Medical cannabis:Applying your knowledge in everyday practice

Presented by:

Author: Name Speaker: Name

Aurora

Speaker & author: Mike Boivin, Rph

Disclosures

• Presenter’s Name: Michael Boivin, Rph

• I have the Relationships with commercial interests:• Advisory Board/Speakers Bureau –J & J, Astra-Zeneca, SDM, Pfizer, Abbvie, Valneva, MedReleaf, Sanofi, Novo-

Nordisk

• Funding (Grants/Honoraria) : Merck, Teva, Pfizer, Abbott Diabetes, Valneva, Novo Nordisk, Khiron, Tilray, Canopy

• Speaker/Consulting Fees: Purdue, J & J, Sanofi-Pasteur, Abbvie, Ascensia, Pharmascience, Pfizer

• Speaking Fees for current program: • I have received a speaker’s fee from EnsembleIQ for this learning activity

Learning Objectives

1. Assess a patient to determine if cannabis is an appropriate option

2. Determine dosing, titration and strain (chemovar) selection

3. Manage common cannabis-related adverse effects

4. Answer your patients most common questions regarding cannabis therapy

Ice Breaker Interactive Poll question

• Which of the following is your favourite Tim Horton’s donut?• Honey cruller

• Sour cream glazed

• Chocolate dip

• Chocolate glazed

• Canadian maple

• Double chocolate

What sources of information are the most reliable for consulting on medical cannabis? a) No consultation/research, do it yourself

b) Physicians

c) Alternative healthcare professional (e.g. homeopath, naturopath)

d) Friend, family member or co-worker

e) General internet search

f) Manufacturers' website search

g) Consult a medical website

h) Visit retail stores or websites that sell cannabis

i) Consult government health information services (e.g. Ontario's TeleHealth, Quebec's Info-Santé, B.C.'s Health Guide)

What should be the most informative source/location for consumers on medicinal cannabis? a) In-store: from a pharmacyb) In-store: from a legal private dispensaryc) In-store: from a government retail dispensaryd) Online: directly from a licensed producere) Online: from a pharmacyf) Online: from a legal private dispensaryg) Online: from a government websiteh) Over the phone: directly from a licensed produceri) Over the phone: from a legal dispensaryj) Over the phone: from a government retailer

Cannabis Use is Increasing and Demographics are Changing

https://www150.statcan.gc.ca/n1/pub/11-626-x/11-626-x2017077-eng.htm

Cannabis Use in Canada – 2nd Quarter, 2019

https://www150.statcan.gc.ca/n1/en/pub/11-627-m/11-627-m2019057-eng.pdf?st=DwTSh07-

You Need to Be Able to Address Questions from Patients Starting

and Using Cannabis

Case 1 – What do I do?

• Call from physician wants your help

• Patient• 46 years old with fibromyalgia• Using dried cannabis

containing 18% THC and 1 % CBD

• Smoking it at bedtime

• Physician • It seems to be working for her • He wants to start her on oil

and wants to know how you convert what she is using

Interactive Question 1

What is the equivalent dosing of cannabis oil for a patient smoking 18% THC and 1 % CBD three times daily?

a) 1 mL of cannabis oil with THC 18 mg/mL and CBD 1 mg/mL

b) 0.25 mL of cannabis oil with THC 22 mg/mL and CBD 0.2 mg/mL

c) 2.5 mL of cannabis oil with THC 10 mg/mL and CBD 10 mg/mL

d) Not possible to calculate the exact equivalent dose

Common Question

• Authorization form for medical cannabis is written in grams per day

• LP’s will do the conversion to mg/mL for the oil

• Virtually impossible to do know the exact dose equivalency • Smoked versus oil – first pass effect

• What to look for:• THC:CBD - drives cannabis selection • More aggressive titration in experienced

patient • Impairment can be different

Interactive Question 2

“Patient is saying if there is no exact equivalent, should we just continue smoking or use a vapourizer.”

Which of the following statements is TRUE?

a) THC seems to be the cause of respiratory deaths in the US

b) With the deaths with vaping, we should be promoting smoked cannabis

c) Vapourization of cannabis extract and flowers pose the same health risk

d) For chronic conditions, oils offer significant advantages over inhaled products

Not All Vapes are Created Equal

• Smoking cannabis • Releases same harmful chemicals in tobacco

smoking (PAH, CO, tar)

• Not linked to lung cancer, but exacerbation of respiratory conditions

• Vapourization• Vapourization of dried cannabis flower

• Different than illegal extract pens associated with harm in the US

• Unsure of health risks of burning chemicals

• Strong reason for promotion of legal products

https://www.canada.ca/en/public-health/news/2019/10/statement-from-the-council-of-chief-medical-officers-of-health-on-vaping-in-canada.html?fbclid=IwAR3P4hC0TTNIDu0_OvhY_RFLf_jMeILo9mHyEBBBMjJ-jfkWV9VF7hUIfVQ

Vapourization or Oil – Depends on the Patient

Smoking Vaporization Oral

Onset (min) 5-10 5-10 60-180

Duration (h) 2-4 2-4 6-8

Benefits Rapid onset Rapid onset, less waste than smoking

Less odour, convenient, discreet

Cons Carcinogens, loss of cannabinoids to side smoke, dexterity required

Cost of vaporizer, dexterity to prepare doses, may not be portable

Titration can be more challenging due to delayed onset

Role in therapy Rarely recommended as more risks with no benefits over vaporization

Ideal for patients with episodic acute symptoms (fast onset)

Ideal for chronic conditions as long-acting requiring less dosage frequency

MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine. January 2018. doi:10.1016/j.ejim.2018.01.004

Interactive Question 3

“How much should I authorize on the form?”

Which of the following would be the most appropriate authorized dose?

a) 0.5 gm/day

b) 1 gm/day

c) 4 gm/day

d) 5 gm/day

Authorized Dose

• Most medical cannabis patients respond on 1 – 3 grams of cannabis/day

• Many clinicians find patients respond on < 1 gram/day

• < 5% of patients use > 5 gram per day• Tolerance to benefits don’t normally occur (not the case in recreational users)

• Doses above this level are likely unjustified

• Could indicate cannabis use disorder

• Recreational users – develop tolerance to euphoria• Take larger THC dose to experience euphoria

MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine. January 2018. doi:10.1016/j.ejim.2018.01.004

Case 2 – Can I Try It?

• Patient• 52 years old • Low back pain for 15 years

• Medications• Naproxen 375 mg BID PRN • Duloxetine 60 mg daily • Acetaminophen/oxycodone (325/5mg)

QID PRN

• Discussion • Wants to try cannabis as current

medications are not working • Heard it can help for his pain and sleep

Interactive Question 4

Looking at the patient case, do you think cannabis is appropriate?

a) Yes, it could improve his pain and insomnia

b) Yes, it may help to reduce pain but is not effective for sleep

c) No, as he is taking an opioid for his pain

d) No, he should try other medications first

Questions to Ask when Considering Cannabis

What are we trying to treat?

Is there any evidence to support cannabis for this symptom?

Has the patient tried currently approved therapies?

Does the patient have any issues that would make cannabis inadvisable?

Has the patient tried cannabis before?

What, when and how?

What are the patient’s goals and expectations for cannabis?

Where Cannabis May Help

Palliative Care • May help for nausea and vomiting, anorexia/cachexia, severe intractable pain, severe depressed mood/anxiety, insomnia

Chemotherapy induced N & V

• Suppress acute nausea and vomiting as well as anticipatory nausea• May provide relief from chemotherapy-induced nausea and vomiting (CINV)

Anorexia/cachexia • May increase appetite and caloric intake, and promote weight gain in patients with HIV/AIDS.

MS • May symptoms encountered in MS and spinal cord injury (SCI) including spasticity, spasms, pain, sleep and symptoms of bladder dysfunction

Epilepsy • Drug-resistant seizures in treatment-resistant Dravet syndrome or Lennox-Gastaut syndrome

Chronic Pain • More consistent evidence of the efficacy of cannabinoids (smoked/vapourized cannabis, nabiximols, dronabinol) in treating chronic pain of various etiologies, especially in cases where conventional treatments have been tried and failed.

Health Canada. “Information for Health Care Professionals: Cannabis (Marihuana, Marijuana) and the Cannabinoids.” Education and awareness;guidance. aem, October 12, 2018. https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids.html.

Where Cannabis May Help?

Dystonia • May improve in symptoms of dystonia with inhaled cannabis, mixed effects of oral THC

• Improvement in symptoms of dystonia with oral CBD

Anxiety or depression

• May improve symptoms of anxiety and depression in patients suffering from anxiety and/or depression secondary to certain chronic diseases (e.g. patients with HIV/AIDS, MS, and chronic neuropathic pain).

Sleep • May improve sleep in patients with disturbances associated with certain chronic disease states.

Inflammatory Bowel Disease

• Patients having IBD and having failed conventional treatments reported improvement in a number of IBD-associated symptoms with smoked cannabis

Health Canada. “Information for Health Care Professionals: Cannabis (Marihuana, Marijuana) and the Cannabinoids.” Education and awareness;guidance. aem, October 12, 2018. https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids.html.

Wait a Minute, I Read or Saw an Expert Say There is No Evidence for Cannabis in Pain

Same Evidence, Vastly Different Efficacy Conclusions

“There are inconsistent results on tolerability and safety of

cannabis-based medicines for any chronic pain.”

“There is conclusive or substantial evidence that

cannabis or cannabinoids are effective: For the treatment of

chronic pain in adults.”

National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, and Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. The National Academies Collection: Reports Funded by National Institutes of Health. Washington (DC): National Academies Press (US), 2017. http://www.ncbi.nlm.nih.gov/books/NBK423845/. Häuser, W., F. Petzke, and M. A. Fitzcharles. “Efficacy, Tolerability and Safety of Cannabis-Based Medicines for Chronic Pain Management – An Overview of Systematic Reviews.” European Journal of Pain 22, no. 3 (March 1, 2018): 455–70. https://doi.org/10.1002/ejp.1118.

Same Can be Said About Harm

“Harms of cannabinoids were consistent and common

across all prescribing considerations.” (NNH = 6)

Medical cannabis users were at increased risk of non-serious

adverse events (adjusted incidence rate ratio = 1.73,95%

confidence interval = 1.41–2.13); most were mild to moderate. There were no differences in pulmonary,

neurocognitive function and standard hematology,

biochemistry, renal, liver or endocrine function.”

Ware, Mark A., Tongtong Wang, Stan Shapiro, Jean-Paul Collet, Aline Boulanger, John M. Esdaile, Allan Gordon, Mary Lynch, Dwight E. Moulin, and Colleen O’Connell. “Cannabis for the Management of Pain: Assessment of Safety Study (COMPASS).” The Journal of Pain 16, no. 12 (December 1, 2015): 1233–42. https://doi.org/10.1016/j.jpain.2015.07.014. Allan, G Michael, Nicole Crisp RN MN, Jessica Kirkwood, Christina Korownyk, Guillermina Noël MDes, and Adrienne J Lindblad ACPR. “Simplified Guideline for Prescribing Medical Cannabinoids in Primary Care.” Canadian Family Physician 64 (February 2018): 111–20.

Without Conclusive Evidence, Perspectives Shape Conclusions

Proponents:Safe and viable treatment option to mitigate symptoms with serious disease states

Opponents:It is a harmful drug that has no evidence of benefits and strong evidence of risk

You

What Does This Mean for Practice

• Cannabis is not a first-line treatment

• Used for symptom management

• Given to patients who are not reaching goals with current therapy

• May be able to reduce other medications but not stop it

• Current data does not support it as a cure for any condition

Interactive Question 5

Patient is going to start cannabis oil. Which of the following is the most appropriate chemovar (strain) for his back pain and sleep?

a) THC:CBD (1:20 mg/mL)

b) THC:CBD (4:16 mg/mL)

c) THC:CBD (10:10 mg/mL)

d) THC:CBD (20:1 mg/mL)

Strain Selection

• Each strain can lead to a slightly different response • One of the key factors when considering a strain is

the ratio of THC:CBD• Poor response or adverse effects with one strain can

be mitigated with a change to another strain

• Many of the key adverse effects are associated with THC • Conservative THC dosing in cannabis naïve patients is

recommended

• No perfect answer and it could involve some trial and error

Strain Selection – Key Considerations

• In older patients (> 65 years), those with complex comorbidities, polypharmacy – consider a CBD predominant product (especially if cannabis naïve)

• Patient could try a number of products using the same authorization• They can try several strains to find the product that leads to the best response

• Remember each patient and condition can lead to a slightly different response, important to follow-up to monitor for efficacy and adverse effects

Interactive Question 6

He is going to be started on cannabis oil with 10 mg of THC and CBD per mL. Which of the following is the most appropriate starting dose and titration for him if he is cannabis naïve?

a) 1 mL BID and increase by 1 mL BID until 3 mL BID

b) 2.5 mL HS and increase by 2.5 mL every 1-3 days until therapeutic effect

c) 1.25 mL HS and increase by 1.25 mL every night until the patient starts to feel ‘high’

d) 5 mL HS and increase by 5 mL every 3rd night until at 20 mg BID

Dosing and Titration of Medical Cannabis

• No guideline recommended dosing for medical cannabis

• Fundamental principle is to ‘start low, go slow, then go’

• For oils:• CBD only – start 2.5-5 mg at bedtime and increase by 2.5-5 mg every 1 to 3

days until therapeutic response or adverse effects

• THC containing product – Start at 1.25-2.5 mg at bedtime and increase by 1.25-2.5 mg every 1 to 3 days until therapeutic response or adverse effects

• For inhalation:• Start with 1 inhalation, wait 15 minutes to several hours, may increase by 1

inhalation every 15-30 minutes until therapeutic response or adverse effects

MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine. January 2018. doi:10.1016/j.ejim.2018.01.004

What is the Right Dose?

• Patient stops titrating when they experience therapeutic response (e.g. 30% reduction in pain or improvement in function)

• They do not continue to titrate until they experience euphoria (‘high’)

• Most patients will respond on < 30 mg of THC

• If CBD dominant strain • Dosing very flexible (20 mg/kg/day in Dravet

trial)

• Cost becomes prohibitive

• After 50 mg/day – consider adding some THC

Interactive Question 7

The patient wants to know about terpene profiles and whether he should pick an indica or sativa strain. Which of the following statements is TRUE?

a) There is no evidence that terpenes are pharmacologically active

b) Terpenes are unique to cannabis

c) Indica strains are preferred for pain and sleep

d) Cannabis experts are trying to move away from the indica and sativa terminology

Terpenes

• Terpenes or terpenoids are the largest group of plant chemicals

• 15,000 and 20,000 compounds

• Not unique to the cannabis plant.

• Many terpenes have biological activity

• Responsible for the cannabis aroma

• Terpene profile - unique aroma profile between different cannabis strains

• These compounds are also pharmacologically active and have a broad spectrum of action

Abramovici H, Chief H-O, Bureau R, et al. Information for Health Care Professionals. http://www.hc-sc.gc.ca/dhp-mps/marihuana/med/infoprof-eng.php.

Entourage Effect – not just THC, CBD but with terpenes and other cannabinoids (e.g. CBG)

Indica versus Sativa

https://www.davincivaporizer.com/news/indica-sativa-or-hybrid-which-strain-is-best-for-you/

• More seen in recreational space

• Not consistent and should not commonly be used

• Most cannabis is hybrid

Interactive Question 8

Patient asks about adverse effects. Which of the following is the most common adverse effect in a patient starting on a 1:1 THC:CBD oil?

a) Euphoria

b) Orthostatic hypotension

c) Dry mouth

d) Diarrhea

Adverse Effects with Medical Cannabis

Very Common Common Rare

Dizziness Drowsiness Fatigue Dry mouth Cough, phlegm,

bronchitis (smoked cannabis)

Anxiety Nausea Cognitive effects

Euphoria Blurred vision Headache

Orthostatic hypotension Psychosis/paranoia

(Mainly with high THC in naïve patient)

Depression Ataxia/dyscoordination Tachycardia (after

titration) Cannabis hyperemesis Diarrhea

MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med [Internet]. 2018 Jan [cited 2018 Jan 12]. Notcutt WG, Clarke EL, editors. Cannabinoids in Clinical Practice: A UK Perspective. In: Handbook of Cannabis. Oxford, United Kingdom ; New York, NY: Oxford University Press; 2014. p. 415–32.

Case #3 – Is this good for me?

• Patient:• 72 years old • Hypertension, afib, diabetes, neuropathic

pain

• Medications:• Metformin/sitagliptin 1000/50 XR mg daily• Rivaroxaban 15 mg daily • Pregabalin 75 mg BID • Acetaminophen 1000 mg QID PRN

• Discussion• Son bought him CBD oil to help with sleep

and pain • Has CKD (eGFR = 48 mL/min)• Wants to know if this is safe for him to take

Interactive Question 9

Looking at this patient’s kidney function (eGFR=48 mL/min) can he take the CBD oil?

a) No, it would be contraindicated with that eGFR

b) No, it should not be used in elderly patients

c) Yes, but at a reduced maximum dose

d) Yes, it is safe to use in patients with CKD

What about Patients with Chronic Kidney Disease?

• Cannabinoids are primarily metabolized by the liver

• Metabolites are primarily excreted in the feces

• 20% of metabolites are urinary excreted

• Cannabinoids are generally safe in patients with CKD

• Patients with end-stage renal function have conditions that might respond to medical cannabis:

• Pain (>50% of CKD patients)

• Nausea (28% of severe CKD patients)

• Anorexia is common in CKD

• Pruritus (40% of patients with end-stage renal disease)

Rein, Joshua L., and Christina M. Wyatt. “Marijuana and Cannabinoids in ESRD and Earlier Stages of CKD.” American Journal of Kidney Diseases 71, no. 2 (February 1, 2018): 267–74. https://doi.org/10.1053/j.ajkd.2017.06.020.

Interactive Question 10

The patient wants to know if it is safe with his other medication. Which of the following are likely to have pharmacokinetic interactions with cannabinoids?

a) Metformin

b) Rivaroxaban

c) Pregabalin

d) All of the above

e) None of the above

Pharmacodynamic Drug Interactions with Cannabis

• Can worsen sedation and cognitive impairment with cannabis• Alcohol

• Opioids

• Antipsychotics

• Benzodiazepines

• Tricyclic antidepressants

• Anti-epileptics

Lucas P., Catherine J., Peter Galettis, and Jennifer Schneider. “The Pharmacokinetics and the Pharmacodynamics of Cannabinoids.” British Journal of Clinical Pharmacology https://doi.org/10.1111/bcp.13710.

Potential Cannabis Pharmacokinetic Drug Interactions CYP 3A4 Inducers ↓ THC and/or CBD

Carbamazepine, phenobarbital, phenytoin, rifampin, St. John’s wort

Inhibitors ↑ THC and/or CBD

Azole antifungals, grapefruit, macrolides, mifepristone, protease inhibitors

CBD is an inhibitor of CYP 3A4 and could ↑ 3A4 substrates

Clobazam, tacrolimus, cyclosporine and phenytoin

CYP 2C9 Inhibitors can ↑ THC and/or CBD

Amiodarone, fluconazole, fluoxetine, miconazole

CYP 2C19 CBD can increase the level of medications metabolized by this isoenzyme

Escitalopram, citalopram, moclobemide, omeprazole, pantoprazole, sertraline

Many drugs metabolized by CYP 2C19 are also metabolized by other

isoenzymes

Health Canada. Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids. aem. https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-

cannabinoids.html. Published October 12, 2018. Accessed October 15, 2018. Canadian Pharmacists Association. Cannabis (CPhA Monograph). https://www.e-therapeutics.ca/. Accessed May 5, 2019. Rong C, Carmona NE, Lee YL, et al. Drug-drug interactions as a result of co-administering Δ9-

THC and CBD with other psychotropic agents. Expert Opinion on Drug Safety. 2018;17(1):51-54. doi:10.1080/14740338.2017.1397128. Alsherbiny MA, Li CG. Medicinal Cannabis—Potential Drug Interactions. Medicines (Basel). 2018;6(1). doi:10.3390/medicines6010003“Evidence of a Clinically

Significant Drug-Drug Interaction between Cannabidiol and Tacrolimus: A Case Report.” ATC Abstracts (blog). Accessed May 16, 2019. https://atcmeetingabstracts.com/abstract/evidence-of-a-clinically-significant-drug-drug-interaction-between-cannabidiol-and-tacrolimus-a-case-report/.

Potential Cannabis Pharmacokinetic Drug Interactions

CYP 1A1 and

CYP 1A2

CBD can increase the level of medications metabolized by these isoenzymes

Amitriptyline, caffeine, clozapine, duloxetine, estrogens, fluvoxamine,

imipramine, melatonin, mirtazapine, olanzapine, theophylline

Smoking cannabis can stimulate these isoenzymes and increase the

metabolism of these medications

CYP 2D6 High dose CBD can inhibit this isoenzyme and may increase the level of:

Amitriptyline, fluoxetine, haloperidol, tamoxifen, mirtazapine, imatinib,

dextromethorphan

Many drugs metabolized by CYP 2D6 are also metabolized by other

isoenzymes

Health Canada. Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids. aem. https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-

cannabinoids.html. Published October 12, 2018. Accessed October 15, 2018. Canadian Pharmacists Association. Cannabis (CPhA Monograph). https://www.e-therapeutics.ca/. Accessed May 5, 2019. Rong C, Carmona NE, Lee YL, et al. Drug-drug interactions as a result of co-administering Δ9-

THC and CBD with other psychotropic agents. Expert Opinion on Drug Safety. 2018;17(1):51-54. doi:10.1080/14740338.2017.1397128. Alsherbiny MA, Li CG. Medicinal Cannabis—Potential Drug Interactions. Medicines (Basel). 2018;6(1). doi:10.3390/medicines6010003

Interactive Question 11

The patient asks if there is any coverage for medical cannabis. Which of the following statements is TRUE?

a) There is no coverage for cannabis

b) There is partial coverage for some patients

c) CBD is widely covered by most plans

Interactive Question 12

The patient’s son received the cannabis from a local dispensary. Which of the following is the best course of action?

a) Advise him not to take it and to see his family physician

b) Advise him to purchase the oil from the legal recreational retailer

c) Advise him to start low and slow

d) Advise him to start with a double dose for quick pain relief

Legal Versus Dispensaries

• Product is illegal in Canada

• Quality of cannabis may be suboptimal

• Supplied cannabis is obtained through illegal activity

• Labelling of cannabis does not match current standards

• Potential exposure to cannabis contaminants such as pesticides and heavy metals

Case # 4 – What do I do?• Patient

• 42 years old• Currently using 1:20 THC:CBD cannabis oil

(1 mg/mL: 20 mg/mL) for chronic pain

• Medication• Currently taking 1.5 mL BID

• Discussion• She finds it is not working well• She wants to know if she should stay on it

Interactive Question 13

Which of the following would be the most appropriate course of action to address her lack of efficacy?

a) Increase her dose of current oil

b) Change to another CBD dominant product from a different LP

c) Add a THC predominant oil to her current product

d) Stop cannabis oil and try other treatments

Change in Dose and/or Strain Can Help

• Is the dose optimized?• Can an increase in dose help to reach goals

• Can a change in strain help?• If CBD predominant – could increasing THC help?

• Small changes can make a difference

• Method of administration• Is it done correctly?

• Adherence• Was the patient adherent to treatment

Interactive Question 14

The patient started a THC predominant cannabis oil. She is experiencing the high and drowsiness. How can this be managed?

a) Decrease the dose of the oil

b) Add a CBD dominant oil

c) Slow the titration

d) All of the above

What if the Patient has Adverse Effects?

• Feeling ‘high’ is usually a sign of • Too high THC• Titrating too quickly

• Normal course• Reduce THC dose• Slow titration• Change to strain with higher CBD – mitigates THC adverse

effects

Key Counselling for Patients Starting Cannabis

Dosing and titration • Titration schedule• Importance of “low, slow and go”• Titrate until reaching therapeutic goal

Adverse effects • What they are • How to mitigate them

Travel • Within Canada • Not across borders

Driving • Not for at least 4 hours after inhalation, 6 hours after oral ingestion, 8 hours if any euphoria

Monitoring • Important for regular monitoring and follow-up

Cannabis care • Storage• Out of reach of children• Not for sharing

1. Download the app and create a profile

2. Go to Agenda and click on the session you are looking for

3. Find the presentation at the bottom of the session page

A PDF of the presentation is availableon the event app!

Search for Pharmacy U

in your app store

Please complete the evaluation form for this session on your table, it helps us develop the curriculum that you want

The room assignment for your next session is listed on the back of your badge

Thank you!

Contact – Michael Boivin

EMAIL: BOIVIN.MIKE@

GMAIL.COM

WEBSITE: COMMPHARM.COM

LINKEDIN: WWW.LINKEDIN.COM/IN/MICHAELBOIVIN

TWITTER: @COMMPHARM