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The Practical Use of
Cannabinoids in the

Dr Willy Notcutt, FRCA, FFPMRCA
James Paget Hospital
[email protected]
• The endocannabinoid system is a therapeutic target yet to be properly explored for pain management • Cannabinoids are a new medicine to clinicians – New role, effects, benefits, side-effects But…• Many of our patients are already using street Cannabis for symptom control using similar materials but different delivery systems.
Focusing on Medicinal Products in use.
Selecting Patients
Pain Problems
Neuropathic (L)
Central (L)
Peripheral (L)
Cancer Pain (L)
Other Areas
Anti-emetic, CINV
• Nabilone (Cesamet) : synthetic THC analogue • Dronabinol (Marinol): synthetic THC 2.5/5/10mg – Appetite stimulation in AIDS– CINV nausea and vomiting • Nabiximols (Sativex): plant extracted THC/CBD – MS related spasticity/spasms– Cancer Pain– Neuropathic Pain • Bedrocan (plant) and Namisol (plant THC tablet) Which Patients ?: Complex not
others are ineffective, insufficient or not tolerated (eg. Baclofen, Tizanidine Gabapentin, Opiates) • Occasional recreational use when young • Smoking a cannabis cigarette at night to • Smoking cannabis 6x /day
Regular recreational use
Dependency history
– IHD– Hypertension– Dysrhythmias– Postural hypotension– Mixture of Medications – Tissue solubility, self administration – Epilepsy– Psychosis, Endogenous Depression, – Addiction/Abuse/Alcohol problems– Note: MS is associated with Suicide, Preparing the Patient
Importance of Titration
– Psychosis– Addiction– Cognitive Impairment, Memory – Increased appetite (Munchies)– Excessive Hypotonia • What happens when an accident occurs? 1 “joint” equivalent to get “high”; ƒ Tracking tasks are affectedƒ Reaction times increased therefore drive more slowly – unlike alcohol Acute cannabis consumption and motor vehicle collision risk:
systematic review of observational studies and meta-analysis

Acute cannabis consumption nearly doubles the risk of a collision resulting in serious injury or death; this increase was most evident for studies of high quality, case-control studies, and studies of fatal collisions The influence of cannabis use on the risk of minor collisions remains unclear Any impairment is probably well within the range of (or lower than) what is currently produced by pharmaceutical agents which are commonly used for similar conditions. (Opiates, Benzodiazepines,Tricyclic Antidepressants, Baclofen, etc) Hadorn. The Medicinal Uses of Cannabis and Cannabinoids Prescribing Cannabinoids
• To increase appetite, 1-2 times a day – bd • The usual dosage of Cesamet is 1 mg or 2 • Nabilone should be given 1 to 3 hours before chemotherapy, and a dose given the night before • Nabilone may be given for the entire course of each chemotherapy cycle and, if needed, for 48 hours after the last dose of each cycle.
vaporizer can be used to inhale cannabis vapor. Further Management
Every Patient is Different in Symptoms and Response
Consider NRS (Numerial Rating Score 0-10) etc.
What If…?
• Patient needs to come into hospital for surgery • Patient is admitted for a medical emergency • Patient wants to go abroad on holiday • Patient wants a break from the medicine • Ensure patients return empty bottles? personal, legitimate recreational drug source • The “High” is better with smoking • Cost of the Medicines
Cost of other MS medicines
Attitudes to Cannabinoids



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