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CANNABIS

WHAT HEALTHCAREWORKERS NEED TO KNOW

A Collaberative Presentiation from Dr. Hilda Chavez ND and William Vogt PA-C, MPAC

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Dr. Hilda Luz Chavez, ND

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Dr Hilda practices and lives by the Hippocratic Oath and upholds the 6 principals of Naturopathic Healing:

Nature has the power to healTreat the cause, not the effectEducate and treat the whole personFirst and foremost, DO NO HARMEncourage PreventionAct as a TEACHER!

Dr. Chavez educates her patients, other practitioners and the community at large about the value of the three Cannabis Strains : (SATIVA, INDICA, AND RUDERALIS aka HEMP)

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A pioneer, leader and healer in the El Paso-Las Cruces area, Dr. Hilda has been in private practice over 40 years. She was the Director of the El Paso Wellness Center from 1983 to 2002 and Director of the El Paso School of Massage from 1986 to 2001.

In 2007, she established NMMCP CONSULTING, specifically to guide, educate and certify patients in the NM MEDICAL CANNABIS PROGRAM. Her practice includes guiding and educating practitioners that want to support their patients with the use of cannabinoids.

Herbal Medicine including Cannabis has always been a part of her life since she was a child. Her maternal grandmother taught her the value of herbal medicine including Cannabis remedies.

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Why Knowing About Cannabis Important?

Many states legalizing prescriptive and or recreational use.Changing views about use.

According to Pew Research Center over Two-thirds of Americans support Marijuana legalization

More available, in many forms.Many of your patients may be using one form or another and may have questions.

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The Recent Rise of Cannabis

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Cannabis is Here

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Brief Cannabis use History

• Many uses documented in ancient times from China (part of 50 fundamental herbs), Ancient Netherlands, Egypt, India, Greece and Medieval Islamic world.

• Used for everything from antiepileptic, anti-inflammatory, analgesic, and a variety of other ailments.

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Cannabis History Continued• Western use began in the 19th

century mostly due to an 1839 publication by Dr. O’Shaughnessy describing successful use in patientsas analgesic, appetite stimulant, antiemetic, muscle relaxant and anticonvulsant.

• At lease 2000 cannabis medicines prior to 1937

• Late 19th to early 20th century was the pinnacle of cannabis use in Western Medicine.

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Cannabis History Continued

• Later 20th century cannabis use in medicine declined due to a number of factors such as difficulty with standardized preparations and the rise of effective medications addressing most treatment areas.

• Cannabis was removed from the US Pharmacopoeia in 1942 due to the Federal Marihuana Tax Act of 1937.

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Cannabis History Continued

Prohibition of Medical Marijuana culminated in the 1970 Controlled Substance Act making it a Schedule 1 Substance. This act made it not only illegal to grow, possess, consume, or sell not only any products from Marijuana but also any hemp products.The 1970 Controlled Substance Act also affected the ability to test/study marijuana which put the US well behind many countries in research

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Cannabis: HEMP vs MARIJUANA

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Cannabis: HEMP vs MARIJUANA

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MARIJUANA

• Varieties of Cannabis that contains more than 0.3% THC

• Can induce psychotropic or euphoric effects on the user.

• Was actually used as a negative term due to its correlation of its use by Migrating Mexicans into the US.

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What is Hemp

• Hemp is a term to classify varieties of Cannabis sativa that contains 0.3% or less THC by dry weight per the legal definition put out under the Agricultural Act of 2018 and has generally been used to describe Non-Intoxicating Cannabis

• Used for Cannabidiol (CBD) in many products.

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Two Important Cannabinoids from the Cannabis Plant

• Δ9-tetrahydrocannabinol (THC)–Marijuana– The principle psychoactive constituent

• Cannabidol (CBD)– Can be extracted from Both Marijuana or Hemp–Minimal involvement with CNS– Lacks Psychoactive Property– Counter regulatory properties on THC

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THE ENDOGENOUS CANNABINOID SYSTEM

• There are Cannabinoid Receptors throughout our bodies, both within the central nervous system including the brain and peripheral nervous system. There are Cannabinoid receptors within all of our organs and skin as well. These receptors act as locks and when stimulated by Cannabinoids that we either produce naturally or take as a supplement, provide a significant number of actions within our bodies.

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Cannabinoid Receptors

• Activated by three major groups of ligands (keys)– Endocannabinoids– Plant cannabinoids– Synthetic cannabinoids

• Currently two major know subtypes– CB1

– CB2

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CB1 Receptors in the Brain and Function (THC)

Highest DensitySubstantia Nigra (Reward, addiction, movement)Cerebellum (Motor control and coordination)

Globus Pallidus (Voluntary movements)Caudate Nucleus (Learning and memmory system)

Moderate DensityCerebral Cortex (Decision-making, cognition, emotion)Putamen (movement, learning)

Amygdala (Anxiety and stress, emotion and fear, pain)Hyppocampus (memmory and learning)

Lower CB1 DensityBody Temp, feeding

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Central Effects (mostly CB1)

• Antinociceptive (pain reduction)• Neuroprotection• Alleviation of spasms and spasticity• Anti-emetic• Regulate food intake and energy expenditure• Effects on Reproductive system

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CB1 Receptors in Periphery

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CB2 Receptors

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Peripheral Effects (mostly CB2)

• Effect on Immune System• Vasodilation, which is particularly marked on

the scleral and conjunctival vessels of the eye• Antiproliferative• Bronchodilation• Reduction of intraocular pressure• Anti-inflammatory Action

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Effects on the Immune System (mostly CB2)

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Endocannabinoids• Substances produced from within the body

that activate cannabinoid receptors• Believed to play important role in almost

every major life function in the human body• Not stored but instead are rapidly synthesized

by neurons.• Two major Ligands (Keys)– Anandamide– 2-arachidonoyl glycerol (2-AG)

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Phytocannabinoids

• These are essentially plant based cannabinoids as discussed.

• There are 100+ cannabinoids that have been isolated from Cannabis sativa, the two most studied are THC and CBD.

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WHAT DO CANNABINOIDS DO

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Clinical Implications

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Methods of Consuming CannabisSmoking and Vaporizing

Pros• The gases enter the lungs

before absorbing into the bloodstream, therefore producing a quick effect.

• Vaporizers are the logical choice for moderate to experienced and/or health-conscious cannabis consumers because it minimizes smoke inhalation and toxins.

Cons• The effects associated with

smoking are widely debated, but health professionals are in agreement that smoke -free methods pose less risk and are medically preferred.

• The most recent research suggests that vaping THC oil could be quite harmful to lung health. The greatest concern at the moment is the severe effects of inhaling vitamin E acetate.

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EdiblesPros

• Because the harmful effects of smoking are well known and the health effects of vaping are unknown, edibles and are a safe and easy alternative to using cannabis.

• Provides sustained effects.

Cons

• Because edibles do not provide immediate effect having too much can lead to adverse and physical reactions such as: paranoia, panic attack, elevated heart rate.

• Edibles can take 30 min to 2 hours to kick in, depending on how a person metabolizes.

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Tinctures

Pros• Tinctures provides dosage

control and fast-acting effects without the health risks associated with smoking.

• Sublingual application allows for a rapid onset of 15-30 minutes with peak effects at around 90 minutes.

• Low-calories.

Cons• Might offer an unpleasant

taste.• If alcohol is used as a

solvent, the tincture may produce a burning sensation to the tongue

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Topicals

Pros• Localized Pain Management• Non-psychoactive• Cannabis helps by fighting

inflammation through activating the CB2 receptors

• May provide relief for those who experience rashes, eczema, and other skin irritations.

Cons• Very few studies have been

conducted regarding the efficacy of topical Cannabis creams, and the vast majority of claims praising their medical performance are purely anecdotal.

• Many products have misleading ingredients and potency claims.

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FDA Approved Cannabis-derived Drugs

• Epidiolex- Treats serious forms of childhood epilepsy and contains the compound cannabidiol (CBD). (No THC)

• Marinol (dronabinol) – A synthetic form of THC and is used to treat chemotherapy-induced nausea and vomiting as well as anorexia from AIDS.

• Syndros (dronabinol)- Same as Marinol but in liquid form.

• Cesamet- Also a synthetic form of THC, but is more potent.

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Cannabis Safety

Little is known about the safety of individual compounds. Serious adverse effects are rare with cannabis or its constituents.

Marijuana has low to moderate dependence potential; the active dose is very far below the lethal dose. In fact you would fall asleep before you could get to a lethal dose. (Gable et al 2006).

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Drug Interaction

• Cytochrome P450 Enzymes• THC and CBD are metabolized by CYP3A4 and

CYP2C9 (Yamaori et al 2012, Watanabe et al 2007). CYP3A4 inhibitors slightly increase THC levels.

• CYP3A4 inducers slightly decrease THC and CBD levels.

• CBD, but not THC, is metabolized by CYP2C19 (Stout and Cimino 2014).

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Common InteractionsDRUG INTERACTION

Warfarin THC and CBD increase warfarin LevelsFrequent cannabis use has been associated with increased INR(Yamaori et al 20120

Alcohol Alcohol may increase THC levels, increased sedation (Hartman 2015)

Theophylline Smoked cannabis can decrease theophylline levels(Stout and Cimino 2014)

Indinavir or nelfinavir Smoked cannabis had no effect(Abrams et al 2003)

Docetaxel or Irinotecan Cannabis infusion had no effect(Engels et al 2007)

Clobazam CBD used for epilepsy in children may increase clobazam levels(Geffrey et al 2015)

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Is Medical Marijuana legal in Texas?

• In 2016 the state of Texas Senate passed the Compassionate Use Act.

• This law made low THC, high CBD oil available for use only for epilepsy patients.

• Many doctors are reluctant to prescribe Marijuana to their patients.

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Texas Compassionate use Program (CUP)

• The Texas Compassionate Use Act was enacted by the Texas Legislature in 2015 for patients with epilepsy.

• Beginning Sept. 1, 2019 CUP was extended for Texans with multiple sclerosis, Parkinson's disease, ALS, terminal cancer, autism, spasticity and many kinds of seizure disorders.

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How does a patient obtain access to low THC Cannabis?

• Ask their Physician if he/she is certified by DPS.• Call one of the 3 companies.• Company will direct them to a physician in their

area.• If there is no physician in their area they can

have a Telemedicine Consultation.• Physician will write prescription• Upon submitting to the company, they will

register the patient to the CUP system.

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Is CBD Oil legal in Texas?• In 2018, the Senate passed the Federal Farm Bill into

law.• This piece of legislation made CBD products legal

nationwide in theory because each state has its own laws regarding CBD.

• In 2019, Texas Governor Greg Abbott signed a bill into law which allowed the cultivation of hemp in Texas. It also approved the sale of CBD oil to those without a prescription, as long as the oil contains less than 0.3% THC.

• Currently, there are no laws against possessing any of the imported hemp CBD products in Texas.

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All CBD is Not Created Equal

• Full Traceability and third party testing with COA.

• Full Spectrum Hemp vs Isolate?• Provides mg. per suggested; not total mg. per

bottle.• No medical claims• Efforts to grow research• Commitment to education• Involvement with trade organization

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SOURCES OF INFORMATIONPrakash Nagarkatti, et al. Cannabinoids as novel anti-inflammatory drugs, Future Med Chem, 2009 Oct. Republished by NIHMSIDRodriguez de Fonseca F, et al. The endocannabinoi system: physiology and pharmacology. Alcohol Alcoholism. 2005;40:2-14 [PubMed]

Klein TW, Newton CA. Therapeutic potential of cannabinoid-based drugs, Adv Exp Med Biol, 2007;601:395-413Helpful Cannabidiol (CBC) Resouces/Articles

http://www.projectcbd.com/index.htmlhttp://micannalytics.com/articles/CBD-Chemical -Aspects.pdf

http://www.beyondthc.com/wp-content/uploads/2012/05/Mechoulam-on-CBD.pdf

MORE INFO WILL BE ADDED

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For More Information• NMMCP CONSULTING, LLC.• 432 E. Lucero Ave LC NM 88001• Green house SW corner of Lucero Ave. and Mesquite

• Hilda Luz Chavez, ND.• TRADITIONAL NATUROPATH• Over 40 years experience in Natural Medicine• Visit our website for more information and resources:• www.NMMCPCONSULTING.com

• Office Manager: Annemarie – 575-496-3360• Dr. Chavez- Cell- (915) 204-5440 FAX –(575) 288-1138

• OR• Tozi Remedies

• Veronica Saenz• www.toziremedies.com

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