20. Integrating Cannabis Into Clinical Care

Cannabis is now available to patients as a medicine in 18 states and the District of Columbia. Unfortunately, due to the long-standing prohibition, most providers have little information regarding the medicinal use of this versatile botanical. The history of cannabis as medicine will be reviewed. This presentation will summarize the main components of the plant and their pharmacologic effects, highlighting the entourage effect of the cannabinoids working in concert with the plant’s terpenoids and flavonoids. The system of cannabinoid receptors and endocannabinoids will be reviewed with a focus on understanding how the phyocannabinoids exert their physiologic effects. The session will highlight results of recently conducted clinical trials investigating the utility of cannabis in painful neuropathic conditions as well as the potential synergistic analgesia that can be achieved through the interaction of cannabinoids and opioids. Attention will be turned to the use of cannabis for symptom management in patients with malignant diagnoses. In view of increasing anecdotes of cancer patients achieving “cures” through the use of heavily concentrated cannabis oil preparations, the body of preclinical evidence suggesting possible direct anti-tumor effects of cannabinoids will be discussed. Patients in states where cannabis is available frequently have a wide range of options in selecting strains (Sativa vs Indica), ratio of tetrahydrocannabinol to other cannabinoids (especially cannabidiol) and mode of delivery (smoking, vaporizing, baked products, tinctures, teas, juices, and oils). A brief overview of these options will be offered. Finally, optimal dosing schedules and safety issues will be discussed. It is anticipated that those attending the session will feel more confident and comfortable discussing medicinal cannabis with their patients at the conclusion of this session.