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CANNABIS

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Qualifying Exam Preparatory Course

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COVERED IN THIS PRESENTATION…

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Ethical, Legal and

Product
Professional Patient Care
care
Distribution
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Responsibilities
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Knowledge and
Practice Setting Health Promotion Research
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Application

Intra and Inter-

Communication
Professional Quality and Safety
and Education
Collaboration

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 LEGEND
CB Cannabinoid Receptor LGS Lennox-Gastaut Syndrome

NHP Natural Health Product

CBD Cannabidiol
NT Neurotransmitters
CINV Chemotherapy-Induced Nausea and Vomiting
PTSD Post-traumatic Stress Disorder

4)
CNS Central Nervous System
PD Pharmacodynamics

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COPD Chronic Obstructive Pulmonary Disease
PK
Pharmacokinetics
CYP Cytochrome P450

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SCI
Spinal Cord Injury
D/C Discontinued

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THC Δ9-Tetrahydrocannabinol
DIN Drug Identification Number

TSC Tuberous Sclerosis Complex

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DS Dravet Syndrome

HR Heart Rate UGT Uridine 5’-Diphospho-Glucuronosyltransferase

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AN INTRODUCTION TO CANNABIS
Jo

• Genus of flowering plants with various species (Cannabis sativa, indica,

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ruderalis), routes of administration, formulations and effects when used

• Marijuana is a psychoactive drug made from the cannabis plant
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Cannabis exerts its effects through compounds called cannabinoids, which

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interact with the endocannabinoid system via cannabinoid receptors

• Most common cannabinoids:
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Sativa
• Δ-9-tetrahydrocannabinol (THC): partial agonist to CB1 and CB2
• Cannabidiol (CBD): indirect CB activity
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• Different cannabis plants have different ratios of CBD and THC

Indica

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 HOW DOES CANNABIS AFFECT THE BODY AND MIND?
Cannabinoid
CB1 receptor CB2 receptor
• Mainly in CNS • On immune cells
• Modulates NT release Neuron • Regulates inflammation
• Affect memory, mood, and immune responses
appetite and pain perception Immune cell

4)
once active

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CBD combined with THC contributes to the entourage effect CB
What about CBD?

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• Lessening negative psychoactive effects (e.g. anxiety, 1.
• It acts as a negative allosteric paranoia, sedation) of THC •
• Enhancing analgesic effects (e.g. anti-inflammatory, pain

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modulator at CB1 receptor (minimal
direct binding) relief) 2.
•

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•
❑ THC  psychoactive (e.g. euphoria, altered perception), analgesia, appetite stimulation
Key
❑ CBD  anti-inflammatory, anticonvulsant, anxiolytic
effects Key
❑ THC + CBD  pain reduction, nausea relief, reduction in muscle spasms
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❑C
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SPECTRUM OF CANNABIS EFFECTS

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Neurological Respiratory
Musculoskeletal
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• Acute: sedation, cognitive • Acute: smoking

• Acute: analgesic effects
impairment, mood enhancement, cannabis is cytotoxic
in acute injuries
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• Long-term: dependency, memory • Long-term: chronic bronchitis,

• Long-term: unknown
impairment, tolerance increased airway resistance
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Psychiatric
Gastrointestinal Reproductive
• Acute: panic attacks,
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• Acute: appetite • Acute: decreased

potential psychosis
stimulation, dry mouth, sperm motility
• Long-term: cannabis use
antiemetic effects • Long-term: irregular menstrual
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disorder, early schizophrenia

• Long-term: unknown cycles, fetal growth restriction
in patients at risk

Endocrine
Ocular
Cardiovascular • Acute: metabolic hormone
• Acute: decreased
• Acute: increased HR, modulation (e.g. increases
intraocular pressure,
blood pressure changes ghrelin
dry eyes, red eyes
eptors • Long-term: tachyarrhythmias • Long-term: altered glycemic
• Long-term: unknown
ceptors control in diabetic patients
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 RESTRICTIONS TO CANNABIS USE
Recommend AGAINST USE of medical cannabinoids for most conditions due to lack of evidence
of benefit and known harms (Strong)*
*Exceptions to the recommendation are on slide 11

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Not recommended/ Contraindications in patients with:

❑ Special populations: pregnancy/ planning pregnancy, breastfeeding, elderly, youth

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❑ Psychiatric disorders: anxiety, PTSD, insomnia, psychotic disorders, schizophrenia,
bipolar disorder, personal or family history of psychosis

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❑ Cardiovascular disease (past event or risk factors)
❑ Respiratory comorbidities (use of dried and smoked cannabis)

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❑ Personal or family history of substance use disorder
❑ Concurrent use of cannabis with other substances (e.g alcohol, tobacco)

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❑ Cannabis use and driving

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ROUTES OF ADMINISTRATION AND THC COMPARISON

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Features Smoking Vaporized Oral consumption

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THC Bioavailability 2- 56% 4-12%

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Onset Almost immediately up to 30 minutes Delayed, 0.5-4 hours

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Peak plasma
6-10 minutes post-inhalation 2-6 hours
concentration
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Duration of
2-4 hours 2-3 hours 4-24 hours
psychoactive effects
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• Highest extraction • Decreased

efficiency bioavailability due to
• Combustion is
• Absent combustion first-pass hepatic
Other comments carcinogenic and causes
• Maximizes metabolism
a loss of cannabinoids
cannabinoids • Erratic/ unpredictable
• No first pass absorption
metabolism • Overdose risk

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 RECOMMENDATIONS FOR NEW NON-MEDICAL CANNABIS USERS

Disclaimer Inhaled use Oral consumption

• PK: start low and go slow • To minimize risk, start with • To reduce risk, start with
products containing ≤10% THC products containing ≤2.5 mg
• PD: variability in CB (100 mg/g) and equal or higher THC

4)
receptors, cannabinoid CBD content
metabolism, prior • Health Canada advises waiting

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exposure (tolerance) • Health Canada advises waiting 30 up to 4 hours before taking
minutes between inhalations to more due to delayed effects and
• Drug factors: plant strain, minimize adverse effects potential risks

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potency, route of
administration • Products with over 20% THC • Use extra caution with cannabis

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(200 mg/g) increase the risk of products containing ≤10mg of
serious adverse effects THC

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GUIDELINE-BASED ALGORITHM FOR MEDICAL CANNABINOID USE

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D
Does the patient have:
Clinical Guidelines •
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• Neuropathic pain
No College of Family Physicians for Management of •
• Palliative cancer pain
of Canada (CFPA) Epilepsy •
• Spasticity from multiple sclerosis or
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recommends against use

spinal cord injury
Suggests •
• Chemotherapy-induced nausea/vomiting
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No
Yes
❑ Purified CBD oil H
Has patient tried/is refractory to any of the following:
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(e.g. Cannabidiol •
• ≥3 neuropathic pain drugs or
(Epidiolex®) •
• ≥2 drugs for palliative cancer pain or
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❑ As add-on •
• Standard drugs for chemotherapy-induced nausea/vomiting
treatment in •
• Standard drugs for spasticity from multiple sclerosis or spinal cord injury
patients with DS,
Yes LGS, and TSC or
As adjunctive therapy, consider diagnosed with A
❑ Nabilone or nabiximols for neuropathic/palliative pain drug-resistant ❑
❑ Nabilone or nabiximols spasticity from multiple sclerosis/spinal cord injury epilepsy ❑
❑ Nabilone for chemotherapy-induced nausea/vomiting ❑
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 MEDICAL CANNABINOIDS COMPARISON
Nabilone (Cesamet®) Nabiximols (Sativex®) Cannabidiol (Epidiolex®)

Active
• Synthetic THC • 1:1 of THC & CBD • Purified CBD
Ingredients

Formulation • Oral capsules • Buccal spray • Oral solution

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• Substrate of CYP3A4 and 2C19,
• Not metabolized
• Metabolized by CYP3A4, 1A2, 2C9, decreased concentration when co-
by CYP

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2D6, 2C19 administered with strong inducer
Cytochrome • Additive CNS
• Possible interaction with strong • Potential to inhibit UGT1A9, UGT2B7,
and drug- depressant effects
3A4 and/ or 2C19 inducers/ CYP1A2, CYP2C8, CYP2C9, and

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drug when taken with
inhibitors CYP2C19 at concentrations relevant to
interactions sedative
• May reduce the effectiveness of clinical use.
medications or
hormonal contraceptives Avoid use with alcohol due to the

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•
alcohol
increased risk of sedation

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Non-medical cannabis
• Smoked cannabis induces CYP1A2
• Oral cannabis inhibits CYP2C19/3A4, space opioids by 4-6 hours
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MONITORING AND FOLLOW-UP

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Parameters Target value

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Clinical response Improvements to pain, decreased spasticity

and/or CINV
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Monitor for tachycardia, BP fluctuations and

CNS and Cardiovascular respiratory complications
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Side effects Monitor for psychiatric symptoms, CNS

depression and drug side effects

Follow-up should be done within 1-2 weeks of initiating medical cannabinoids

to assess the safety, tolerability, and early improvement in symptoms

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 LEGAL CANNABIS USE
• >18 years old is the federal minimum age to engage in cannabis activities
• Note: Federal legislation allows provincial/ territorial restrictions to set higher age requirements

The Cannabis Act allows:

• Purchase dried or fresh cannabis and cannabis oil from a provincially licensed retailer, or federally

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licensed producers online in provinces and territories without a regulated retail system

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• Possess up to 30 g of legal cannabis, dried or equivalent in non-dried form, in public
• Share up to 30 g of legal cannabis with other adults

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• Grow, from licensed seed or seedlings, up to 4 cannabis plants per residence for personal use

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• Permission to make cannabis products like food and drinks at home, if organic solvents are not being
used to create concentrates

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• 1 gram of dried cannabis is equivalent to: 5 grams of fresh cannabis, 15 grams of edibles, 70 grams of
liquid product, 0.25 grams of concentrates (solid or liquid), or 1 cannabis plant seed

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CANADA’S LOWER-RISK CANNABIS USE GUIDELINES FYI

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Canada's Lower-Risk Cannabis Use Guidelines (LRCUG) are a groundbreaking, evidence-based

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public health initiative aimed at helping individuals minimize the health risks linked to
cannabis use following its legalization in 2018.
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1. The most effective way to avoid the risks of cannabis use is to abstain from use
2. Delaying cannabis use, at least until after adolescence, will reduce the likelihood or severity of adverse health
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outcomes regarding brain development

3. Use products with low THC content and high CBD:THC ratios
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4. Synthetic (illegal) cannabis products, such as K2 and Spice, should be avoided

5. Avoid smoking burnt cannabis and choose safer methods, including vaporizers, e-cigarette devices, and edibles
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6. If cannabis is smoked, avoid harmful practices such as inhaling deeply or breath-holding

7. Avoid frequent or intensive use, and limit consumption to occasional use
8. Do not drive or operate other machinery for at least 6 hours after using cannabis. Combining alcohol and
cannabis should be avoided since it increases risk of impairment
9. People with a personal or family history of psychosis or substance use disorders, as well as pregnant women,
should not use cannabis at all
10. Avoid combining any of the risk factors related to cannabis use. Multiple high-risk behaviours will amplify the
likelihood or severity of adverse outcomes
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 TAKEAWAY
• Cannabis plants contain cannabinoids like CBD and THC
• THC is associated with feelings of being ‘high’ due to its psychoactive nature
• Two types of receptors in endocannabinoid system: CB1 and CB2.
• CBD has anti-convulsant, anti-inflammatory and anti-anxiety effects

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• CBD does not interact with CB1 or CB2 receptors.

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• Medical Cannabis Canadian Guidelines recommend against prescribing medical marijuana
(particularly smoked) as first-line cannabinoid due to biased studies and known harmful effects

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• If medical marijuana is to be used, nabilone or nabiximols are preferred

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• Nabiximols are metabolized by the CYP enzymes but nabilone is not

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• There are currently no pharmacological treatments for cannabis-use disorder

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CASE 1
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KJ is a 35-year-old female patient with epilepsy who is stabilized on

clobazam 20mg per day monotherapy. She works as a construction site
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manager, often working long hours on the job site, enforcing workplace
safety, accepting deliveries and occasionally filling in when short-staffed to
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help her team meet deadlines. With a workplace history of heavy lifting,
physically demanding shifts and using vibrating tools, she often smokes
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cannabis to help with her chronic lower back pain and general aches.
Recently, after using a jackhammer to break up the pavement, she noticed
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sharp, burning pain accompanied by numbness and tingling in her hands,

which prevented her from performing tasks that require fine motor
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movements. KJ arrives at the pharmacy today looking to get some

information on medical cannabis, as her supervisor suggested it is safer than
smoking and has helped him with similar symptoms. KJ consumes a case of
beer a week, smokes 1-2 joints every evening, and does not exercise. She is
sexually active and adherent to her hormonal contraceptive. KJ occasionally
uses naproxen 500 mg twice daily and diclofenac extra-strength topical gel
as needed, applied twice daily, for her lower back pain. KJ has no known
allergies.
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 CASE-BASED QUESTIONS
1. Which of the following cannabis-derived pharmaceutical products are currently approved by
Health Canada for specific medical indications?
a) Nabilone and Dronabinol
b) Nabilone and hemp
c) Nabiximols and kratom

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d) Nabilone and Nabiximols

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2. Which of the following cannabis products would be the SAFEST to try first?

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a) A product from dispensary A with a 7:1 THC:CBD ratio
b) A product from dispensary B with a 5:2 THC:CBD ratio

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c) A product from dispensary C with a 11:1 CBD:THC ratio
d) A product from dispensary D with 100mg of THC and no CBD

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CASE-BASED QUESTIONS
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3. Which of the following conditions is the most appropriate indiciation nabiximol in Canada?
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a) Fibromyalgia-related sleep disturbances

b) Spasticity in multiple sclerosis
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c) Pediatric epilepsy
d) Rheumatoid arthritis pain
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4. KJ’s physician calls into the pharmacy, stating that the patient wants a formulation that she
does not have to swallow. Which of the following would be the best recommendation?
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a) Nabilone
b) Nabiximols
c) Cannabidiol
d) Dronabinol

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 REFERENCES
1. Kahan M, Srivastava A, Spithoff S, Bromley L. Prescribing smoked cannabis for chronic noncancer pain: preliminary recommendations. Can Fam Physician.
2014;60(12):1083-1090.
2. College of Family Physicians of Canada. Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance. Can Fam Physician. 2018;64(2):111-120.
Available from: [Link]
3. College of Family Physicians of Canada. Cannabis for medical purposes: GIFT handout. Available from:
[Link]
4. Health Canada. Lower-Risk Cannabis Use Guidelines. Available from: [Link]
medication/cannabis/resources/[Link]
5. Centre for Addiction and Mental Health (CAMH). Canada’s Lower-Risk Cannabis Use Guidelines: Evidence-based recommendations for health care

4)
professionals. Available from: [Link]
6. Health Canada. Information for health care professionals: Cannabis and cannabinoids. Available from: [Link]
canada/services/drugs-medication/cannabis/information-medical-practitioners/[Link]#a2.2

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7. College of Family Physicians of Canada. Guidance in Cannabis Within Primary Care. Available from: [Link]
[Link]
8. Centre for Effective Practice. Non-Medical Cannabis Resource. 2018. Available from: [Link]

17
Medical_Cannabis_Resource_2018.pdf
9. Canadian Public Health Association. Cannabasics. Available from: [Link]
10. Centre for Addiction and Mental Health (CAMH). Canada’s Lower-Risk Cannabis Use Guidelines. Available from: [Link]
reports-and-books---research/[Link]

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11. McGilveray IJ. Pharmacokinetics of cannabinoids. Pain Res Manag. 2005;10(Suppl A):15A-22A. doi:10.1155/2005/242516
12. Ontario Brain Institute. Clinical Practice Guidelines for the Management of Epilepsy: Patient Summary 2023. Available from:
[Link]
13. UpToDate. Cannabis: Monitoring. Available from:

(ID
[Link]
e_link
14. Health Canada. Lower-Risk Cannabis Use Guidelines: Evidence Brief. Available from:
[Link]
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CHANGE LOG
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August 2024
• Content reviewed, no changes made
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September 2024
• Slide 19: Minor grammatical changes made. 3 approved products, updated
bubble
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February 2025
• Content reviewed, only stylistic changes made
March 2025
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• Slide 22: removed (CBD only) after CYP2C9

July 2025
• Significant changes made throughout
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• Information consolidated
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