____________________________________________________ Medical Marijuana and Other Cannabinoids
from its 100% THC content versus the 10% to 20% THC (and variable CBD) content in natural cannabis [229]. Also, dronabinol is often poorly absorbed as an oral agent, and the dosage is difficult to monitor and control. Patients with severe nausea and vomiting, or who otherwise cannot swallow, are unable to ingest oral medication (or keep it down). Cannabis possesses therapeutic constituents in addition to Δ 9-THC, and the rapid onset of effect attained by inhalation can provide quick relief and allow dose titration unable to be achieved with slower-onset oral agents [88].
[232]. For the treatment of chemotherapy-induced nausea and vomiting, nabilone is preferred over cannabis [232]. The recommended initial oral dose is 0.25–0.5 mg at bedtime and not more than 6 mg/day [232]. Studies conducted in Israel and the Netherlands found the average dose for patients in their medical cannabis programs was 1.5 g/day and 0.68 g/ day, respectively [27; 233]. The recommended initial dose of dronabinol is 2.5 mg twice daily, but this may be reduced to 2.5 mg once daily at bedtime if the patient is unable to tolerate twice-daily dosing [83; 232]. This may be titrated up to effect to a maximum of 20 mg per day. Nabilone for chemotherapy-induced nausea and vomit- ing is started at 1–2 mg twice daily and may be increased to a maximum of 6 mg/day in three divided doses [83; 232]. In all cases, it is important to begin with the lower dose in the range and increase if needed. If the starting dose is tolerated but the desired effects are not achieved, slowly increase the dose [14; 232]. One should keep in mind that the therapeutic dose is usually lower than the recreational dose. For medicinal purposes, the OMC recommends vaporized or oral ingestion; smoking is not recommended [14]. Patients orally ingesting cannabis or cannabinoids should be advised of the slow onset and the need to ingest small amounts spaced several hours apart [14]. Vaporizing Though it is often recommended in discussions of medical marijuana use, many healthcare professionals are not familiar with the process of administering cannabis through vaporizing. In essence, active cannabis ingredients can be vaporized if can- nabis is heated and inhaled without combustion. The right temperature is reached when vapor is just visible as a light mist, but no smoke has formed, usually at a temperature of 180°C to 195°C. Using this method, the same cannabis can be used two to three times. In most cases, the recommended initial dosing is one to two times per day, with a minimum of 5 to 15 minutes between inhalations. Patients may need to inhale a few times, until the desired effect is reached or side effects occur. It may take up to two weeks to achieve steady-state THC concentrations and full therapeutic effect. Tea As discussed, a cannabis tea may be used to ingest medical marijuana, though the limited THC bioavailability and lack of water solubility make this a less attractive option in most cases. To brew the cannabis tea, 0.5 g cannabis is boiled in a pint of water for 15 minutes. The plant material is then strained out of the tea and sweeteners are added. The addition of a substance containing fat (e.g., milk powder) can improve the availability of THC in the tea. The tea may be kept refrigerated for up to five days. The usual initial dose is one cup in the evening, though if the effects are insufficient after two weeks, an additional cup (usually in the morning) may be added.
INDICATIONS AND PRACTITIONER CONSIDERATIONS
INDICATIONS As noted, cannabis is generally recommended for patients in whom standard therapies have been ineffective or intoler- able. Appropriate indications for medical cannabis have most recently been formalized by the State of New York, the OMC in the Netherlands, and Health Canada and include [230; 231; 232]: • Disorders of pain and spasticity, including intractable spasticity, multiple sclerosis, and spinal cord damage or injury • Chronic neuropathic pain, including nerve damage, phantom limb pain, facial neuralgia, and postherpetic neuralgia • Pain from cancer and HIV/AIDS • Nausea and vomiting from chemotherapy, radiotherapy, and/or medication for HIV and hepatitis C • Neuropsychiatric disorders, including tics associated with Tourette syndrome, epilepsy, neuropathy, Parkin- son disease, and PTSD • Autoimmune conditions, including arthritis, lupus, and Crohn disease • Palliative treatment of cancer and AIDS to stimulate appetite, avoid weight loss, and reduce debilitation and wasting syndrome • Treatment-resistant glaucoma • A debilitating symptom associated with a medical condition or the medical treatment of that condition, other than those described above DOSE AND ADMINISTRATION GUIDANCE The ideal dosage of cannabis or THC varies by condition and patient characteristics. Inhaled cannabis is not a preferred route of administration due to difficulty with dosing, risk of respira- tory damage, and multi-component composition [232]. For the treatment of refractory pain, nabiximols spray is preferred over smoked cannabis. The initial recommended dose is one spray sublingually at bedtime and not more than 12 sprays daily
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