Louisville Medicine Volume 69, Issue 6 | Page 19

oporosis , nausea , gastrointestinal diseases , chronic pain and more . 3
CB1 is the most abundant cannabinoid receptor in the central nervous system and is where THC binds and generates the psychoactive effects ( i . e ., the “ high ”) associated with THC . 4 In contrast , CB2 receptors are widespread in the periphery . 5 CBD acts upon a range of endocannabinoid receptors , modulates various bodily processes , and has relatively little psychoactive or addictive potential . 6
“ Is it legal ?”
Technically , marijuana is classified as a schedule 1 controlled substance . According to the Controlled Substance Act ( CSA ), schedule 1 substances have no accepted medical use and a high potential for abuse . Schedule 1 substances are supposed to be illegal to prescribe . However , to date , forty-one states have enacted medical marijuana laws that , to varying degrees , allow its use . Kentucky and Indiana are not on the list , although over the counter CBD products manufactured from hemp can be acquired legally in Kentucky and Indiana .
“ I live in Kentucky . How can I see if cannabinoids will help my condition ?”
CBD is a cannabinoid , and one can definitely find any number of CBD products to purchase . There are many vendors and manufacturers of CBD derived from marijuana ’ s less nefarious cousin – the hemp plant . CBD can have many beneficial effects , but CBD is not medicine . It is essentially a dietary supplement and , as such , is not monitored by the FDA . In other words , “ buyer beware .” Consumers must do their own research on companies who make CBD products in order make informed decisions . Most of the CBD you can buy over the counter is not so potent that you ’ ll risk harming yourself by using in moderation . That ’ s not to say it is risk free ( e . g ., it can make you sleepy , affect the metabolism of other medications and thin your blood ). It ’ s always best to consult with a health care professional . And CBD products , though not rife with THC , do contain traces of it and can give you a positive drug screen for THC – important to know , especially if your physician or employer requires drug testing .
There is one CBD product derived from cannabis that is actually an FDA approved medicine . Epidiolex ( a schedule 5 controlled substance ) is a potent form of CBD indicated for the treatment of seizures associated with Lennox-Gastaut syndrome , Dravet syndrome or tuberous sclerosis complex . 7 One of the major warnings on the Epidiolex FDA approved label pertains to potential liver damage . This may be due to the relatively high concentration of CBD found in Epidiolex .
There is also an FDA approved form of synthetic THC used to treat anorexia associated with weight loss in patients with AIDS and to treat nausea and vomiting associated with cancer chemotherapy - Marinol . 8 Marinol ( dronabinol ) is classified as a schedule 3 controlled substance .
While Epidiolex remains a medicine that has yet to find an off label niche , the same cannot be said of Marinol . Like any FDA approved medication , Marinol can legally be prescribed off label
SMOKING : SLOWLY TAKING YOUR BREATH AWAY for conditions where the health care provider determines there is a legitimate medical need , especially if other drugs have proven to be inadequate . 9 For example , off label use of Marinol might be considered for patients needing appetite stimulation or relief from nausea , spasticity , neurologic diseases , gastrointestinal disorders and chronic pain . 10 One advantage of prescribing Marinol off label ( as opposed to recommending medicinal marijuana ) is that Marinol , in fact , has a label with dosages , warnings , precautions and other pertinent information prescribers can utilize to optimize safety even when prescribing the drug for conditions other than those for which Marinol is FDA approved .
Consequently , it stands to reason that if under the care and guidance of a knowledgeable physician , if one wanted to experience the full potential medical benefit of marijuana , a regimen combining Marinol with CBD might be a reasonable ( and legal ) option . Over the years , I have employed this strategy with a select group of my patients , most of whom were suffering from severe neuropathic pain , often with co-morbid gastrointestinal diseases . In the majority of this cohort , I found the combination of Marinol and CBD to help not only a range of unpleasant symptoms , but to have an opioid-sparing effect as well . Some patients were even able to discontinue opioids altogether .
“ Can I try medical marijuana from the plant ?”
This is where it gets a little more nuanced , especially for Kentuckiana physicians , because medical marijuana from the plant is still not legal in Kentucky or Indiana . When faced with this dilemma , I default to my basic ethical responsibilities as a physician . After a thorough assessment , I educate and advise my patient as to the risks and benefits of the range of available treatment options in order to facilitate an informed decision by my patient , respectful of my patient ’ s right to agency and self-determination . 11 There have been some instances where I could not look my patient in the eye and tell them that I believe a trial of medical marijuana ( or , more commonly , continued use ) is unequivocally not in their best interest . In these cases , though not a prescriber , I am still their educator , still their doctor . As with any drug or treatment , the goal is to recommend the most effective regimen possible where the benefits outweigh the risks . Ultimately , marijuana must be viewed through this lens as well .
In truth , while there certainly is evidence that cannabinoids can be helpful in some cases , there has not been enough strong scientific evidence to persuade me to advocate for widespread use of medical marijuana . A 2017 review by the National Academies of Sciences , Engineering , and Medicine found that cannabinoids were effective in only three conditions : chemotherapy-induced nausea and vomiting , multiple sclerosis-related spasticity , and chronic pain . And the American Psychiatric Association is on record stating that there is no convincing scientific evidence that cannabis is beneficial for the treatment of any psychiatric disorder . 1
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