The use of cannabis has been well documented for both recreational and medicinal purposes since the late 20th century. In recent years, many states have enabled legislation to allow the use of cannabis for medicinal purposes to treat a variety of conditions. Providers in both the acute and community settings are encountering patients using cannabis in a variety of forms.
The endo cannabinoid system is a lipid signaling network which modulates neuronal functions in the inflammatory processes. The system down regulates stress related signals that lead to chronic inflammation and pain. The EC is composed of endocannabinoids, which are endogenous lipid based retrograde neurotransmitters that bind to cannabinoid receptors and proteins located in the CNS and PNS. Receptors for CBD-1 are found mostly in the brain with high concentrations in the hippocampus, associated cortical regions, cerebellum, and basal ganglia. They are sparse in the brainstem, medulla and thalamus thus limiting the life-threatening effects on vital physiological functions. CBD-1 receptors are also found in the testis, sympathetic nervous synapses, adrenal glands, heart, lungs, prostate, bone marrow, thymus, and tonsils. CBD-2 receptors are found mainly in the immune system, with the highest expression seen in B lymphocytes. They also serve an important role in immune function and inflammation (Fine, P and Rosenfeld, M.).
The two main chemical components of cannabis are THC and CBD. THC is known for its psychotropic effect while CBD is used more for pain control. A secondary main component of cannabis are the terpenes. Terpenes provide an “entourage effect” which can be described as enhancements derived from combining phyto-cannabinoids with other plant-based molecules. Terpenes are full of flavor and fragrances that are common to the human diet such as lemon, pine, lavender, mango, and vanilla (Pertwee, R.).
Cannabis is grown as sativa, indica, or hybrid plant. Sativa based products are known for their stimulation effect while Indica based products can be utilized for sedation and pain control. Hybrid products are utilized frequently for patients attempting to achieve both pain control as well as appetite stimulation. Many patients will utilize both types of products within a 24-hour period to achieve maximum control of symptoms (Wilkie, S., Sakr, B., Rizack, T).
Cannabis has a favorable safety profile when compared to other analgesic medications. THC can be more sedating than codeine, but unlike opiates, it is not associated with respiratory depression. Possible side effects within the CNS include euphoria, disorientation, drowsiness, dizziness, motor incoordination, and poor concentration. Patients may also report tachycardia, hypotension, bronchodilatation, muscle relaxation, and decreased GI motility (Fine, P., and Rosenfeld, M.).
Currently, 29 States and the District of Columbia have medical cannabis programs in place. Many states also allow recreational cannabis. While currently no advanced practice providers in any of the 29 states can prescribe or recommend medical marijuana, APPs can take an active role in education of patients and evaluation of efficacy of symptom control.
As the use of cannabis becomes more widespread in the United States, providers must take an active role in understanding the pharmacokinetics of cannabis in its utilization in practice. Providing other advanced practice providers, patients, and their caregivers with additional information on the utilization of cannabis will help our patients become better informed and take a more active role in their care.
Fine, P. and Rosenfeld, M. (2013). The Endocannabinoid System, Cannabinoids and Pain. Rambam Maimoines Medical Journal. 4 (4): e0022. DOI: 10.5041/RMMJ.10129
Pertwee, R. (2006). Cannabinoid Pharmacology: the first 66 years. British Journal of Pharmacology. 147 (S1). S163-S171. DOI:10.1038/sj.bjp.0706406
Wilkie, G., Sakr, B., Rizack, T. (2016). Medical Marijuana Use in Oncology A Review. JAMA. 2(5):670-675. DOI:10.1001/jamaoncol.2016.0155
Cannabis Use in Practice
Katherine Alexander, MS, APRN-CNP, BBA
The Zangmeister Cancer Center, Columbus, Ohio
The use of cannabis has been well documented for both recreational and medicinal purposes since the late 20th century. In recent years, many states have enabled legislation to allow the use of cannabis for medicinal purposes to treat a variety of conditions. Providers in both the acute and community settings are encountering patients using cannabis in a variety of forms.
The endo cannabinoid system is a lipid signaling network which modulates neuronal functions in the inflammatory processes. The system down regulates stress related signals that lead to chronic inflammation and pain. The EC is composed of endocannabinoids, which are endogenous lipid based retrograde neurotransmitters that bind to cannabinoid receptors and proteins located in the CNS and PNS. Receptors for CBD-1 are found mostly in the brain with high concentrations in the hippocampus, associated cortical regions, cerebellum, and basal ganglia. They are sparse in the brainstem, medulla and thalamus thus limiting the life-threatening effects on vital physiological functions. CBD-1 receptors are also found in the testis, sympathetic nervous synapses, adrenal glands, heart, lungs, prostate, bone marrow, thymus, and tonsils. CBD-2 receptors are found mainly in the immune system, with the highest expression seen in B lymphocytes. They also serve an important role in immune function and inflammation (Fine, P and Rosenfeld, M.).
The two main chemical components of cannabis are THC and CBD. THC is known for its psychotropic effect while CBD is used more for pain control. A secondary main component of cannabis are the terpenes. Terpenes provide an “entourage effect” which can be described as enhancements derived from combining phyto-cannabinoids with other plant-based molecules. Terpenes are full of flavor and fragrances that are common to the human diet such as lemon, pine, lavender, mango, and vanilla (Pertwee, R.).
Cannabis is grown as sativa, indica, or hybrid plant. Sativa based products are known for their stimulation effect while Indica based products can be utilized for sedation and pain control. Hybrid products are utilized frequently for patients attempting to achieve both pain control as well as appetite stimulation. Many patients will utilize both types of products within a 24-hour period to achieve maximum control of symptoms (Wilkie, S., Sakr, B., Rizack, T).
Cannabis has a favorable safety profile when compared to other analgesic medications. THC can be more sedating than codeine, but unlike opiates, it is not associated with respiratory depression. Possible side effects within the CNS include euphoria, disorientation, drowsiness, dizziness, motor incoordination, and poor concentration. Patients may also report tachycardia, hypotension, bronchodilatation, muscle relaxation, and decreased GI motility (Fine, P., and Rosenfeld, M.).
Currently, 29 States and the District of Columbia have medical cannabis programs in place. Many states also allow recreational cannabis. While currently no advanced practice providers in any of the 29 states can prescribe or recommend medical marijuana, APPs can take an active role in education of patients and evaluation of efficacy of symptom control.
As the use of cannabis becomes more widespread in the United States, providers must take an active role in understanding the pharmacokinetics of cannabis in its utilization in practice. Providing other advanced practice providers, patients, and their caregivers with additional information on the utilization of cannabis will help our patients become better informed and take a more active role in their care.
Learn More
To learn more about this topic and earn CE credit, register for our NPacers Aug 30th – Sept 1st Virtual Conference, which features a session on Medical Marijuana.
References:
Fine, P. and Rosenfeld, M. (2013). The Endocannabinoid System, Cannabinoids and Pain. Rambam Maimoines Medical Journal. 4 (4): e0022. DOI: 10.5041/RMMJ.10129
Pertwee, R. (2006). Cannabinoid Pharmacology: the first 66 years. British Journal of Pharmacology. 147 (S1). S163-S171. DOI:10.1038/sj.bjp.0706406
Wilkie, G., Sakr, B., Rizack, T. (2016). Medical Marijuana Use in Oncology A Review. JAMA. 2(5):670-675. DOI:10.1001/jamaoncol.2016.0155
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