The Endocannabinoid System:
It’s not just about weed!
J. Randle Adair, D.O., Ph.D.
Diplomate, American Board of Internal Medicine
Certified, American Society of Addiction Medicine
Attending, Adult Hospital Medicine
Albuquerque VA Medical Center
Albuquerque, NM
What is weed?
• Americans for Safe Access, a medical marijuana advocacy group,
stated in its website article "Research: Definitions and Explanations"
(accessed Dec. 7, 2006):
• "...there are 483 different identifiable chemical constituents known to
exist in cannabis. The most distinctive and specific class of compounds
are the cannabinoids (66 known), that are only known to exist in the
cannabis plant.
Other constituents of the cannabis plant are: nitrogenous compounds
(27 known), amino acids (18), proteins (3), glycoproteins (6), enzymes
(2), sugars and related compounds (34), hydrocarbons (50), simple
alcohols (7), aldehydes (13), ketones (13), simple acids (21), fatty
acids (22), simple esters (12), lactones (1), steroids (11), terpenes
(120), non-cannabinoid phenols (25), flavonoids (21), vitamins (1)
[Vitamin A], pigments (2), and elements (9).
The very most of these compounds are found in other plants and
animals and are not of pharmacological relevance with regard to the
effects exerted by cannabis preparations."
Are there differences in weed?
• Indica:
Indica has a higher CBD (Cannabidiol) content than THC. CBD has a
sedative effect, producing a more relaxing/sleepy type of effect.
According to extensive anecdotal evidence, Indica strains are more
effective in treating ailments including anxiety, pain, nausea, appetite
stimulation, sleep, muscle spasms and tremors, and much more.
• Sativa:
Sativa conversely has a higher THC content making it much more
potent. This creates a more cerebral, energetic, and soaring effect.
These Sativa strains create more of a stimulant effect, which has
shown to be effective in treating migraines, pain, nausea, depression,
and is also good for appetite stimulation.
Neural Reward Circuits Important in the Reinforcing Effects of Drugs of Abuse
Camí, J. et al. N Engl J Med 2003;349:975-986
The Architecture: The Synapse
• from Mihic & Harris, 1997
Metabotropic Mechanisms of Action of Drugs of Abuse
Camí, J. et al. N Engl J Med 2003;349:975-986
Are there valid medical uses for
endocannabinoid drugs?
Marinol
•
•
•
•
•
•
"Marinol (dronabinol) is the only cannabinoid with approval for marketing in the United
States....
Marinol is manufactured as a capsule containing THC in sesame oil; it is taken orally. It
was approved by the FDA in 1985 for the treatment of nausea and vomiting associated
with cancer chemotherapy. In 1992, the FDA approved marketing of dronabinol for the
treatment of anorexia associated with weight loss in patients with AIDS. The preclinical
and clinical research on THC that culminated in the FDA's 1985 approval was supported
primarily from the National Cancer Institute (NCI), whose research support goes back to
the 1970s....
Marinol is synthesized in the laboratory rather than extracted from the plant. Its
manufacture is complex and expensive because of the numerous steps needed for
purification. The poor solubility of Marinol in aqueous solutions and its high first-pass
metabolism in the liver account for its poor bioavailability; only 10-20% of an oral dose
reaches the systemic circulation.
The onset of action is slow; peak plasma concentrations are not attained until two to four
hours after dosing. In contrast, inhaled marijuana is rapidly absorbed....
Marinol's most common adverse events are associated with the central nervous system
(CNS); anxiety, confusion, depersonalization, dizziness, euphoria, dysphoria, somnolence,
and thinking abnormality."
http://medicalmarijuana.procon.org/view.answers.php?questionID=000089
Rimonabant
a/k/a
Accomplia
Effect of Placebo or Rimonabant for 52 Weeks on Body Weight, Waist Circumference, Plasma
Triglyceride Levels, and High-Density Lipoprotein (HDL) Cholesterol Levels
Despres J et al. N Engl J Med 2005;353:2121-2134
Other scientific trials
• Rimonabant improves tobacco cessation
and blocks inhibition produced by alcohol
in amygdala projections
• Modulation of CNR1 gene receptor reduces
cocaine dependence and IV drug use
• Stimulation/blockade of EC systems
modulates GABA, glutamate and dopamine
systems
More scientific studies
• “Knockout” of CB1 receptors blocks social
withdrawal in PCP-induced schizophrenic
activity in mice
• Chronic stimulation of CB2 liver receptors
results in regression of fibrosis in cirrhosis
• High incidence of Q63R polymorphism of
the CB2 gene in Japanese alcoholics and
depressed subjects
CB2 and pain
• CB2 agonists (AM1241) inhibit nociception
without producing CNS effects
– The effects do not cross-over to morphine effects
• CB2 appears to modulate:
–
–
–
–
–
Acute pain
Chronic inflammatory pain
Post surgical pain
Cancer pain
Pain associated with nerve injury
Are there valid medical uses for
marijuana?
NEW MEXICO
Medical Cannabis in the U.S.

Many other states have
legislation pending


Six states recognize or
regulate medical marijuana
production or dispensaries


AL, AZ, CT, DE, IL, KS, MD,
MN, NH, NY, OH, PA, SD,
TN, WI
CA, CO, ME, NJ, NM, RI
Shift in public acceptance
over time
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Purpose of the Program
The Lynn and Erin Compassionate Use Act:
“The purpose of the act is to allow the beneficial use
of medical cannabis in a regulated system for
alleviating symptoms caused by debilitating medical
conditions and their medical treatments”
Established July 2007
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NM Medical Cannabis Program
Legislative Statute
Medical Advisory
Board
Register
Production and
Eligible
Distribution of
Patients
Product
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NM Program Structure
STD
Harm
TB
Reduction
Infectious
HIV
Disease
HIV
Bureau
Prevention
Services
Viral
Immunization
Hepatitis
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Qualifying Conditions
Original Conditions
Conditions Added

Cancer

Painful peripheral neuropathy

Glaucoma

Intractable nausea/vomiting

HIV/AIDS

Severe anorexia/cachexia

Multiple Sclerosis

Hepatitis C infection currently

Epilepsy

Spinal Cord Damage with
Intractable Spasticity

Crohn's disease

Post-traumatic Stress Disorder
Patients in hospice care

Amyotrophic Lateral Sclerosis

Severe Chronic Pain

Autoimmune mediated
inflammatory arthritis

receiving antiviral treatment
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Numbers of Licensed Patients
1 condition
added
Cumulative # Approved
2500
2043
2000
1 condition
added
1500
7 conditions
added
1000
500
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Qualifying Conditions
Original Conditions
Conditions Added

Cancer

Painful peripheral neuropathy

Glaucoma

Intractable nausea/vomiting

HIV/AIDS

Severe anorexia/cachexia

Multiple Sclerosis

Hepatitis C infection currently

Epilepsy

Spinal Cord Damage with
Intractable Spasticity

Crohn's disease

Post-traumatic Stress Disorder
Patients in hospice care

Amyotrophic Lateral Sclerosis

Severe Chronic Pain

Autoimmune mediated
inflammatory arthritis

receiving antiviral treatment
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

Distribution System in NM
must provide for…..
Production facilities
within New Mexico

Housed on secure
grounds

Operated by producers
licensed by the DOH
Distribution to qualified
patients or their
qualified caregiver
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Personal
Production
License
Licensed
Non-profit
Producers
NEW MEXICO
Supply Options
Personal Production
License



Any patients enrolled in the
medical cannabis program may
apply for a personal production
license
Grants permission to grow 4
mature cannabis plants and 12
seedlings at any given time
$15 fee – waived if income <400%
of the Federal Poverty Guidelines
Licensed
Non-profit Producers

Non-profit businesses that have
been granted a production license
from the Department of Health

Regulations for oversight by DOH

Allows up to 95 plants + seedlings
in total

Purchase of product is an individual
transaction between program
participant and producer (DOH does
not control pricing or product)
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

What the Program is…..
What the program IS….

An opportunity for patients who have not gained
relief from other interventions (medical, surgical)
to find relief of symptoms

Compassionate use
What the program is NOT….

A primary medical therapy for conditions

A naturopathic option for patients who prefer not
to use allopathic medications

Legal cover for those who wish to use for nonmedical or mixed purposes
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What does a provider
certification mean?

A recommendation that you feel a patient may
benefit from the use of medical cannabis to
relieve symptoms

Verification


That the patient has the diagnosis stated

That the patient has symptoms unrelieved by
other treatments

That the potential benefits of cannabis use
outweigh the risks
It is NOT a prescription for cannabis!!
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Application Requirements

Consent to Release Medical Information

Government issued photo I.D. confirming New
Mexico residency for patient

Medical Provider Certification

Provider information

Qualifying medical condition

Certification

Debilitating medical condition

Symptoms requiring cannabis

Risks vs. benefits
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Provider
Information
Diagnosis and
special
requirements
Fill-in section
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
Severe Chronic Pain


Requires confirmation of the diagnosis from an ophthalmologist
Painful Peripheral Neuropathy


Requires confirmation of the diagnosis from a psychiatrist
Glaucoma


Requires a second certification from a specialist with expertise in
pain management or expertise in the condition that is causing
the Severe Chronic Pain
PTSD


Some Conditions have
Additional Requirements
Medical records must be sent to document objective evidence of
neuropathy
Auto-immune mediated inflammatory arthritis

Certification must come from a rheumatologist
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Application Requirements

Applicants are sometimes asked to submit
additional medical records

Medical Records are requested on a case-bycase basis

Records may be requested in order to verify
prior treatments, verify the debility of the
patient’s condition, etc.
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Review Process

Program staff verify that all required documents are present. If
documents are missing, staff contact the applicant.

IDB Medical Director reviews application

Verifies provider’s authority to certify

If needed, calls certifying provider for verification of the patient’s
medical condition and need for compassionate use

If denied, a formal notice is mailed to the patient.

If approved, a ‘new patient packet’ is mailed to the applicant. This
includes:

Copy of the Lynn and Erin Compassionate Use Act,

Patient’s registry I.D. card

Contact information for state-licensed producers
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
Website


For More Information…….
www.nmhealth.org/IDB/medical_cannabis.shtml
Program Staff

Program Manager: Dominick Zurlo

Medical Director: Linda Gorgos

Phone (505) 827-2321

Email medical.cannabis@state.nm.us
Building A HEALTHY New Mexico!
The 7% Solution to the
Recession!!!
• Currently before the NM State legislature is
a proposal to apply a 7% “gross receipts”
tax on producer revenues
• Indistinguishable from tobacco or alcohol
taxes
• Similarly “addictive” as a State policy
• About as medically scientific as chewing
chicona bark to get the antimalarial effect of
quinine.
Now, if nothing else, you
understand………..
The “munchies”
Thank you!!!