What integrative providers need to know about medicinal cannabis

By Katherine Shagoury

We need to end the stigma around cannabis use, said Carey Clark, PhD, RN, AHN-BC, at the 2019 Integrative Healthcare Symposium in New York City.

The endocannabinoid system is a signaling system composed of cellular cannabinoid receptors CB1 and CB2; endogenous agonists of the receptors, mainly anandamide and 2-arachidonoyl-glycerol; and other enzymes and proteins that regulate endocannabinoid levels.

Endocannabinoid receptors are active mainly in the brain, peripheral nervous system, and the immune system, CB1 receptors inhibiting release of glutamate and GABA and CB2 receptors modulating cytokine release and immune response. For example, CB1 decreases gut motility and CB2 reduces bowel inflammation.

The endocannabinoid system’s main role is to maintain homeostasis, Clark said. It controls and central and peripheral nervous systems and other physiology such as energy uptake, immune responses, processing and storage, reproduction, and cellular fate. Endogenous and exogenous cannabinoids held create balance through inhibition and excitation of the nervous system, bone formation and resorption, inflammatory and anti-inflammatory signaling, fat storage and release, and support the management of blood sugar levels, blood pressure, and hormone levels.

There are many cannabinoids in cannabis, though the well-known are tetrahydrocannabinol (THC) and cannabidiol (CBD). Cannabis is comprised of over 500 chemicals that work together to create different effects versus any one chemical alone, Clark said.

TCH, the psychoactive compound in cannabis, works primarily with CB1 receptors, but also has indirect interactions with CB2. CBD, on the other hand, works primarily in the immune system and CB2 receptors, creating homeostasis around the inflammatory response through influencing neurotransmitters. It does not have any psychoactive effects, Clark said, though it does modulate effects of THC by changing the shape of the CB1 receptor.

Our bodies react to both our own production of endogenous cannabinoids and to the ingestion of phytocannabinoids found in the cannabis plant, as well as other non-psychoactive plants such as echinacea.

Clark describes what she calls the Entourage Effect, over 100 cannabinoids and 500 compounds in cannabis working together to interact with the endocannabinoid system. All components of cannabis work together to interact with the endocannabinoid system, Clark said. This means there are implications for future strains, with new combinations of cannabinoids and terpenoids, to create effective personalized medicines for specific health issues. Clark encourages practitioners to consider the benefits of whole plan medicine versus selected synthetic cannabinoids.

The most common terpenes found in cannabis include myrcene, found in mango and lemongrass, limonene, found in citrus fruit rinds and peppermint, caryophyllene, found in black pepper and cloves, linalool, found in lavender and mints, and a-pinene, found in parsley and orange peel. Terpenoids are generally recognized as safe by the U.S. Food and Drug Administration and share a precursor with phytocannabinoids. Other cannabinoid plants include black peppercorns, rosemary, copaiba, black truffles, chocolate, echinacea, kava, liverwort, and hemp.

The common effects of cannabis depend on both context and dose, Clark said, and include nausea relief, relaxation, increased heart rate, lowered blood pressure, enhanced creativity, changes in sexual desire, and changes in anxiety levels.

It should be clear that everyone makes cannabinoids and everyone needs cannabinoids to function, said Clark. People who do not make enough cannabinoids need to supplement with exogenous cannabinoids through cannabis ingestion, in much the same way a diabetic needs insulin supplementation, Clark said.

However, though cannabis is becoming more widely accepted, there are still several challenges in supporting patient use of cannabis. These include prohibition, the complexity of the plant, and quality control, Clark said. The plant can vary from Sativa, Mycerene, or a hybrid, all of which have different effects, and the strains can vary from version to region, calling for personalized medicine based on symptomology management, efficacy, and side effects.

Cannabis medicine, Clark said, is ideally cultivated organically, extracted and processed using Good Manufacturing Practice, tested with information on cannabinoid and terpene profile, and free of pesticides and contaminants. It can be ingested using a variety of methods, from raw to topical to oral ingestion, and dosing should follow a “start low, go slow, stay low” mentality.

If cannabis is legal in the state, Clark suggests starting with cannabis versus synthetics. Use CBD primarily, she said, to avoid the side effects of THC.  A common dosing strategy might look something like this:

• Start with oral preparations at bedtime
  • Day 1-2: 1.25-2.5 mg THC
  • Day 3-4: increase by 1.25-2.5 mg THC
  • Days 5-6: increase again by 1.25-2.5 mg THC every two days until symptom relief is achieved
  • Side effects: reduce back to best-tolerated dose
• Daytime strategy: dose 2-3 times/day
  • Day 1-2: 2.5 mg THC once/day
  • Day 3-4: 2.5 mg THC/BID
  • Increase as tolerated up to a max of 15 mg THC, divided BID or TID
  • Doses > 20-30 mg may increase adverse effects or cause tolerance with no increase in efficacy.
• CBD: 5-20 mg, divided BID or TID

Clark urges practitioners to consider cannabis as part of a larger integrative healthcare model, which includes a balanced, anti-inflammatory diet, exercise, sleep, managing stress, and may include yoga, acupuncture, massage, and osteopathy.

“Patients are using cannabis,” said Clark. “We need to work with the patients and support their autonomy.”