  Felt 100% relief of opioid withdrawal symptoms in a few minutes lasting about 3 or 4 hours but only 1 point decrease in pain level.

–Next day, used a vaporizer with digital read out. Initially set temperature higher than 300 degrees Fahrenheit, used Cannabis Sativa, not moist but not dry

Took the first 8 to 10 puffs. The first puff was deep, “really sucked it in” and felt burning in lungs and “coughing like crazy”

Changed technique to breathe in very slowly in small amounts, very little with each puff. No burning or coughing.

At 11:50 AM, before the vapor, blood pressure was 142/60; after use, blood pressure 108/51, pulse unchanged 72 before and 70 after.

5 or 10 minutes after vapor used, pain dropped from 6 to 3; and two hours later, pain in feet was rated 4 to 5/10, other areas of pain rated 3 or 4 — slowly creeping back up. It also relieved opioid withdrawal that has occurred in recent months: icky feeling with nausea that goes away after dose of opioid.

Side effects: felt light headed, loopy continuing at 1:45 PM when blood pressure 129/60, still loopy, still a little light headed though the side effects were 50% better.


Patient MR

Patient with multilevel bilateral cervical radiculopathy (pinched nerves from disc disease in neck at several levels, nerve pain, muscle spasm). Pain interferes severely with falling asleep and staying asleep. Loss of sleep leads to more pain, irritability, difficulty concentrating, relating to others and working.

Vaporizer is easy. It takes about 3 to 5 minutes to start to relieve pain. It starts by almost dulling the sharp pain, then settles in for a reduction from 7 or 8 to a 4 on scale of 10. I really think it halves it. Relief lasting about 2 hours for a level of 4, then creeps up slowly over the next 4 hours until it is back to original level. 6 hours of some kind of relief is very interesting.

Pulse went up a bit right after but settled back in 10 minutes from 80 to 96 and then back to 80 or lower! Blood pressure before 148/100, after (still taking Norvasc) 126/78.

Finding the right strain is an adventure in personality analysis – a few of the collectives seem knowledegable, and a few more haven’t got a clue. I’ve tried a glycerin tincture. I am not sure it works well. I am pretty sure it is the specific tincture I bought. Having some experience with making herbal tinctures, I don’t think it was prepared for maximum effect. I am still checking out the collectives. All are not alike by any means, and my search for ones with some solid advice is ongoing. So far the collective we discussed at our meeting is so far the most informative I’ve found.

High percentage Indica is definitely soporific and not suitable for day use. I am still trying to find the best combo. Am working with 1/2 brownie and one vapor inhale.

The temp for the vaporizer is critical. We need to clarify Celsius or Fahrenheit – according to the  San Fransisco General people  aroung 170 – 190 C is the point where volatile compounds vaporize. CBD a little lower. That works out to 338 Fahrenheit. At that point my medical marijuana starts to scorch. When set to 312, it vaporizes without smoke. I tried lower settings and got some vapor going but it didn’t seem as effective as the higher temp (312 F).

The sleep comes only with a real focus on calming my mind. No question the stuff accesses parts of the brain that normally are in background mode. It is nothing of concern, but it helps to try meditation techniques the were not really possible with straight opioid therapy, quieting techniques. The vapor kicks in very quickly; the brownie, very slowly, but for nights when I just can’t stay asleep, the combo does seem to give me a few hours uninterrupted sleep, a vast improvement.

I haven’t found a good daytime strain that doesn’t give me a buzz at therapeutic levels, but I am told by a number of people to keep trying different strains.

Good choice of bud for me to help to sleep: Grand Daddy Purple or Green Kush.

A few herbalists I know said they consider the “freezing alcohol”  method of extraction to be the gold standard, but it does have the drawback of alcohol. They claim the number of cannabinoids leached is greater with this method than with the glycerin method. It also limits the time for organic changes in the marijuana – a few days versus multiple weeks with the glycerin. They all believe in utilizing all the cannabinoids for most effective.

Sativa and Indica have been so crossbred that a pure Sativa is almost mythical around here. The high CBD content strain is called “White Widow” and is not available in its clean form, but bred with “Train Wreck” to become, attractively, “Brain Wreck”. Such creativity is wasted on youth.

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The material on this site is for informational purposes only, and

is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.~

August 20, 2009

Adverse Effects, Preparation, Dosing, Contraindications

In the Summer 2009 edition of  O’Shaughnessy’s, the Journal of Cannabis in Clinical Practice, edited by Fred Gardner,  is a review by Frank Lucido, MD, of a book that I have ordered.  I just need to time to read.

Marijuana Medical Handbook by Dale Gieringer PhD, Ed Rosenthal, and Gregory T. Carter MD; Quick American, Oakland, 2008; 257 pages (paperback); $19.95

I found the review to be very helpful and want to simply mention a small section of it below.

But first, and NOT in the review, though perhaps it is in the book, it is difficult to find mention of contraindications in the literature. I list them here.

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Contraindications

Ischemic heart disease or low blood pressure are contraindications to use. Cannabis may lower blood pressure 10 or 20 points and increase heart rate as much as 50 to 60 points according to one protocol that tested it for postoperative pain. This is dose related. If your blood pressure is already as low as 100 or 105, it may drop your blood pressure too low for safe use.

One patient on a higher dose developed a profound vasovagal reaction with severe slowing of the heart rate and blood pressure that ended the study. Again, that is dose related.

Immunosuppressed patients may be wise to avoid smoking it or risk infection with Aspergillus which is a fungus that may affect lungs or sinuses.  The spores are in the air; using filters in growing rooms should prevent it from growing. Large collectives may use forensic microscopes to examine their harvest and they avoid package in cellophane which can cause formaldehyde to form.

To avoid risk of Aspergillus, you may use cannabis under your tongue, swallow it or use it topically in an ointment.

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Returning now to advice from the book and review by Dr. Frank Lucido:

Adverse Effects

Providing the pros and cons, as any good clinician should, the authors devote a chapter to “real and imaginary” side effects. Allergic reactions, though rare, are real and can manifest as rapid heartbeat, faintness/fainting, twitches, numbness, headaches and rashes. “If you regularly experience discomforting reactions from marijuana, the best treatment is to avoid it,” the authors wisely advise.

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Preparation and Dosage Methods

Delivery systems available to medical marijuana users include smoking, vaporization, tinctures, edibles, and topicals. Edibles typically take 45-60 minutes to come on, but their effects can last six to eight hours. One question frequently asked by patients who are new to using marijuana as medicine concerns the difference between smoking and ingesting via edibles. The handbook explains: “Anything absorbed through the stomach is processed by the liver before it reaches the brain. In the liver, THC is converted to 11-hydroxy-THC, a metabolite that is if anything more psychoactive than ordinary THC. Because 11-hydroxy-THC is not produced when marijuana is smoked, eating and smoking produce different pharmacological effects. “Some people regulate their conditons by eating small amounts of marijuana on a regular basis, sometimes just once or twice a day. They barely feel any effect from the drug except for the relief of their symptoms.

“The major drawback of ingesting marijuana is that the effective dose can be difficult to predict.”

The review is excellent and I need this book.

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For my own patients with complex medical conditions, I recommend they pay attention to the details in the last section.  I am advising that they avoid swallowing the drug, and consider the potential interactions with multiple medications they use for their medical conditions. Once Sativex is available, or once clones with CBD content become available, there will be fewer psychotropic side effects such as euphoria. I refer you to O’Shaughnessy’s for Fred Gardner’s exciting report 3-31-09 on cannabidiol (CBD).  “CBD is the nonpsychoactive cannabis constituent that is “an oral anti-arthritic therapeutic in murine collagen-induced arthritis.” See also research mentioned on this blog by GW Pharmaceuticals that has found it to be more easily tolerated and more effective than THC for neuropathic pain, for spasticity of Multiple Sclerosis, and other conditions. GW Pharmaceuticals’ product Sativex is a 50:50 mixture of THC and CBD, which they are bringing to market. It is an oral spray now used in 20 countries.

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Pharmacokinetics:  In a 2003 review by Franjo Grotenhermen, onset of effect varies with route used. Higher bioavailability may be obtained in an oral matrix such as sesame oil. Absorption may be 95% in an oil vehicle, and still as high as 90 to 95 % in a water based cherry vehicle. But ingesting THC 20 mg in a chocolate cookie or dronabinol 10 mg results in very low bioavailability of 6% to 7% with a range of 2% to 14%, and high inter-individual variation.

With oral ingestion, absorption is slow and erratic, onset of effect may be delayed 30 to 90 or even 120 minutes, reach a peak in 2 to 3 hours or even 6 hours in some cases —  “Several subjects showed more than one plasma peak” — and last 4 to 12 hours depending on dose. In the meantime, you may have eaten much more, and it may be too late to discover 6 hours later that you have overdosed.  When it is eaten, the effect is longer. I fear the first time you try ingesting it, you may use too much. Who doesn’t love brownies?

With inhalation, the maximum plasma concentration occurs in minutes, effects start in seconds to minutes, reach maximum after 15 to 30 minutes and taper off in 2 to 3 hours.

Using a liquid form under the tongue is likely to be similar to inhalation with the rate of onset and duration of effect, i.e. faster onset and shorter duration depending upon the dose.

If you are new to using it, then start with a low dose and increase slowly. Avoid ingesting brownies or cookies or tea until you have established a comfort zone with your use and get a sense of how your system is responding to that mixture. Watch for the psychotropic side effects that are worse when ingesting the drug.

If you are working with a psychiatrist or psychologist for panic attacks and depression, it would be helpful to include that specialist in your plans and limit your dose until you are comfortable with use. It may relieve depression and anxiety, give a sense of relaxation and well being, but overdose may cause panic, with rapid pulse and lower blood pressure.

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Heavy regular use may lead to dependency  – being dependent is not the same as being addicted – and withdrawal may cause side effects lasting 10 to 14 days in some, but it is not as severe as from opioids or alcohol.

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Acute overdose may result in panic attacks or anxiety, rapid heart rate, low blood pressure. So the rule is to start a low dose and go slowly. This is not a race.

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The material on this site is for informational purposes only, and

is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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