Cannabinoids in medicine – an overview for doctors and professionals
Medicine Are you a medical practitioner, specialist/consultant, nurse or caregiver? Are you asked by patients about the therapeutic potential of cannabis and want to know more about it yourself as well? If so, this paper on the various aspects of the use of medicinal cannabis will help you to familiarise yourself with the topic.
The therapeutic potential of cannabis explained
Are you a medical practitioner, specialist/consultant, nurse or carer? Are you asked by patients about the therapeutic potential of cannabis and want to know more about it yourself as well? If so, this paper on the various aspects of the use of medicinal cannabis will help you to familiarise yourself with the topic. The related links are intended for the retrieval of detailed and country-specific information about the use of cannabinoids in medicine.
About medicinal cannabis and cannabinoids
When reference is made to medicinal cannabis, medicinal hemp or mediweed, the focus is on the therapeutic use of the active substances in the cannabis sativa L. plant, the cannabinoids.
It is assumed that cannabis contains approximately 60 phytocannabinoids. The most familiar cannabinoids, in particular when it concerns medicinal use, are tetrahydrocannabinol (THC) and cannabidiol (CBD) and cannabinol (CBN).
THC is a psychoactive cannabinoid and known for the intoxicating effect of cannabis. THC has a high therapeutic benefit and was isolated for the first time in 1964 by Prof. Raphael Mechoulam at the Weizmann Institute of Science in Israel.
CBD is also one of the more well-known and extensively researched phytocannabinoids. It acts as facilitator of THC’s effects and is therefore generally inherently classified as non-psychotropic. Studies have shown that CBD has a calming effect and this could go some way towards explaining why types with a high proportion of CBD are known for their “stone” rather than their “high”. Both of these effects will be considered in more depth further on in the text.
After THC and CBD, CBN is another notable cannabinoid. CBN has only a slight psychotropic effect and presumably acts as a weak agonist of the CB1 and CB2 receptors in the endocannabinoid system. Furthermore, it is known for its many medicinal applications, e.g. as an anticonvulsant and as an antiemetic. Moreover, CBN may be responsible in part for the calming effect of some cannabis types.
The endocannabinoid system and the benefit of therapy with cannabinoids
The human brain produces the neurotransmitter anandamide, which also belongs to the group of cannabinoids. The receptors for anandamide are distributed throughout the human body: in the nervous system, the intestines and in other organs, the brain in particular. These receptors send impulses to the brain. The network in which these processes occur is the endocannabinoid system, to which the two aforementioned receptors, CB1 and CB2, are connected.
The phytocannabinoids contained in cannabis are capable of binding to the endocannabinoid receptors in the human body and activating them in a process that is the basis of all the psychotropic and medicinal effects of cannabis.
The cannabinoid receptor 1 (CB1 for short) is found predominantly in nerve cells most commonly located in the cerebellum, the basal ganglia and in the hippocampus, as well as in the peripheral nervous system.
The cannabinoid receptor 2 (CB2 for short) on the other hand is mainly found in the cells of the immune system and in the osteoblasts or osteoclasts.
Cannabis-based medications are geared towards activation of the CB1 and the CB2 receptors. The fact that cannabinoids have a therapeutic benefit for a range of conditions has now been proven.
Which type of cannabis is best suited for medicinal applications?
The various types of cannabis differ in terms of their psychoactive and also their therapeutic effects.
In principle, all varieties of cannabis are suitable for medicinal use, which however does not mean that all types are actually available to patients. The different cannabis medications available on the market will be clarified later on in the text.
Because of their “high” effects, cannabis sativa strains are suited more for medicinal application during the daytime, e.g. if a high degree of alertness is needed. Similarly, cannabis indica strains are more suitable for evening and night-time use thanks to their calming effects and “stoned” effect. Hybrids, a combination of sativa and indica genetics, are suitable for patients who require the effects of both varieties in their individual therapy.
The differentiation between cannabis sativa and cannabis indica often leads to problems. This is why the medical scene often takes into account the cannabinoids THC and CBD when reference is made to the use of medicinal cannabis.
Medicinal cannabis is essentially available from pharmacies in three forms:
- high THC content and low CBD concentration;
- high THC concentration and high CBD content;
- low THC and high CBD content.
Nevertheless, the effect of cannabis and its areas of therapeutic application are illustrated below using the distinction between indica/sativa.
Medicinal cannabis indica strains
Cannabis indica strains have a high CBD and THC content. Indicas typically act like a sedative, leaving the user feeling “stoned”. This is physically perceptible to the patient in particular, as they experience a reduction in their muscle tension. Indicas are most effective for the treatment of muscle spasms and tremor symptoms, which occur for example in multiple sclerosis and Parkinson’s disease. Especially for chronic pain, cannabis represents an alternative to opiates worth considering, as well as for arthritic and rheumatic stiffness and swelling, and sleep problems and insomnia.
Medicinal cannabis sativa strains
Cannabis sativa strains tend to have a high THC and a lower CBD content. Sativas have a cerebral, energetic “high” effect, which is perceptible to the patient, both mentally and physically. Sativas are effective in the treatment of nausea and vomiting caused by chemotherapy or HIV/AIDS drugs, for loss of appetite, migraines, depression, chronic pain and related indications.
Medicinal indica/sativa hybrids
Hybrids of indica and sativa strains display the characteristic features of both cannabis types. This is beneficial for some patients, particularly if cannabis is prescribed to alleviate chronic pain since the indica and sativa strains are equally suitable for this purpose. The inclusion of sativa genes in an indica strain can promote mental clarity and attenuate calming/sedative effects, whilst the addition of indica genes to sativa strains can alleviate the occasional tendency of pure sativas to arouse fear or distress.
The nature of the disease being treated provides a good guide for whether an indica or a sativa strain is more appropriate. When selecting the most suitable type of medicinal cannabis in an individual case of illness, it is generally best to first of all ascertain the nature of the symptoms from which the patient would like to receive relief.
Points to be aware of
It is important to remember that every person has a totally different subjective experience of the medicinal application of cannabis, just as people differ from one another in their physiological predispositions. The information provided here is intended as a basic guide.
Medicinal cannabis and cannabinoid preparations in Europe
Generally, in Europe cannabis flowers and cannabis extracts can be prescribed by doctors of different disciplines. The following cannabis preparations are available on the market:
Medicinal cannabis flowers (cannabis flos)
Since 2005, the Dutch firm Bedrocan has been cultivating cannabis for the Dutch Ministry of Health, Welfare and Sport. Cannabis Flos Bedrocan®, Bedrobinol®, Bediol® and Bedica® can be prescribed by the doctor provided the patient is entitled to take cannabis flowers.
Bedrocan® has a THC concentration of around 22%. Its CBD concentration is under 1%. This cannabis type is a sativa.
Bedrobinol® has a THC concentration of around 13.5%. Its CBD concentration is under 1%. This is also classified as a sativa type.
The granulate Bediol® contains a CBD concentration of approximately 8% as well as a lower THC concentration of around 6.3%. This granulate is also a sativa.
Bedica® is the indica type amongst the medicinal cannabis flowers produced by Bedrocan. The THC concentration is around 14% and CBD concentration is less than 1%.
Bedrocan also has two other types in the range: Bedrolite® and Bedropuur®, however these two varieties are not available everywhere.
With a CBD content of 9% and a THC concentration of 0.4% Bedrolite® is a non-psychoactive type available to patients and for research purposes. Currently, this variety is only available in the Netherlands and countries supplied with the approval of the Dutch… Work is still being carried out towards a standard for this type
To date, Bedropuur® is only available in Canada and is solely for research purposes. This indica has a high THC content and a CBD concentration of less than 1%.
Bedica®, Bedrolite® and Bedropuur® are being standardised at the moment. Bedrocan®, Bediol®, Bedrobinol®, Bedica® and Bedrolite® were registered under Dutch law as medical resources.
The mouth spray sold under the name of Sativex and its active substance Nabiximols is licensed in a total of 15 countries, including Great Britain, Spain, Italy, the Czech Republic, Denmark and Germany. Nabiximols contains standardised quantities of tetrahydrocannabinol (THC) and cannabidiol (CBD), and is subject to drug regulations.
Sativex is licensed for the treatment of neuropathic pain and spasms in multiple sclerosis, and is currently also being developed for cancer therapy, specifically the treatment of cancer-related pain.
Medical practitioners and patients who want to obtain further information about Sativex can do so via this link.
Dronabinol, also known under the trade name of Marinol, is synthetically manufactured tetrahydrocannabinol (THC) and subject to the Narcotics Act. Marinol capsules or oily dronabinol drops contain a substance identical in structure to the herbal THC compounds.
Dronabinol is mainly used in the treatment of sickness and nausea following rounds of chemotherapy, and in the treatment of loss of appetite and weight loss in AIDS patients.
Dronabinol is not licensed in all European nations. Therefore, it is advisable to request information on the specific legislation for each country.
FAQs about Marinol are answered here by the manufacturer.
The fully synthetically manufactured THC derivative Nabilon is, like Dronabinol, prescribed and sold in Germany as a narcotic but, since 1991, is no longer available on the market as a finished medicinal product. Compounds are still available for example in Canada or in Great Britain. They are used to treat cachexia in AIDS patients, and to treat nausea and sickness caused by chemotherapy and radiotherapy in the context of cancer therapy.
Indications for the use of cannabis and cannabinoids
Cannabinoids have the potential to treat many illnesses and complaints. Their effectiveness has been well-documented against the following symptoms:
- Muscle cramps and spasms caused by multiple sclerosis or spinal cord injuries,
- Nausea/vomiting, loss of appetite, weight loss and weakness caused by cancer or AIDS,
- Drug-related, chemotherapy-related or radiation therapy-related nausea and sickness in cancer, hepatitis C, HIV or AIDS patients,
- Chronic pain, particularly if the pain relates to the nervous system or caused by a nervous disorder,
- Therapy-resistant glaucoma,
- Tourette’s Syndrome,
- Post-traumatic stress disorder,
- Depressive disorders,
- Morbus Crohn.
On page 43 of the Alternative Drugs and Addiction Report 2015 there is a list of other diagnoses which are treated with medicinal cannabis.
What are the side effects of cannabis therapy?
Frequent side effects of cannabis are tiredness, dizziness, psychoactive effects including feelings of euphoria, and dryness of the mouth. Nonetheless, patients report that tolerance is quickly built up against the so-called side effects. It is also important to mention that in therapeutic use of cannabinoids withdrawal symptoms are scarcely a problem.
Clinical studies pertaining to the use of cannabis and cannabinoids in medicine
In the past few years numerous studies pertaining to the use of medicinal cannabis have been carried out internationally.
Recently, the International Association for Cannabis as Medicine (IACM) published a summary of clinical studies on cannabis and cannabinoids, which contains detailed information.
In addition, the multilingual Information platform of the IACM provides a wealth of information relating to medicine, science, law and politics regarding medicinal cannabis and cannabinoids.
For doctors and patients: Ways to obtain information and medicinal cannabis
The option to employ cannabinoids in medicine varies from one country to another. The following information and links are intended to provide country-specific information about medicinal cannabis.
In Germany, treatment with cannabis and cannabinoids consists of either the prescription of cannabis-based drugs or an application for an exemption to use cannabis flowers (cannabis flos) from the Federal Institute for Drugs and Medical Devices – Federal Opium Agency (BfArM). To provide cannabinoid drugs via a narcotic prescription, a medical practitioner does not require an exemption. Every doctor can prescribe these drugs on a private narcotic prescription. The German government has announced its intention to promulgate a law in 2016 which will ensure the following:
- make cannabis flowers a relatively uncomplicated drug available to patients, doctors and pharmacies via a narcotic prescription
- allow the roundabout approach via government special permits to be discontinued;
- provide for costs to be reimbursed by the health insurance companies “in certain cases”;
- provide for a cannabis agency to ensure supply, and award, allocate and monitor licences for cultivation of cannabis as a medicine.
Medical practitioners have the opportunity to discuss the issue with colleagues and professionals. The German Association for Cannabis as Medicine (ACM) has compiled a guide for doctors and patients which contains all the necessary information. The information sheet can be downloaded here.
The ACM also has an internal mailing list for doctors and issues a regular informative magazine . Its website contains a section called “Von Arzt zu Arzt” (From doctor to doctor) where, amongst other things, a video about the options for legal use of medicinal cannabis can be accessed.
In the Netherlands, since 2003 cannabis flos can be prescribed by doctors and distributed by pharmacies. Currently, Bedrocan supplies five types of medicinal cannabis. Scientists, universities, hospitals and pharmacies can obtain information from the Office for Medicinal Cannabis about medicinal cannabis. An informative brochure has also been compiled for patients.
The independent foundation Dutch Association for Legal Cannabis and its Constituents as Medicine (NCSM) has set itself the target of improving the level of knowledge about medicinal cannabis amongst patients and doctors. There are practical tips about prescribing, payment and use, even as a patient travelling abroad.
For patients, other information platforms are available, such as that of the Mediwiet foundation, which explains and regularly posts interviews with concerned parties.
Medicinal cannabis is illegal in France. In June 2013, a decree was issued which supplemented the existing paragraphs contained in the legal code for healthcare, which serves as established case law for drug users, whilst producers or dealers are prosecuted under the Criminal Code. This decree licences cannabis-based drugs although not medicinal cannabis flowers.
The UFCM icare (French Union for the use of cannabinoids in medicine) holds an annual symposium for doctors from all over Europe in which discussion focuses on pharmaceutical advances and the therapeutic use of cannabinoids in medicine. The organisation is also an extremely important link between medical practitioners and patients.
Cannabis is not recognised in England and Wales as a remedy with therapeutic benefits. Cannabis-based medicines nevertheless may be prescribed under certain conditions, e.g. the above-mentioned remedy Sativex. Doctors can prescribe this mouth spray on a private prescription at their own risk, pharmacies are allowed to prepare it on prescription and patients who have such a prescription can obtain Sativex.
The remedy Nabilon which was licensed in Great Britain in 1982 is available on prescription for use in hospitals, as already described for the treatment of nausea following chemotherapy.
Doctors who wish to be informed about (medicinal) cannabis in Great Britain can do so at the independent drugs institute drugscience .
It is also important to note that non-UK residents who are in possession of a cannabis prescription and correct documentation are allowed as part of the Schengen Agreement to bring their cannabis to Great Britain if they intend to travel to the country. This law does not apply to UK residents; they cannot travel to another country, get a prescription and re-enter the country with cannabis.
The therapeutic application of cannabis in Spain is regulated via hospital prescriptions. It should be noted that medicinal users do not enjoy any benefits, since in Spain no distinction is drawn at the legislative level between recreational and medicinal use. The latter is being tolerated more and more, however.
In Spain, Catalonia and the Basque region have so far advocated official legalisation of medicinal cannabis. Catalonia’s Ministry of Health has taken steps to regulate the use of cannabis for medicinal purposes. Patients with painful diseases such as cancer and AIDS, for example, can be provided with Sativex to ease their symptoms. The medication was licensed in Catalonia and can be used by all patients who suffer pain because of their disease (cancer) or because of chemotherapy. Sativex can fundamentally be prescribed to patients who do not respond well to conventional therapies.
Another option for patients who wish to receive and use medicinal cannabis are the so-called Cannabis Social Clubs.
Cannabinoids in medicine – conclusion
One plant, one Europe, different laws. With this overview of cannabinoids in medicine, products, facts, current knowledge, and information on the legal situation and the many links included, we hope that we have been able to help you to familiarise yourself further with the topic. Do not hesitate to get in touch with us if you require any additional information. You can use the comments box below to contact us.