Cannabis A Clinician's Guide - 1st Edition
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Cannabis
A Clinician’s Guide
Edited by
Betty Wedman-St. Louis
CRC Press
Taylor & Francis Group
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Library of Congress Cataloging-in-Publication Data
Names: Wedman-St. Louis, Betty, author.
Title: Cannabis : a clinician’s guide / Betty Wedman-St. Louis.
Description: Boca Raton : Taylor & Francis, 2018.
Identifiers: LCCN 2017061827| ISBN 9781138303249 (pbk. : alk. paper) | ISBN
9781138303447 (hardback : alk. paper)
Subjects: | MESH: Medical Marijuana--therapeutic use | Cannabis
Classification: LCC RM666.C266 | NLM WB 925 | DDC 615.3/23648--dc23
LC record available at https://lccn.loc.gov/2017061827
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To the hospice patients who opened my eyes
to cannabis when they asked me to get them
some “weed” for their pain
and
many others denied to right to marijuana
as a remarkably safe medicine
Contents
Preface..................................................................................................................xi
Acknowledgments...........................................................................................xix
Introduction......................................................................................................xxi
Editor............................................................................................................. xxvii
Origins and history of cannabis..................................................................xxix
Contributors................................................................................................. xxxiii
Section I: Cannabis Science
Chapter 1 Cannabis 101................................................................................. 3
Betty Wedman-St. Louis
Chapter 2 Endocannabinoid system: Master of homeostasis,
pain control, & so much more................................................. 15
Jordan Tishler and Betty Wedman-St. Louis
Chapter 3 Endocannabinoid system: Regulatory function in
health & disease......................................................................... 29
Betty Wedman-St. Louis
Chapter 4 Cannabinoid medications for treatment of
neurological disorders.............................................................. 43
Juan Sanchez-Ramos and Betty Wedman-St. Louis
Chapter 5 Cannabinoids and the entourage effect................................ 53
Betty Wedman-St. Louis
Chapter 6 Terpenes....................................................................................... 63
Betty Wedman-St. Louis
Chapter 7 Cannabis and pain..................................................................... 67
Michelle Simon and Betty Wedman-St. Louis
vii
viii Contents
Chapter 8 Cannabis and mindfulness: A method of harm
reduction...................................................................................... 75
Amanda Reiman
Chapter 9 Cannabis and addiction............................................................ 79
Betty Wedman-St. Louis
Section II: Clinical Practice
Chapter 10 What should we tell our patients about marijuana? .......... 93
Joseph Pizzorno
Chapter 11 What is a medical marijuana program?............................... 103
Betty Wedman-St. Louis
Chapter 12 The clinical use of cannabinoid therapies in
oncology patients..................................................................... 109
Paul J. Daeninck and Vincent Maida
Chapter 13 Clinical rationale for CBD in cardiovascular, brain,
and liver function and optimal aging................................. 131
Betty Wedman-St. Louis
Chapter 14 Clinical rationale for CBD use on mood, depression,
anxiety, brain function, and optimal aging....................... 139
Chris D. Meletis and Betty Wedman-St. Louis
Chapter 15 Cannabis in palliative care.................................................... 147
Betty Wedman-St. Louis
Chapter 16 What to expect at the cannabis dispensary........................ 153
Betty Wedman-St. Louis
Chapter 17 Cannabis nutrition................................................................... 159
Betty Wedman-St. Louis
Chapter 18 Clinical recommendations and dosing guidelines
for cannabis............................................................................... 181
Betty Wedman-St. Louis
Contents ix
Section III: Regulations & Standards
Chapter 19 Cannabis identification, cultivation, analysis,
and quality control.................................................................. 193
Betty Wedman-St. Louis
Chapter 20 Commercial cultivation of cannabis.................................... 205
Ashley Vogel
Chapter 21 Quality assurance in the cannabis industry....................... 217
Robert W. Martin
Chapter 22 Cannabis microbiome: Bacteria, fungi,
and pesticides........................................................................... 227
Betty Wedman-St. Louis
Chapter 23 Cannabis testing: Taking a closer look................................ 233
Scott Kuzdzal, Robert Clifford, Paul Winkler,
and Will Bankert
Chapter 24 Legal aspects of cannabis....................................................... 247
Vijay S. Choksi and Betty Wedman-St. Louis
Appendix A: Glossary.................................................................................... 259
Appendix B: Recipes....................................................................................... 265
Index................................................................................................................. 275
Preface
Marijuana—A plant that spread
throughout the world
Weed, pot, grass, Mary Jane—whatever name you call it, marijuana, or
cannabis, originated thousands of years ago in Asia and has now been
grown throughout the world. It was used as a medicine, in spiritual
ventures, and has been legal in many regions of the world throughout its
history [1].
An important distinction needs to be made between subspecies of the
cannabis plant. Cannabis sativa, also called marijuana, has psychoactive
properties from the active component tetrahydrocannabinol (THC). The
other subspecies of Cannabis sativa is known as hemp, the nonpsychoactive
form containing no more than 0.3% THC [2]. (Cannabis sativa L. is a
subspecies with the “L” used to honor the botanist Carl Linnaeus). Hemp
from the nonpsychoactive Cannabis sativa has been used in manufacturing
oil, cloth, and fuel, along with hemp seed products sold in health food
stores for over 20 years as a source of omega-3 fatty acids and vegetarian
protein.
Cannabis indica is a second psychoactive species that was identified by
Jean-Baptiste Lamarck, a French naturalist. The third species of cannabis
is uncommon—Cannabis ruderalis. It was named in 1924 by the Russian
botanist D.E. Janischevisky [3].
Hemp and psychoactive marijuana were used in China, with records
of medical use dating back to 4000 bc where it was used as an anesthetic
during surgery. From the Asian continent, marijuana traveled throughout
the world for use in smoking and cooking.
From seed to consumer shelf
Louis Herbert, a French botanist in 1606, is credited with planting the first
hemp crop in North America in Port Royal, Arcadia (present day Nova
Scotia). By 1801, the lieutenant governor of the province of Upper Canada
began distributing hemp seeds free to Canadian farmers for hemp fiber
xi
xii Preface
production [4], but by the early twentieth century, Canada and the United
States confused Cannabis sativa with hemp, resulting in legal regulations
on all production.
U.S. laws never recognized the difference between hemp and Cannabis
sativa. Legal action against its use in the United States began in 1915
when it was outlawed in Utah. By 1930, with Harry Aslinger as the first
commissioner of the Federal Bureau of Narcotics (FBN), action to make
marijuana illegal in all states began. In 1937, the Marijuana Tax Act put
cannabis under the regulation of the Drug Enforcement Agency (DEA)
where possession of it became a crime.
Hemp has a long history of use. Mark Blumenthal, founder and
executive director of the American Botanical Council (ABC) in Austin,
Texas, has called CBD from Cannabis sativa “one of the most therapeutic
compounds in cannabis” [5]. Chris Boucher, vice president of CannaVest
Corporation in San Diego, California, described the difference between
agricultural hemp and industrial hemp. The former is used primarily as a
nutrition product and the latter as a source for wax, rope, paper, and fuel [5].
Hemp seed products have been sold in the natural foods industry for
over two decades. Products such as hemp powder, hemp oil, and hemp
snacks are marketed for their nutritional benefits—protein and omega-3 fatty
acids. Examples of those products available in local health food stores follow.
Preface xiii
When is medicine not medicine?
In 1850, cannabis was listed in the U.S. Pharmacopoeia as a cure for many
ailments, and by the early 1900’s, Squibb Company, Eli Lilly, and Park-
Davis were manufacturing drugs produced from marijuana for use as
antispasmodics, sedatives, and analgesics.
The Controlled Substances Act of 1970 listed marijuana as a Schedule
1 drug that has no currently accepted medical use but excludes the seed
and seed oil (CBD), according to American Herbal Products Association
(AHPA) past president Michael McGuffin [5]. Hempseed and hemp oil
products are available as capsules, chewables, emulsions, and softgels in
addition to hulled hempseeds and hempseed burgers.
The same cannabis preparations once accepted as therapeutically
useful drugs became illegal with marijuana, hashish, dagga, bhang,
ganja, hash oil, sinsemilla, etc., comprising the world’s most common and
widely used group of illicit drugs. Worldwide about 300 million people are
estimated to have used these drugs. In the United States, 36 million people
have reported using some form of cannabis [6].
Marijuana politics
Cannabis grew popular for its medical properties and use in treating
many ailments from insomnia, menstrual cramps, nausea, muscle spasms,
xiv Preface
and depression, but a 1936 film entitled Reefer Madness caused people to
demonize it and believe its use could create drug zombies.
In the 1960’s, Americans began smoking “weed” or cannabis as a
political dissent over U.S. involvement in the Vietnam War. Thirty years
later, California, Oregon, and Maine approved the medical use of cannabis
as public opinion changed. Colorado became the first U.S. state to legalize
cannabis in 2012, and the market flourished to over $100 million a month in
revenue in just three years [7]. Since cannabis is illegal at the federal level,
it forces marijuana operations to be an all-cash business because banks are
federally regulated.
Cannabis sativa needs to be grown in the United States and reclassified
from a narcotic to an agricultural crop. The federal law on hemp “has been
a waste of taxpayer’s dollars that ignores science, suppresses innovation,
and subverts the will of states that have chosen to incorporate this versatile
crop into their economies,” Representative Jared Polis (D-Colorado) told
the Huffington Post [8]. He is a co-sponsor of the Industrial Hemp Farming
Act of 2015.
U.S. government policy is totally confused concerning cannabis.
One agency, the Drug Enforcement Agency (DEA), says hemp and hemp
extracts are a Schedule 1 drug with no medicinal use, while the U.S.
Department of Health and Human Services (HHS) owns the patent on
CBD use as an antioxidant, and the U.S. Food and Drug Administration
(FDA) is reviewing cannabis as a prescription drug [9].
Research stymied
According to the Handbook of Cannabis Therapeutics: From Bench to Bedside,
the discovery of the endocannabinoid system in the past 15 years has
markedly stimulated research into the cannabis mechanisms of action,
including CB receptors, antioxidant activity, and the role of natural
lignands in medical use of cannabinoids [10].
Grotenherman explains that unlike opiates and other medicinal
plant constituents, cannabinoids were not identified before the twentieth
century so dosing oral cannabis extracts was a problem, but in 1964,
Δ-9-tetrahydrocannabinol was defined and synthesized, which led to
further research on cannabinoid receptors in mammals [11].
The federal government has not allowed farmers to grow hemp,
and the only source of cannabis that can be legally produced in the
United States is grown for research by the University of Mississippi [12].
Numerous studies reported throughout this book have used cannabis
supplies that were confiscated by the DEA to further knowledge about
cannabinoids. Individual states are currently passing legislation to
legalize production and use of cannabis despite the threat of drug raids
and prosecution.
Preface xv
Legalizing marijuana
According to the Pew Research Center in 2016, 57% of U.S. adults want to
see the use of marijuana made legal, and 37% want it to remain illegal. Ten
years ago, the statistics were the exact opposite—32% favored legalization,
and 60% were opposed [13]. A 2012 National Survey on Drug Use and
Health reported that 49% of Americans have tried marijuana with 12%
indicating use in the past year. Four states—Colorado, Washington,
Oregon, and Alaska—and the District of Columbia have passed legislation
to legalize marijuana use.
Recent research by Bradford and Bradford [14] found that medical
marijuana reduced prescription drug use. The University of Georgia study
reviewed prescription drug use in 17 states with medical marijuana laws
in place by 2013 and found prescriptions for painkillers and other drugs
fell sharply compared to states without a medical cannabis law. In medical
cannabis states, doctors wrote 265 fewer doses of antidepressants each
year, 486 fewer doses of seizure medication, 541 fewer antinausea doses,
and 562 fewer doses of antianxiety medications. Even more striking was
that physicians in medical cannabis states prescribed 1826 fewer doses of
painkillers in a given year.
According to the Bradford research, Medicare could save $468 million
per year if marijuana was legalized in all U.S. states. The study calculated
over $165 million had been saved in 2013 in the 18 states studied where
medical cannabis is legal.
Denying patients their right to cannabis
Debate about the use of medical marijuana is challenging the accepted
practice of medicine, as patients are demanding the right to any beneficial
treatment available. Denying a patient knowledge of and access to a therapy
to relieve pain, reduce seizures, modify nausea from toxic drugs, or to
minimize suffering from a terminal illness violates the basic philosophy
of healthcare [15].
Ethically, physicians have the right to prescribe a therapy that relieves
pain and suffering for their patients without fear of retaliation from federal
and state governments. Scientific research has shown that the benefits of
medical cannabis greatly outweighs the risk from inadequate government
legislation and lack of double-blind-controlled clinical studies.
Hemp versus marjuana
Cannabis sativa has been cultivated by humans throughout the world
since antiquity, so it should come as no surprise that different species
and subspecies of cannabis have different properties. Industrial hemp
xvi Preface
is produced from Cannabis sativa strains that have been cultivated to
produce minimal levels of THC. These plants are taller and sturdier
than the Cannabis sativa that is bred to maximize the concentration of
cannabinoids—mainly THC, the psychoactive cannabinoid.
The major difference between industrial hemp and medical marijuana
is that industrial hemp is exclusively bred to produce a low THC species.
The tall, fibrous stalks have very few flowering buds compared to medical
cannabis strains that are short, bushy, and contain many buds with high
amounts of THC. Industrial hemp has a small amount of THC and a high
amount of CBD, meaning that it is incapable of inducing an intoxicating
effect or getting anyone “high” from ingesting it.
As Doug Fine discusses in Hemp Bound, many American farmers are
waiting for the day when industrial cannabis farming is legalized. Fine
writes that a fifth-generation Colorado rancher named Michael Bowman is
willing to test his right to grow hemp in the U.S. legal system because “We
can eat it, wear it, and slather it on out bodies, but we can’t grow it?” [16].
His proclamation illustrates the ignorance that surrounds the
marijuana debate.
References
1. Blaszczak-Boxe, A. Marijuana’s history: How one plant spread through the
world. www.livescience.com/48337.
2. Watts, G. Cannabis confusions. BMJ, 2006; 332(534): 175–176.
3. Warf, B. High points: an historical geography of cannabis. Geographical
Review, 2014; 104(4): 414–438.
4. Canadian Hemp Trade Alliance. www.hemptrade.ca
5. Richman, A. Cannabis conundrum. Nutraceuticals World, March 2015.
6. Turner, C.E., ElSohly, M.A., and Boeren, E.G. Constituents of cannabis sativa
L. XVII. A review of the natural constiuents. J Nat Prod, 1980; 43(2): 169–234.
7. Gupta, S. Weed. CNN. March 6, 2014.
8. Polis, J. Huffington Post, Jan 22, 2015.
9. Rules and Regulations—Department of Justice-Drug Enforcement
Administration 21CFR Part 1308 (Docket No DEA-342) Federal Register, 2014;
81(240): 90194–90196.
10. Russo, E.B. and Grotenherman, F. (eds). The Handbook of Cannabis Therapeutics:
From Bench to Bedside. Routledge, 2014.
11. Grotenherman, F. Clinical Pharmacodynamics of Cannabinoids. Handbook of
Cannabis Therapeutics. The Haworth Press, 2006.
12. Fetterman, P.S., Keith, E.S., Waller, C.W. et al. Mississippi-grown Cannabis
sativa L.: Preliminary observation on chemical definition of phenotype and
veriations in tetrahydrocannabinol content versus age, sex, and plant part.
J Pharmaceutical Science, 1971, 60(8): 1246–1249.
13. Support for marijuana legalization continues to rise. Pew Research Center.
Oct 12, 2016. www.pewresearch.org.
