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Reefer madness or real medicine? A plea for incorporating medicinal cannabis in pharmacy curricula.

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Currents in Pharmacy Teaching and Learning

“Over the past twenty years, the acceptance and use of medicinal cannabis has increased in the United States. However, there is still a lack of education and comfort as it relates to the therapeutic uses of botanical cannabis and cannabidiol in pharmacy professional curricula. Professional training programs have failed to keep pace with the evolving national landscape and growing acceptance of this therapy.

PERSPECTIVE:

In this manuscript, the current landscape of pharmacy professional involvement in the dispensing and administration of medicinal cannabis throughout the United States is described. A concern exists that there is a knowledge gap among pharmacists and pharmacy students, as demonstrated by recent survey results, related to the pharmacology, dosing, administration, adverse effects, drug interactions, and monitoring of both medicinal and recreational cannabis use.

IMPLICATIONS:

While cannabis use is still considered illegal by the federal government, it is imperative pharmacy educators prepare the next generation of pharmacists to be knowledgeable on the safe and effective use and communication tactics related to cannabis. As a therapy garnering national attention with growing support for use, education on this topic must be included in pharmacy curricula and pharmacy continuing education.”

https://www.ncbi.nlm.nih.gov/pubmed/30497617

https://www.sciencedirect.com/science/article/abs/pii/S1877129717304860?via%3Dihub

Stilbenoids and cannabinoids from the leaves of Cannabis sativa f. sativa with potential reverse cholesterol transport activity.

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“Three new stilbenoids (1-3) and 16 known stilbenoids (4-6) and cannabinoids (7-19) were isolated from the leaves of hemp (Cannabis sativa L.). The structures of the three new compounds were identified as α,α’-dihydro-3′,4,5′-trihydroxy-4′-methoxy-3-isopentenylstilbene (HM1), α,α’-dihydro-3,4′,5-trihydroxy-4-methoxy-2,6-diisopentenylstilbene (HM2), and α,α’-dihydro-3′,4,5′-trihydroxy-4′-methoxy-2′,3-diisopentenylstilbene (HM3) by 1D and 2D NMR spectroscopy, LC-MS, and HRESIMS. The known α,α’-dihydro-3,4′,5-trihydroxy-4,5′-diisopentenylstilbene (5) and combretastatin B-2 (6) were isolated for the first time from C. sativa f. sativa.

These isolated compounds exhibited cytotoxic effects on human cancer cells via inhibiting the proliferation of cancer cells and inducing cell death. Among them, compounds 4, 5, 10, 12, 13, 15, and 19 displayed broad-spectrum cytotoxicity, and 1, 7, and 11 displayed selectivity in inhibition efficiency on MCF-7 and A549 cells, which suppressed the proliferation of cancer cells significantly by inducing cell death.

The effects of compounds 1-3 on improving reverse cholesterol transport (RCT) were evaluated by isotope-tracing and western blotting. Results showed that the three stilbenoids showed a cytotoxicity above 1.0 mg L-1, especially that of HM3. They could improve [3H]-cholesterol efflux from Raw 264.7 macrophages to high density lipoproteins by enhancing the protein expression of ABCG1 and SR-B1, and HM1 and HM2 showed a significant difference compared with fenofibrate at 1.0 mg L-1. The three stilbenoids could also significantly improve the protein expression of ABCA1. Further study on HepG2 cells indicated that they improve the protein expression of LDLR, SR-B1 and CYP7A1, especially that of HM1 and HM3. However, they showed no significant effect on PCSK9.

The above results indicated that these stilbenoids may elevate the transfer of cholesterol to hepatocytes by improving the protein expression of SR-B1 and LDLR, and the synthesis of bile acid by increasing the protein expression of CYP7A1.

In conclusion, HM1 showed lower cytotoxicity and higher activity in improving the RCT-related protein expression. Our study suggests that it may be explored as a novel lipid-lowering drug and as a beneficial ingredient in health functional foods and pharmaceuticals.”

https://www.ncbi.nlm.nih.gov/pubmed/30500001

https://pubs.rsc.org/en/Content/ArticleLanding/2018/FO/C8FO01896K#!divAbstract

Medical Cannabis for Older Patients.

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“Interest in the medicinal use of cannabis and cannabinoids is mounting worldwide. Fueled by enthusiastic media coverage, patients perceive cannabinoids as a natural remedy for many symptoms. Cannabinoid use is of particular interest for older individuals who may experience symptoms such as chronic pain, sleep disturbance, cancer-related symptoms and mood disorders, all of which are often poorly controlled by current drug treatments that may also incur medication-induced side effects. This review provides a summary of the evidence for use of cannabinoids, and medical cannabis in particular, for this age group, with attention to efficacy and harms. Evidence of efficacy for relief of an array of symptoms is overall scanty, and almost all study participants are aged < 60 years. The risk of known and potential adverse effects is considerable, with concerns for cognitive, cardiovascular and gait and stability effects in older adults. Finally, in light of the paucity of clinical evidence and increasing patient requests for information or use, we propose a pragmatic clinical approach to a rational dialogue with older patients, highlighting the importance of individual benefit-risk assessment and shared patient-clinician decision making.”

https://www.ncbi.nlm.nih.gov/pubmed/30488174

https://link.springer.com/article/10.1007%2Fs40266-018-0616-5

“Our study finds that the therapeutic use of cannabis is safe and efficacious in the elderly population. Cannabis use may decrease the use of other prescription medicines, including opioids.” https://www.ncbi.nlm.nih.gov/pubmed/29398248

“Medical cannabis significantly safer for elderly with chronic pain than opioids: study” https://medicalxpress.com/news/2018-02-medical-cannabis-significantly-safer-elderly.html

Cannabidiol reduces airway inflammation and fibrosis in experimental allergic asthma.

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European Journal of Pharmacology

“Asthma is characterized by chronic lung inflammation and airway hyperresponsiveness. Asthma remains a major public health problem and, at present, there are no effective interventions capable of reversing airway remodelling.

Cannabidiol (CBD) is known to exert immunomodulatory effects through the activation of cannabinoid-1 and -2 (CB1 and CB2) receptors located in the central nervous system and immune cells, respectively. However, as the role of CBD on airway remodelling and the mechanisms of CB1 and CB2 aren’t fully elucidated, this study was designed to evaluate the effects of cannabidiol in this scenario.

Allergic asthma was induced in Balb/c mice exposed to ovalbumin, and respiratory mechanics, collagen fibre content in airway and alveolar septa, cytokine levels, and CB1 and CB2 expression were determined. Moreover, expressions of CB1 and CB2 in induced sputum of asthmatic individuals and their correlation with airway inflammation and lung function were also evaluated.

CBD treatment, regardless of dosage, decreased airway hyperresponsiveness, whereas static lung elastance only reduced with high dose. These outcomes were accompanied by decreases in collagen fibre content in both airway and alveolar septa and the expression of markers associated with inflammation in the bronchoalveolar lavage fluid and lung homogenate. There was a significant and inverse correlation between CB1levels and lung function in asthmatic patients.

CBD treatment decreased the inflammatory and remodelling processes in the model of allergic asthma. The mechanisms of action appear to be mediated by CB1/CB2 signalling, but these receptors may act differently on lung inflammation and remodelling.”

https://www.ncbi.nlm.nih.gov/pubmed/30481497

https://www.sciencedirect.com/science/article/pii/S0014299918306836?via%3Dihub

Aerobic Fitness Level Moderates the Association Between Cannabis Use and Executive Functioning and Psychomotor Speed Following Abstinence in Adolescents and Young Adults.

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“The high rate of cannabis (CAN) use in emerging adults is concerning given prior research suggesting neurocognitive deficits associated with CAN use in youth. Regular CAN use downregulates endocannabinoid activity, while aerobic exercise upregulates cannabinoid receptor 1 activity and releases endocannabinoids. Here we investigate the influence of regular CAN use on neuropsychological performance, and whether aerobic fitness moderates these effects.

RESULTS:

Increased CAN use was associated with decreased performance on working memory and psychomotor tasks. High aerobic fitness level was related to better performance on visual memory, verbal fluency, and sequencing ability. CAN*VO2 max predicted performance of psychomotor speed, visual memory, and sequencing ability.

CONCLUSIONS:

Following monitored abstinence, increased CAN use was associated with poorer performance in working memory and psychomotor speed. Higher aerobic fitness level moderated the impact of CAN on visual memory, executive function and psychomotor speed, as more aerobically fit CAN users demonstrated better performance relative to low-fit users.

Therefore, aerobic fitness may present an affordable and efficacious method to improve cognitive functioning in CAN users.”

https://www.ncbi.nlm.nih.gov/pubmed/30474579

https://www.cambridge.org/core/journals/journal-of-the-international-neuropsychological-society/article/aerobic-fitness-level-moderates-the-association-between-cannabis-use-and-executive-functioning-and-psychomotor-speed-following-abstinence-in-adolescents-and-young-adults/B033EA73E6C1FBFFBC75F45CC426C1CC

“Exercise activates the endocannabinoid system.”  https://www.ncbi.nlm.nih.gov/pubmed/14625449

Disentangling longitudinal relations between youth cannabis use, peer cannabis use, and conduct problems: developmental cascading links to cannabis use disorder.

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“To determine whether cannabis use during adolescence can increase risk not only for cannabis use disorder (CUD) but also for conduct problems, potentially mediated by exposure to peers who use cannabis.

Change in cannabis use did not predict changes in conduct problems or peer cannabis use over time, controlling for gender, race-ethnicity and socio-economic status.

Cannabis use in adolescence does not appear to lead to greater conduct problems or association with cannabis-using peers apart from pre-existing conduct problems.

Instead, adolescents who (1) increasingly affiliate with cannabis-using peers or (2) have increasing levels of conduct problems are more likely to use cannabis, and this cascading chain of events appears to predict cannabis use disorder in emerging adulthood.”

https://www.ncbi.nlm.nih.gov/pubmed/30457181

https://onlinelibrary.wiley.com/doi/full/10.1111/add.14456

Impact of recreational and medicinal marijuana on surgical patients: A review.

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American Journal of Surgery Home

“As medicinal and recreational marijuana use broadens across the United States, knowledge of its effects on the body will become increasingly important to all health care providers, including surgeons.

DATA SOURCES:

We performed a literature review of Pubmed for articles discussing the basic science related to cannabinoids, as well as articles regarding cannabinoid medications, and cannabis use in surgical patients.

CONCLUSIONS:

The primary components in the cannabis plant, tetrahydrocannabinol (THC) and cannabidiol (CBD), have been made available in numerous forms and formulations to treat multiple medical conditions, and recreational access to marijuana is increasing. Of particular importance to the surgeon may be their effects on prolonging intestinal motility, decreasing inflammation, increasing hunger, mitigating pain, and reducing nausea and vomiting. Perioperative use of medicinal or recreational marijuana will become increasingly prevalent, and the surgeon should be aware of the positive and negative effects of these cannabinoids.”

https://www.ncbi.nlm.nih.gov/pubmed/30471810

https://www.americanjournalofsurgery.com/article/S0002-9610(18)31123-1/fulltext

A meta-analysis of the crash risk of cannabis-positive drivers in culpability studies-Avoiding interpretational bias.

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Accident Analysis & Prevention

“Culpability studies, a common study design in the cannabis crash risk literature, typically report odds-ratios (OR) indicating the raised risks of a culpable accident. This parameter is of unclear policy relevance, and is frequently misinterpreted as an estimate of the increased crash risk, a practice that introduces a substantial “interpretational bias”.

RESULTS:

The model outperforms the culpability OR in bootstrap analyses. Used on actual study data, the average increase in crash risk is estimated at 1.28 (1.16-1.40). The pooled increased risk of a culpable crash is estimated as 1.42 (95% credibility interval 1.11-1.75), which is similar to pooled estimates using traditional ORs (1.46, 95% CI: 1.24-1.72). The attributable risk fraction of cannabis impaired driving is estimated to lie below 2% for all but two of the included studies.

CONCLUSIONS:

Culpability ORs exaggerate risk increases and parameter uncertainty when misinterpreted as total crash ORs. The increased crash risk associated with THC-positive drivers in culpability studies is low.”

https://www.ncbi.nlm.nih.gov/pubmed/30468948

https://www.sciencedirect.com/science/article/pii/S0001457518304706?via%3Dihub

The level of evidence of medical marijuana use for treating disabilities: a scoping review.

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“There is sufficient evidence that medical marijuana is effective in treating epileptic seizures and chronic pain.

Medical marijuana may improve the level of functioning and quality of life for individuals with certain disabilities.”

https://www.ncbi.nlm.nih.gov/pubmed/30456993

https://www.tandfonline.com/doi/abs/10.1080/09638288.2018.1523952?journalCode=idre20

Cannabis Systematics at the Levels of Family, Genus, and Species.

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Cannabis and Cannabinoid Research cover image

“New concepts are reviewed in Cannabis systematics, including phylogenetics and nomenclature. The family Cannabaceae now includes Cannabis, Humulus, and eight genera formerly in the Celtidaceae. Grouping Cannabis, Humulus, and Celtis actually goes back 250 years. Print fossil of the extinct genus Dorofeevia (=Humularia) reveals that Cannabis lost a sibling perhaps 20 million years ago (mya). Cannabis print fossils are rare (n=3 worldwide), making it difficult to determine when and where she evolved. A molecular clock analysis with chloroplast DNA (cpDNA) suggests Cannabis and Humulus diverged 27.8 mya. Microfossil (fossil pollen) data point to a center of origin in the northeastern Tibetan Plateau. Fossil pollen indicates that Cannabis dispersed to Europe by 1.8-1.2 mya. Mapping pollen distribution over time suggests that European Cannabis went through repeated genetic bottlenecks, when the population shrank during range contractions. Genetic drift in this population likely initiated allopatric differences between European Cannabis sativa (cannabidiol [CBD]>Δ9-tetrahydrocannabinol [THC]) and Asian Cannabis indica (THC>CBD). DNA barcode analysis supports the separation of these taxa at a subspecies level, and recognizing the formal nomenclature of C. sativa subsp. sativa and C. sativa subsp. indica. Herbarium specimens reveal that field botanists during the 18th-20th centuries applied these names to their collections rather capriciously. This may have skewed taxonomic determinations by Vavilov and Schultes, ultimately giving rise to today’s vernacular taxonomy of “Sativa” and “Indica,” which totally misaligns with formal C. sativa and C. indica. Ubiquitous interbreeding and hybridization of “Sativa” and “Indica” has rendered their distinctions almost meaningless.”

https://www.ncbi.nlm.nih.gov/pubmed/30426073

https://www.liebertpub.com/doi/10.1089/can.2018.0039