Medicinal Cannabis

This module examines the role of medicinal cannabis in treating neuro-inflammatory and neurodegenerative conditions such as multiple sclerosis, Parkinson's disease, and dystonia syndrome. It explores the involvement of the endocannabinoid system in the regulation of motor behaviour and the high density of cannabinoid receptors in the central nervous system, suggesting that modulating this system may be pertinent in treating motor symptoms such as spasticity, tremor, and dystonia. Medicinal cannabis in the form of an oro-mucosal spray has been shown to be beneficial at reducing spasticity in multiple sclerosis and has been registered on the Australian Register of Therapeutic Goods for some years. Other medicinal cannabis formulations may also be useful in managing movement disorders such as Parkinson’s and dystonia. This module also reinforces the important role of medicinal cannabis in alleviating non-motor-related symptoms such as depression, pain, insomnia, and anxiety as well as more broadly improving the patient's quality of life.

Cannabis-based medicine has been used to treat various pain states for centuries. But given the growing challenges in chronic pain management, we have begun to seek a more scientific, evidence-based approach to its use. This module weighs the evidence from significant research, reviews, and clinical trials regarding the use of medicinal cannabis in chronic, neuropathic, and intractable pain. It examines the role of cannabinoids in managing pain as an adjunctive or opioid-sparing therapeutic agent or as a third-line therapy when other treatments have failed. The module also examines medicinal cannabis use in ubiquitous headache disorders, which confer a significant personal and social burden of pain and disability and are also, often inadequately managed by conventional treatments. The module devotes a unit to the practical considerations of medicinal cannabis therapy. It recommends a treatment agreement between doctor and patient and outlines the features it should include such as setting goals, managing expectations, scheduling follow-up, and planning an exit strategy.

This module examines the use of medicinal cannabis in the treatment of autoimmune disorders and inflammatory conditions, particularly rheumatoid arthritis and fibromyalgia. These conditions are common, debilitating chronic pain syndromes with serious comorbidities and can impose a considerable personal and social disease burden. The conventional treatments for both conditions are problematic, lacking specificity in fibromyalgia and poor adherence to the pharmacological load. Side effects in rheumatoid arthritis are considered. For both conditions, cannabis and cannabinoids may offer a source of hope for sufferers and their physicians. When other treatment lines have been exhausted, medicinal cannabis may be a reasonable option to reduce pain and comorbidities, support deficient endocannabinoid tone and affect disease progression by modulating autoimmune and inflammatory responses. The module, therefore, provides guidelines for choosing a cannabis product and formulation, managing dosing and titration, and enfolding this into a holistic approach to reducing inflammation.

As the incidence of inflammatory bowel diseases rises, medicinal cannabis has been increasingly researched for employment in these diseases, particularly in the symptomatic relief from abdominal pain, nausea, diarrhoea and an improved sense of well-being. This module examines the role of medicinal cannabis in the management of Crohn's disease and ulcerative colitis. As with many chronic disorders, lifelong therapy is required and the pharmacological load in these conditions can be considerable with unacceptable side effects and only moderate control of symptoms. Given these factors, there is a role for medicinal cannabis; not curative or as a substitute for conventional medications aimed at altering the underlying disease, but for symptom management and improved quality of life. The module takes the form of four case studies, which examine different methods of approaching medicinal cannabis therapy given the relative paucity of specific recommendations for usage. The cases represent four inflammatory bowel states and guide the practitioner through negotiating what is in essence, a very personalised medicine.

This module considers the role of medicinal cannabis in the treatment of obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD) and Tourette's syndrome - all of which are encompassed in a wide spectrum of disease states. These neuropsychiatric disorders present a complicated diagnostic area where certain disease states may be comorbidities of another. Indeed, all conditions may exist concurrently with various ratios of each. In each condition, there is some form of dysregulation of the endocannabinoid system (ECS) and associated positive response to cannabis medicine when used to stimulate and support the ECS to facilitate better neurological functioning. Given that these conditions usually commence in childhood, the module discusses protocols and ethical considerations for treating the paediatric population with cannabinoid medicines. Case studies highlight the caution and flexibility required to achieve acceptable results with this highly individualised therapy, including careful, stepwise titration and monitoring with THC, consideration of different chemovars, and frequent communication with patients and carers.

This module examines the role of medicinal cannabis in type 1 and type 2 diabetes, metabolic syndrome, the comorbidity of glaucoma (secondary to retinopathy) and hypertension, which accelerates the risk and course of cardiovascular and other comorbidities. The module discusses salient evidence and research findings such as the effects of recreational cannabis use in diabetes, the uniquely diverse properties of THCV, and the anti-diabetic effects of Rimonabant. THC, CBD, and minor cannabinoids such as THCV, may be beneficial in the management of diabetes but  should be used adjunctively with conventional treatments. Careful monitoring of changes in the diabetic patient's blood sugar is necessary and glycaemic medications altered only if indicated. Cannabinoids may also treat a raft of diabetes-associated conditions such as hypertension and retinopathy. Case studies explore the use of medicinal cannabis for symptoms such as neuropathic pain, insomnia and restless leg syndrome in both cannabis experienced and naive patients as well as possible benefits such as changes in weight, blood sugar, and blood pressure.

This module examines the endocannabinoid system in the female reproductive tissues and the potential role of medicinal cannabis in women’s health. The symptoms of endometriosis and premenstrual syndrome may be extreme, debilitating and significantly impact the quality of life. Conventional treatments for these conditions are limited, with severe side effects making medicinal cannabis treatment a reasonable option. Conversely, osteoporosis may be asymptomic until fractures profoundly impact the morbidity and mortality of the patient. The module also considers research indicating that endocannabinoid dysregulation is involved in each of these disorders and the potential for activation or suppression of certain receptors with cannabinoids may support healthy endocannabinoid system homeostatic function in women's health. THC and CBD may play a role in modulating pain, reducing inflammation, regulating immune function, rebalancing endocannabinoid tone, enhancing bone healing and regeneration, and treating/preventing age-related and hormone deficiency-related bone loss and osteoporosis. The module guides the practitioner through choosing a cannabis product for these conditions.

This module discusses the considerable potential for medicinal cannabis (particularly CBD) to treat skin disorders, particularly those with an inflammatory component. It examines conditions such as eczema, psoriasis, fibrotic disorders (scleroderma), and non-melanoma skin cancer. The endocannabinoid system of the skin maintains cutaneous homeostasis and plays an important role in the regulation of the physiology of the skin, including the hair follicle and the immune system. The dysregulation of this system is linked to a wide variety of dermatological disorders. Research suggests that modulation of the endocannabinoid system could be a promising strategy for the treatment of skin disorders. The module also explores the relatively new area of cannabis support for pulmonary conditions given the bronchodilatory effect of THC and the anti-inflammatory effect of CBD. There is also the potential for endocannabinoid system-mediated immune modulation and anti-inflammatory responses. The module offers guidelines for the treatment of skin and pulmonary conditions with medicinal cannabis including the specific cannabis formulations for topical and inhaled administration.