What is medical cannabis?

Cannabis, commonly known as marijuana, is a group of plants that produce biologically active compounds. There are 2 main strains of the Cannabis plant used for recreational and medicinal purposes – sativa and indica.  Cannabis can be used to help manage symptoms like pain, fatigue and sleep disturbance in chronic conditions like Spondyloarthritis (SpA). It has a long history of use as a medication all over the world and in many cultures.

Medical cannabis specifically refers to the use of cannabis for medicinal purposes. It is made from sativa, indica or a mixture of both strains so that it contains specific amounts of cannabinoid molecules like tetrahydrocannabinol (THC) and cannabidiol (CBD). They can be used whole or in extract form.

• These two compounds, among other similar compounds in cannabis, interact with the body’s own endocannabinoid system (CB1 and CB2 receptors in the brain and throughout the body on immune cells, respectively) and other important receptors. This can regulate bodily processes like pain, mood, appetite, and memory.
• THC has a psychoactive (mind-altering) and pain-relieving properties.
• CBD may also reduce pain while having no known psychoactive side-effects. However, some patients may experience drowsiness with CBD.
• Both compounds have been reported to help manage symptoms such has chronic pain.

The family of cannabinoid molecules that may be used as treatments exists as either pharmaceutical preparations or herbal product derived from plant material.

• Pharmaceutical preparations may be ingested orally (pills) or as a spray applied to the inside of the mouth. These preparations contain isolated THC and CBD (and nothing else – sativex), or their synthetic versions (nabilone). These have undergone clinical trials to demonstrate they are safe and effective. They have been approved for various conditions through the arduous process undertaken by Canada’s Food and Drugs Act.
• Herbal cannabis, in contrast, is generally not pharmaceutically manufactured and is available as whole dried plant, or plant extracts in oil or capsule format. These can be ingested or inhaled. To date, research and clinical trials of herbal cannabis are very limited and, as a result, both positive and negative effects have not been clearly determined.  Some companies are now producing cannabis flowers under GMP conditions.

It is the Canadian Spondyloarthritis Assocation position that: 

• Medical cannabis offers a potential adjunctive to traditional pharmaceutical medications to treat chronic pain and other symptoms of SpA.  The decision to initiate medical cannabis should be based on a shared discussion of the patient and the physician;
• Like all medications, medical cannabis has  potential side effects. Drug-drug interactions in particular are important since patients are often taking other, often many, medications with cannabis.  Patients must be aware of what they are and make informed decisions;
• Patients consult with a physician to determine the product that would work best for them and the THC/CBD cannabis ratio;
• Patients should obtain a prescription from their doctor, nurse practitioner or other prescribing healthcare professional outlining use and dosing and the CSA stresses recreational cannabis consumption is not a medicine;
• Cannabis be purchased from a licensed seller and delivered to the patient by courier and signed for by an adult over the age of 18;
• The licenced seller/manufacturer demonstrates comprehensive compliance and regulatory requirements (quality control standards, record-keeping and intensive security measures to protect against theft);
• Medical cannabis can be an alternative to opioids to help manage pain; and may positively impact the current opioid crisis;
• Does not recommend smoking or vaping. There are several delivery methods for cannabis which may alter product effect and present a variety of side effects. Herbal cannabis may be ingested in the form of oils (used in food preparation) or inhaled using a vaporizer or by smoking. Onset of action is achieved more quickly when inhaled vs ingested. Ingested medical cannabis products last longer and may be more beneficial for chronic, long-lasting pain however, inhaled cannabis is associated with respiratory adverse effects, especially when used chronically over a long period of time;
• Healthcare professionals should have access to trained physicians who are  able to effectively prescribe and engage in discussions about medical cannabis as a treatment.
• Needs and preferences of people with SpA  should be considered in decisions made about medical cannabis in Canada.
• There is an unmet need to develop a research strategy to determine the safety and efficacy of medical cannabis in SpA.
• Both compounds (THC and CBD) have been reported to help manage symptoms such has chronic pain, but there have been no studies to date that have tested cannabis specifically for AS and demonstrated its efficacy.

Guiding Principles:

• Patient safety is paramount, and a patient-centered approach is crucial;
• Patients must use medical cannabis responsibly and keep out of the hands of minors;
• Decisions about the use of medical cannabis be in the hands of people living with SpA and their physician;
• People living with SpA and their physicians need to have access to evidence based guidelines to make informed choices;
• All stakeholders are responsible for funding research into the safety and efficacy of medical cannabis as a therapy for managing symptoms of SpA. Stakeholders include government, manufacturers, licensed sellers and others;
• The supply of medical cannabis be controlled and regulated by the federal government and licensed sellers who manufacture and distribute any product remain under strict oversight and control and that licensed sellers are regulated;
• As with any medication, there are both benefits and risks of using medical cannabis as a treatment for arthritis. Weighing these benefits and risks is an individual decision to be made based on an informed conversation between a patient and their healthcare provider.

The Canadian Spondyloarthritis Assocation’s Role: 

• Continue to prioritize patient care, access, needs and outcomes in any discussion pertaining to medical cannabis;
• Educate individuals living with SpA on the complicated characteristics of medical cannabis to allow individuals have informed discussions with accurate and evidence-based information with their physicians;
• Remain to be committed to ensuring decision makers clearly recognize the effect medical cannabis has on patients and influence policy change as necessary;
• Actively encourage and support the funding of research;
• Advocate that medical cannabis be tax exempt consistent with other medications; and patients have fair and equitable access (through public and private funders);
• Bring awareness to reduce stigma association with cannabis.

Sources:

1. Abramovici, H, et al. Cannabis – Information for Health Care Professionals. Prepared by Health Canada. Available at: https://www.canada.ca/content/dam/hc-sc/documents/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf
2. Klumpers LE, Thacker DL. A Brief Background on Cannabis: From Plant to Medical Indications. J AOAC Int. 2019;102(2):412‐420. doi:10.5740/jaoacint.18-0208
3. Sarzi-Puttini P, Ablin J, Trabelsi A, Fitzcharles MA, Marotto D, Häuser W. Cannabinoids in the treatment of rheumatic diseases: Pros and cons. Autoimmun Rev. 2019;18(12):102409. doi:10.1016/j.autrev.2019.102409
4. Capano A, Weaver R, Burkman E. Evaluation of the effects of CBD hemp extract on opioid use and quality of life indicators in chronic pain patients: a prospective cohort study. Postgrad Med. 2020;132(1):56‐61. doi:10.1080/00325481.2019.1685298