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Cannabis as Medicine

Since endocannabinoid receptors can be found in almost every organ in the body, it shouldn’t be hard to understand why cannabis-based medicines may help with a wide range of conditions. Unfortunately, the lack of clinical trials in this area means that there is limited evidence on its use in a number of conditions. Despite this, cannabis has been used as a medicine for more than 5000 years and its versatility and safety make it a great alternative for patients reluctant to take pharmaceuticals.

 

Luckily, there is sufficient evidence for cannabis to be used as a safe and effective treatment for chronic pain. In future, cannabis-based medicines will probably be the mainstay of chronic pain management since they also target concomitant symptoms such as anxiety, depression and insomnia without the side effects experienced with conventional painkillers such as NSAIDS and opiates.

 

When choosing a cannabis-based medicine, one should initially go for a preparation which is well-tolerated and which is least likely to cause side effects. The usual practice is to start with a CBD-only preparation since CBD (cannabidiol) is very well-tolerated in high doses exceeding 1000mg daily. The usual starting dose is around 2mg every 8hours and this can slowly be increased until a therapeutic effect is obtained.

 

In cases where high doses of CBD (such as >50mg daily) do not provide sufficient therapeutic effect, one may need to introduce a preparation with THC (tetrahydrocannabinol), starting at the lowest possible level and slowly titrating upwards until an appropriate therapeutic effect is obtained. Many conditions respond well to a THC: CBD 1:1 ratio and that is how Sativex was created.

 

The most effective cannabis medicines are those that contain the full plant profile, that is THC, CBD, cannabinoids, terpenes and flavonoids. All of these therapeutic compounds act synergistically to produce the entourage effect, providing the patient with optimal symptom relief.

Types of Medicines

CBD is commonly available as an oil or tincture and is legal throughout most of Europe (not Malta). This is applied sublingually using a pipette where the patient places 1-2 drops under the tongue while in front of a mirror. The dose per drop may vary depending on the concentration of the tincture. CBD is also available as capsules (approx. 25mg per capsule). When the patient needs quick and effective relief from symptoms, they can use vaporized CBD, which is in the form of an electronic cigarette and the CBD can be inhaled in the same way as smoking.

Medicinal preparations of cannabis containing >0.3% THC are controlled substances and are only available from a pharmacy with a prescription for narcotic and psychotropic drugs and a control card which has been approved by the Superintendent of Public Health.

Sativex (nabixmols) is an oromucosal spray which is has been approved in UK and many other countries for the treatment of neuropathic pain, spasticity and overactive bladder in multiple sclerosis. Sativex is a cannabis extract containing 2.7mg THC and 2.5mg CBD per spray, giving it a ratio of THC:CBD of approximately 1:1

 

Sativex can also be used off-label to treat other types of pain but because of the high doses required and the price of this medicine (approx. €500 per 10ml), other therapeutic options are usually preferred.

 

With the growth of medical cannabis industry worldwide, new companies which manufacture medicines under Good Manufacturing Practice (GMP) are developing new medicines which are turning out to be much more affordable and effective. Most medicinal extracts are in the form of tinctures which provide a specific dose of cannabinoid per drop. Topical preparations can help with localized inflammatory conditions and soft tissue injuries. Oromucosal sprays and metered-dose inhalers are also available as alternative methods of delivery.

 

Smoking is not recommended as a mode of administration because of the possible harmful chemicals produced during combustion. Vaporizing raw plant material is the most common mode of administration where this is allowed. The plant material is heated in an approved medical device and the vapours emitted are inhaled by the patient. The temperature of the vaporizer is adjusted according to the therapeutic effect required as different cannabinoids and terpenes are activated at different temperatures. Vaporizing cannabis provides a quick therapeutic effect which lasts up to approximately 4 hours, which means that the medicine would need to be administered at regular intervals.

 

 Is it Legal?

On 23rd March 2018, the new Drug Dependence Act (Treatment not Imprisonment) amendment was enacted allowing:

1) All doctors to prescribe medical cannabis products

2) Patients to access all forms of medical cannabis with a prescription from their own family doctor after a control card has been approved by the Superintendent of Public Health

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