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Contemporary Cannabis and Its Medicalization

Legal Status and Accreditable Practice Standards

Cannabis is undergoing a social process of “medicalization” similar to what has been described with how contested illnesses come to be recognized as legitimate and within the domain of medicine.1 That process differentiates medicinal cannabis use from drug abuse and is reflected in the various medical access laws and institutional initiatives such as professional organization endorsements. Physician-led initiatives directed through the American Society of Cannabinoid Medicine (ASCM) provide responsible legislative guidance and leadership to advance high-quality education and clinical research. Physician-focused organizations including the American Academy of Cannabinoid Medicine and the Society of Cannabis Clinicians provide a basis through which contemporary practice standards are being established. Such standards of care are essential to assess and correct for negative patient outcomes. Accreditable goals will be essential to this emerging healthcare sector’s ultimate success. Enforcing these practices through licensing dependent on accreditation will ensure continuous quality improvement benefits, similar to the metrics used elsewhere in healthcare. The medicalization of cannabis is currently incomplete, but it is slowly being incorporated into physician education and practice, and gradually becoming less controversial.

Until then, as a Schedule I substance, cannabis cannot be legally “prescribed” anywhere in the United States. Federal courts have ruled that First Amendment protections of free speech cover doc- tor-patient communications, including the written “recommendations” required to participate in state medical cannabis programs. Doctors who recommend cannabis to their patients may experience heightened scrutiny from their peers, including state medical boards. These boards in states with medical cannabis programs have begun to develop limited practice standards for recommending cannabis. Those typically entail a physical exam and preservation of patient records, but minimal follow-up requirements to assess patient outcome. Careful re-evaluation is important to determine underlying conditions producing pain or other symptoms that may necessitate additional therapeutic or curative interventions. Cannabis can be considered as a complementary palliative medicine; however, at this time its recommendation should not be intended as an alternative medicine if that implies it to be a substitute for the evidence-based data essential to Western medicine’s diagnostic and therapeutic advances.

Guidelines vary between countries such as Israel and Canada that allow access via a physician’s prescription. Health Canada has developed medical cannabis access regulations, and the Canadian Medical Association, the Canadian Medical Protective Association, and the College of Family Physicians of Canada have published practice guidelines for responsibly treating chronic pain and other debilitating illnesses.80-84

Future Developments

At this time, whole-plant preparations of cannabinoids and terpenoids produce multiple effects that are inseparable from one another. Future phytocannabinoid medicines may be developed which can exert their effects in isolated areas, including operating in the periphery on pain and other conditions without crossing the blood-brain barrier to include central effects. Developing methods of selectively inhibiting the psychoactive side effects of THC, such as increased synthesis of pregnenolone, may also enhance the versatility and tolerability of cannabinoid medicines.

E-cigarette technology developed for nicotine delivery has recently extended to the systemic absorption of vaporized cannabis plant flower oils by utilizing so-called vape pens. While many vaporizers of cannabis are commercially available, devices that allow precise, consistent temperature control are ideal, as different temperatures will release varying combinations of these cannabinoid and terpene chemicals. Nevertheless, the black market operating within a largely unregulated vaporizing device industry currently appears to be responsible for increasing pulmonary deaths. These lethal complications associated with inhaled super-heated carrier chemicals or contaminants will renew clinical interest in the dermal absorption of therapeutic lipids.

Topical application and transdermal methods of delivery using nanoscale molecules such as liposomes improve the local site-specific and systemic delivery of the lipophilic cannabinoids and terpenoids produced by the cannabis plant. Nanotechnology can facilitate the transportation of these drugs across epithelial and endothelial barriers, as well as extending their bioactivity and retention in the body to allow a more effective duration of treatment.85

Drug development may profitably focus on enhancing natural ECS activity, but basic lifestyle adjustments are also likely to contribute to a healthier ECS response to stressors. That may be as simple as advising patients not only on the importance of exercise and sleep, which are both tied to ECS function, but also on what to eat. Because the endogenous ligand anandamide and other important, related lipids are synthesized in humans from omega-3 fatty acids (such as fish oil), dietary adjustments or supplements may also serve to improve ECS function.

The biosynthesis and degradation of enzymes such as fatty acid amide hydrolase (FAAH) and monoglyceride lipase (MGL) that break down endocannabinoids are prime targets for new drug development. Manipulating these enzymes may harness innate processes that counteract disease states, and plant-derived molecules such as cannabidiol (CBD) hold significant promise for this. Allosteric modulators of endocannabinoid receptors other than CBD are a target of future drug development, as their effects on the receptors’ activity can potentially enhance endogenous cannabinoid function.

The 2019 case report of a woman who did not manifest anxiety or perceive pain as a noxious stimulus discovered that she had a pseudogene microdeletion compromising FAAH’s breakdown of anandamide.86 Not unexpectedly, this individual’s extraordinary phenotype also appears to cause other central nervous system side effects, including memory impairment. Future work will help to understand if targeting this link using viral short hairpin RNA or gene-editing techniques could be effective as an analgesic or anxiolytic drug development strategy.

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