2019-05-07

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CANNABIS

AT

CAMP Matthew Canning NP-PHC

Disclosures Staff at Northstar Wellness Cannabis

Clinic, subsidiary of Starseed.

2019-05-07

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AIM OF PRESENTATION:

Increase knowledge around cannabis, the legislation around its use, medicinal indications, side effects.

To foster greater comfort and reduce stigma associated with use for medicinal purposes.

To facilitate greater safety at camp via discussion of hypothetical cases

OUTLINE

Cannabis Defined

History of Cannabis

Components of Cannabis and the ECS

Legislation

Medicinal Use in Adults– re: staffers

Medicinal Use in Children–re: campers

Dangers of adolescent use

Side Effects

Overdose

Case studies

Questions

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WHAT COMES TO MIND?

What is Cannabis & Where is it from?

Cannabis/Marijuana/POT/Weed:

A plant largely known for its recreational and medicinal properties

Flowers or buds hold the medicinal properties of the plant

western china

Himalayas

Kush/Indica

Middle East/Africa

Sativa

Groom et al. (2013)

Hybrid of the Two

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HISTORY LESSON

1st Medicinal use 5000 years ago in China

William O’Shaughnessy first physician to study cannabis using animal models

19th century used as tincture in Europe

1923 Prohibition and creation of the pill makes cannabis old news

1963 via chromatography CBD &THC Identified

1988 Allyn Howlet identified receptors CB1 receptor

1992 Endogenous Cannabinoid Anadamide (mimics THC), and later 2AG in 1995

1993 Discover of CB2 receptor

2001 medical cannabis legalized in Canada

2018 Legalized for recreational purposes in Canada

Hanus (2007); Mechoulam et. Al (2014) O’Shaughnessy (1843)

Evolved Perception

https://archive.attn.com/stories/2912/cannabis-kills-cancer-cells

https://www.youtube.com/watch?v=CWxgfTMLtc0

https://nationalpost.com/news/canada/ontario-residents-can-now-buy-cannabis-online-must-wait-for-retail-stores

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Components of Cannabis

CBD –Non intoxicating

THC – Intoxicating

Terpenes – provide smell and are associated with additional sensations

Flavonoids – found in plants/fruit with medicinal properties

& Many more

Fine et, al. (2014); Malfitano et, al. (2014); Panche et a., (2016)

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The Major Components of Cannabis

CBD THC

• Anti-Inflammatory/ Analgesia

• Anxiolytic

• Antiepileptic

• Possible Anti-psychotic

• Analgesic –neuropathic pain

• Sedative

• Appetite Stimulant

• Anti-emetic

(Crippa et al., 2018; Fine et la., 2014;

Masccarone et al., 2015)

Non intoxicating intoxicating

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CBD - Antianxiety

Mouhamed, Et, al. (2018); Mesamore, E.(2019); Bakas et a., (2017)

NO CB1 receptors in

cardiac/respiratory

locations of the pons

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Lowin (2015) ; Mouhamed, Et, al. (2018); Medical Cannabis Mentor (2019)

CBD Effects

Act on TRPV receptors

to reduce pro-

inflammatory peptides

(chemical messengers

Immune System

Anti- Inflammatory

Inhibit immunoregulatory

proteins ie. cytokines

At certain levels ie.

40mg may increase IOP.

CB2 Receptors:

Immune cells at tonsils, thymus, spleen, bone

marrow ad enteric nervous system in GI tract

CB1 Receptors:

CNS, GI, Adipocytes (fat cells), liver

tissue, and skeletal muscle

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How is Cannabis Administered?

Ingestion

Inhalation Transdermal

Joint

Spliff

Blunt

Bong

Pipe

Vaporizer

Oils

Edibles

Concentrates

Creams

Salves

Patches

Cannabis Mentor (2019)Hammel et al., (2016)

Pharmaceuticals/Synthetics

ACMPR

Access to Cannabis for Medical Purposes Regulations (2016)

Indications include but not limited to:

Severe refractory nausea and vomiting associated with cancer chemotherapy

Loss of appetite and body weight in cancer &HIV/AIDS

Pain & muscle spasms associated with multiple sclerosis

Chronic non-cancer pain (neuropathic)

Severe refractory cancer-associated pain Symptoms encountered in palliative or end-of-life care

Insomnia and depressed mood associated with chronic diseases

Other symptoms or conditions authorized by a health care practitioner

Possession Limits: the amount a patient may possess is limited to “30 times the daily quantity of cannabis prescribed, or a monthly maximum of 150g.”

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Current Canadian Legislation Bill c-45

The Cannabis Act: controls the production, distribution, sale and possession of

cannabis across Canada

Age Restrictions: 19 and older to buy, use, possess and grow recreational cannabis.

This is the same as the minimum age for the sale of tobacco and alcohol in Ontario. If

sold to minor (up to 14 yrs in jail)

Promotion Restrictions: products, packaging/labelling should not be appealing to

youth, no self service/vending machines, only promote in narrow circumstances where

youth don’t see

Travel Restrictions: illegal to cross Canadian international border. Use or work with

Cannabis may deem you Inadmissible to other countries. Domestic travel is ok, but

must know provincial rules.

Legislation Continued.. The RULES

The Rules for 19+

Purchase dry or oil cannabis up to 30 grams (dried equivalent) in public and can

share up to 30 grams

Can purchase from federal LP if no framework in your province

Grow from licensed seeds or seedling up to 4 plants/household

Edibles and concentrates likely legal in 2019

Possession production and distribution outside legal system = illegal

No driving under the influence – law enforecement using Drager 5000, Field

sobriety testing and blood testing

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How are patients getting Cannabis?

Licensed Providers:

Illegal Dispensaries

Medical Prescriptions Sent to LPs

Authorized

retailers must

display the

official cannabis

retail seal

Current Medicinal Use

ADULTS:

Chronic pain/neuropathic pain

Spasticity related to MS

Fibromyalgia – fibro fog, generalized pain etc

Harm Reduction

Anxiety

Migraine management

Epilepsy

Anorexia

Chronic Nausea/vomiting

Menorrhagia

Cancer Treatment (Research)

Glaucoma (debate)

Pediatrics

Epilepsy

Behavioral Issues – Autism Spectrum

Cyclic/Chronic Vomiting

Anxiety/Depression (refractory)

Chronic pain/neuropathic pain

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Contraindications: ABSOLUTE:

Pregnancy/Lactation

History of psychosis, Bipolar, Schizophrenia

Unstable cardiac conditions – ischemic heart disease & arrhythmias

NOACs - Anticoagulants –”blood thinners”

Allergy to Cannabis

RELATIVE:

<19 years of age

Trying to conceive

Hx of glaucoma with poor control

Family Hx of schizophrenia

Significant Chronic Respiratory Conditions

Adolescent Use – should be 3rd line treatment.

Severe Immunosuppression (rt inhalation) *

Brents et al., (2016);Ko, et al.(2016)

DRUG INTERACTIONS

Sedatives: Potentiation

Anti-epileptics: ^ serum levels/ potentially ^liver enzymes

Warfarin/Antiplatelets/NOACs– slowed metabolism and

increased effect

Theophylline – reduced by smoking cannabis

Other theoretical interactions

Arrelano et, al. (2017); Damkier et al. (2019; Gaston et al.,

(2017) Hartman (2015); Yamaori et al. (2012)

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Dangerous and risk of Addiction?

Cannabis a Gateway Drug?

Cannabis an Exit Drug?

Long Term Implications of Chronic Use ?

Budney et, al. (2007); Cannabis Mentor (2018);

Government of Canada (2018); Hall et al., 1999; wiese, et al. (2018)

CASE STUDIES 1

Josie is a 7 year old camper with a long standing history of

cyclic vomiting syndrome. Her symptoms have been so severe

that she has required cannabis oil (THC & CBD). Josie’s mom is

anxious about Josie going away to camp for the first time since

starting the cannabis oil. She asks the camp counselor if they are

aware of the side effects in case Josie were to experience any.

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Side Effects of Use

Dose dependent

Recreational vs. Medicinal

Generally Self limiting

Tolerance as benefit

COMPASS Study

Short Term COMPLICATIONS

Cannabis Mentor (2019) ;McCallum, et, al. (2018); Ware et al. (2015)

CANNABIS OIL STORAGE

Cool

Dark

Sealed

Locked

Dry

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CASE STUDY 2

Sara one of the campers comes to the Camp Nurse Practitioner in a panic she reports Thomas another camper snuck off to the woods, “Thomas ate a weed gummy and now he’s acting strange, im scared”. The camp counsellor finds Thomas and sees that he is exhibiting signs of cannabis overdose. How should the counsellor respond?

A) give Thomas a bag of chips

B) Call Thomas’ parents and have them take him home so he can sleep it off in his own bed and explain that he cannot return to camp due to breaking the rules

C) Call 911

Overdose

Potent psychoactive properties

Symptoms Include: cannabis side effects more pronounced

Relatively low toxicity

A case report.

CDC (2019); Government of Canada (2018); Wang et al,( 2019)

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CASE STUDY 3

Jack is a 9 yo male with a history of Lennox-Gastaut syndrome (LGS). His parents

have recently started him in conjunction with their pediatric neurologist on CBD.

The staff taking care of jack should be aware of which of the following ?

1) CBD oil should be given to Jack with a high fat content food

2) Staff should be on the look out for any signs of sedation and have a safety plan in

place as CBD can affect the serum levels of some antiseizure meds

3) All Cannabis medication should be stored in a locked cabinet to prevent

intentional or accidental ingestion

4) All the above

Gaston (2017); Zgair et al. (2016);

CASE STUDY 4 Tim is a administrative staff member of camp. He discloses to the leadership

team upon being hired that he has severe chronic neuropathic leg pain

secondary to tissue excision of cancerous tissue 3 years ago. CBD oil and dry

cannabis prescribed by Matthew the NP, is the only medication controlling his

pain. What are some factors the team should consider prior to Tim starting

work at Camp.

Should Tim Be allowed to bring his Cannabis to Camp?

A) Yes

B) No

There are several stipulations/considerations

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Considerations for Employers/Employees

Reduce stigma – foster environment that’s non punitive for home use

Safety is non negotiable, intoxication is not allowed while at work ****

No exposure to children visually or via 2nd hand smoke

Employers duty to accommodate for medical needs

Employees Duty to ensure safe work

QUESTIONS ?

Contact Information:

matthew.canning@northstarwellness.ca

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