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