medical marijuana – the nj experience marijuanaksw_2017.pdffemale buds –female bud richer in thc...
TRANSCRIPT
Medical Marijuana –
The NJ ExperienceKathy Smith-Wenning, MA, RRT
Monmouth University – Practical Anthropologist
Rutgers Respiratory Care Program – Program Director
Objectives
Original Objective: Find dose and delivery
Qualification Process – NJ Medical Marijuana
Program card (MMP)
Qualifying conditions – 11 as of 2016
Dose – variable – dose to effect
Delivery methods and Delivery devices
Smoke/Vaporize
Digest/Ingest
Sublingual
The Story Begins with Mandy
You are a what?
What is a budtender?
?Insert a picture here
And then the call
from Katia…
Garden State Dispensary – Fieldwork
begins 6/24/15 Counselor agrees to meet
Talks me through process –same process as NJ State website
NJ MM only dispensed thru approved Alternative Treatment Centers – 4 operational
NJ Law – dispense only plants “flowers”
No MM processed for ingestion
How is the prescription written?
Dose?
Delivery device?
http://www.state.nj.us/health/medicalmarijuana/http://www.gardenstatedispensary.com/about-us/#!
NJ Medical Marijuana Program card needed for
admittance into dispensing area
http://www.gardenstatedispensary.com/about-us/#!
Goals of Medical Marijuana treatmentas per Counselor Jeff
Lessen use of opiates
Lessen use of seizure medications
Lessen use of other medications with difficult side effects
Testimonials
“Opiate free after 8 years”
“No more anxiety meds after 20 years”
“3 seizures a day before, now zero”
“I am actually off Zoloft!
Counselor training … depends on site - the
Rite Aid Metaphor
Feels like Respiratory Care in the 1980’s the land of the OJT
No formal training, might happen on-the-job (OJT)
A few legitimate online training programs
Need knowledge of strains and concentrations of THC:CBD
Seizures low THC, high CBD
Pain, muscle spasticity higher THC
Anxiety and panic attacks – CBD rich, stay away from high THC strains
Case Study : Pt. comes in with debilitating pain but still works during the day. Needs
something to help relax spastic condition and sleep. Pt. asks for a strain that puts him into a
“couchlock.”
Couchlock refers to marijuana that “leaves you where it found you”
Some strains very high in THC – great distraction from pain
Strains lower in THC and higher in CBD allow functionality during the day
NJ Medical Marijuana Program (MMP)
March 2016 – Annual Report
Patient must first qualify with approved physician in MMP –maintain a relationship
Patient/Caregiver Registry
Qualifying patients registered – 5060
Primary caregivers registered – 315
Registry Fee - $200,
Reduced - $20 – NJ Medicaid, SSI, SSD, NJ Temporary Disability
48% of all registered patients receive this reduced rate
PHYSICIAN REGISTRY
Physicians registered – 529 but only 70% authorize patient for MMP
http://www.state.nj.us/health/medicalmarijuana/
Steps to qualification for Medical Marijuana
Program (MMP) – path to prescription
Qualifying condition – 11 approved
Find a qualifying physician with the MMP
Maintain that relationship, multiple visits prior to
physician decision to prescribe
Apply to MMP
Register with an Alternative Treatment Center
Bring prescription to ATC to purchase product and
delivery devices, all out of pocket costs
http://www.state.nj.us/health/medicalmarijuana/qual.shtml
NJMMP – Qualifying Conditions
Approved debilitating medical conditions include:
Amyotrophic lateral sclerosis (ALS)
Multiple sclerosis (MS)
Terminal cancer
Muscular dystrophy (MD)
Inflammatory bowel disease; Crohn’s disease
Terminal illness, with prognosis of less than 12 months of life
PTSD – Feb. 2016
Conditions apply, if resistant to, or intolerant to, conventional therapy:
Seizure disorder, including epilepsy
Intractable skeletal muscular spasticity
Glaucoma
Conditions apply, if severe or chronic pain, severe nausea or vomiting, cachexia or wasting syndrome results from:
Positive status for human immunodeficiency virus
Acquired immune deficiency syndrome
Cancer
http://www.state.nj.us/health/medicalmarijuana/qual.shtml
Prescription and dose – trickier than you
think…
How much medicinal marijuana can I get approved for?
Medical marijuana packed at GSD 1/8 and 1/4 ounce denominations
Physician determines dosage; maximum amount allowed by law is 2 ounces in a 30 day period, renewals every 30 days, max. 90 days
After 90 days re-certification needed by physician
No mention or advice of strain for physicians on MMP website
Strain and delivery device – advice of dispensary
http://www.state.nj.us/health/medicalmarijuana/pat_faqs.shtml#16
Credible Source:An appropriate medical marijuana candidate
Debilitating medical condition which responds to medical marijuana
pharmacotherapy
nausea and vomiting associated with cancer chemotherapy
chronic pain, neuropathic pain, or spasticity associated with multiple sclerosis
Multiple failed trials of first- and second-line pharmacotherapies for these
conditions
No active substance use disorder or psychotic disorder or no unstable
mood disorder or anxiety disorder
Residence in a state with medical marijuana laws and meets requirements
of these laws
JAMA. 2015;313(24):2474-2483. doi:10.1001/jama.2015.6199
POSSIBLE CONTRAINDICATIONS --Before Using Cannabis
CONSULT YOUR PHYSCIAN if you have
Schizophrenia or family history of the disease
Bipolar disorder
Severe depression
Heart disease, angina, irregular heartbeat
High blood pressure
Chronic obstructive pulmonary disease
An immune disorder
Michael Backes, “Adverse Effects of Medical Cannabis,” Cannabis Pharmacy (2014): 34-36
Date of download: 8/21/2015Copyright © 2015 American Medical
Association. All rights reserved.
From: Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems: A Clinical
Review
JAMA. 2015;313(24):2474-2483. doi:10.1001/jama.2015.6199
Common Cannabis Preparations
Table Title:
NJMMP - Patient Frequently Asked Question
When my 30, 60, or 90 day certification for medicinal
marijuana expires, do I have to re-register with the
program?
Answer: No
Patient registration is valid for 2 years.
Expiration of your 30, 60, or 90 day certification, physician
must re-assess condition, determine need to continue
authorized use for an additional 30, 60, or 90 day period.
Physician required to log into the registry and update your
physician statement.
Hence – must maintain physician relationship
http://www.state.nj.us/health/medicalmarijuana/pat_faqs.shtml#21
Cannabinoids
The body produces endogenous cannabinoids to
maintain homeostasis
Marijuana provides numerous exogenous
cannabinoids – most common THC, CBN, CBD
Psychoactive effects
THC – tetrahydrocannabinol – the signature “high”
CBN – cannabinol – minor effect
Non-psychoactive effects
CBD – Cannabidiol
Endocannabinoid System: https://youtu.be/ERq0WCL0jwk
K.P. Hill, “Medical Marijuana for Treatment of Chronic Pain”, JAMA, Vol. 313, No. 24
Pot is pot, right?
No, it all depends upon THC, CBD, the
endocannabinoid system and strains
Cannabis Sativa high THC
Cannabis Indica – high CBD
Recreational use—Cannabis Sativa
MM use hybrid of both
Concentration of THC and CBD vary by strain and each individual plant
Each substance is found in bud – flower, many plants have both male and female buds – female bud richer in THC and CBD
Male buds usually discarded
THC and CBD only available once dried and heated
Plant itself no psychoactive properties – salad of greens will not get you high
Stalk – hemp – no psychoactive properties
David Casarett, "That's Ms. Sativa to You", Stoned, (2015) 78-83
Strains and concentrations, THC, CBD
http://www.gardenstatedispensary.com/about-us/#!
Dose and caution regarding potential
contamination
Research – wide variability by a factor of 10 – blood level
concentrations
Cannot prescribe right dose for right patient with consistency
Plants vary in concentration
Strains
Hybrids
Growing conditions
Grower-to-grower consistency not monitored
Purity loosely monitored
Contamination always potential issue with soil growers and fertilizer
6/25/2017David Casarett, "Vapor Science", 114-118, "Bodily Harm“184-188 , Stoned, (2015)
Delivery of Medical Marijuana
Smoke – covered above
Digestibles / Ingestibles
Brownies, cookies, oils and butters
“First-Pass” Effect – Metabolic Tax – liver takes its “tax” as a drug passes through
Wide variation in concentration, risk of over-dose
Sublingual Tinctures –
Alcoholic, medicinal plant extract
Soak cannabis in ethanol (Everclear) neutral grain spirit
High quality potent tincture – 80 mg. cannabinoid
Best doing method – send to lab for potency – 2.5 mg usual starting dose
But is that mg/drop or mg/ml? Depends
Each drop or ml will contain the same dose – more reliable
David Casarett, "Beer and Brownies", Stoned, (2015) 102-106; Michael Backes, “Sublingual Tinctures-Using Cannabis in the Mouth,” Cannabis Pharmacy (2014): 101-102
Pulmonary Function Soothsayer
Dr. Donald Tashkin, Pulmonologist, UCLA
Big surprise #1 -- in decades of research -- no evidence linking marijuana
smoke to lung damage
Research followed smokers for 20 years
Slight reduction FEV1 in heavy users, increased FVC (practice breathing
deep – probable cause)
Marijuana contains anti-inflammatory properties
Much less smoke inhaled when compare to tobacco
Initial bronchodilation
Transient bronchitis – ends when cessation of smoking
Big surprise #2 – possible treatment for asthma
1976 study THC inhaler effect mimicked that of salbutamol
Edibles might work but smoke is quicker
Never made it to clinical trials
David Casarett, “Pulmonary Soothsayer", Stoned, (2015) p. 171-174
Delivery Devices, etc…
http://www.gardenstatedispensary.com/about-us/#!
Vaporizing Pens – “Vape Pens”
Better dosing because of poor performance – what?
Small puffs, small dose, dose to effect through out the day
Slow gradual dosing – lacks peaks and troughs
No big high concentrated dose as with joints, pipes, bongs, “The Volcano”
NJ Vaping – only dried MM (no oils sold in NJ)
Grind product
Place in “oven”
Press “on” light indicates chosen heat setting
Puff
David Casarett, "Vapor Anywhere", Stoned, (2015) 118-11; https://www.paxvapor.com/pax-2/
Vaporizers and pulmonary risk
Vaporizer function
Runs heat across plant without igniting it
Release of cannabinoids vapor free of combustion byproducts
Cannabis vapor composed of high cannabinoids no pyrolytic
compounds
Does not increase exhaled CO2
Anecdotal research shows decrease in lung irritation (cough)
when former users of other devices switched to vaporizer
More rapid on-set than edibles
Pulmonary Risks – evidence shows risk to lungs
Loflin, Malory and Mitch Earleywine, Can J Respir Ther Vol 51. No. 1. Winter. 2015
Story Telling Format
“Good guys”
The Science, scientists, doctors, cannabis professionals
Patients, families, caregivers
Coalition for Medical Marijuana – Ken Wolski, MPA, RN
“Bad guys”
Myths and realities
Disease causing pain, discomfort, spasticity
Government policies road blocking access
Triumph over adversity
Finding another tool to relieve suffering