Medicinal Cannabis

Cannabis plant with oil

MEDICINAL CANNABIS IS ONLY OFFERED BY CERTAIN DOCTORS. An upfront deposit is generally required to make this long appointment. Please do not book on-line. Prepare for the appointment by reading this page and watching the videos linked below.
Please also note our Website Disclaimer Updated 8/5/2022

Overview of medicinal cannabis VIDEO

Overview of treatment VIDEO - MUST WATCH THIS


Video on the nonsense of cannabis-presence driving offences

Here is a link to a video that explores the nonsense of Australia’s cannabis-presence driving offences, and the nonsense of Australia’s police roadside drug testing (RDT) regimes in relation to the enforcement of those offences. This is recommended viewing.




History

Old cannabis medicine bottles

Prior to 1937, cannabis had enjoyed a 5000 year history as a therapeutic agent across many cultures. By the late 19th Century, cannabis-based medications were manufactured by Burroughs-Wellcome & Co. (GSK), Bristol-Myers Squib, Parke-Davis (Pfizer) and Eli Lilly. During hearings on marijuana law in the 1930’s, claims were made about marijuana’s ability to cause men of color to become violent and solicit sex from white women. This imagery became the backdrop for the Marijuana Tax Act of 1937 which effectively banned its use and sales.

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Indications

Medicinal cannabis is now legal and available for medicinal use in Australia. Treatment with medicinal cannabis is not about curing the condition being treated. It is about alleviating symptoms, generally with mild side effects, and improving quality of life. There is the potential for one medication to assist with multiple symptoms. The main uses at present are listed below. According to the National Academies of Sciences, there is substantial or moderate evidence for the first 6 in the list, and limited evidence (ongoing trials) for the remainder.

  • Chronic pain in adults – in particular neuropathic
  • Intractable childhood epilepsy (e.g. Dravet Syndrome)
  • Spasticity in multiple sclerosis
  • Chemotherapy induced nausea and vomiting
  • Sleep problems
  • Palliative Care
  • Anxiety including PTSD
  • Fibromyalgia
  • Symptoms of IBS
  • Cancer treatment, incl glioma and cancer-associated anorexia
  • Achieving abstinence in the use of addictive substances
  • Mental health outcomes in individuals with schizophrenia

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Dependency & Safety

Addiction risk scale

Medicinal cannabis is NOT street cannabis where the composition is unknown, and which may even be contaminated with strongly addictive drugs such as heroin or ICE. This may be why it used to be said that teenagers would "start on weed and end up on heroin."

Cannabis is actually less addictive then caffeine, and much less addictive than opioids.

No-one has ever died from an overdose of medicinal cannabis due to the lack of CB1 receptors in the brainstem cardiorespiratory centres.

Medicinal cannabis is relatively expensive. It is not on the PBS (subsidised by government). You need to budget for $200 per month, or more, depending on symptoms and dose needed.

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Entourage effect

Entourage effect

Medicinal cannabis is a combination of two main cannabinoids, the psychoactive THC, and the more immune stimulating CBD, along with hundreds of other compounds (terpenes, which give cannabis its odour, and flavonoids). None of the individual cannabinoids have medicinal broad-spectrum properties. Even a trace of THC makes the CBD more effective. This is why synthetic (lab-derived) cannabinoids such as Nabilone have limited effects, or even cause problems. The benefit arises from the combination of all these compounds, called the entourage effect.

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Endocannabinoid system

CBD receptors

The human body has an in-built (endogenous) cannabinoid system. This means that, like endorphins (natural opioids), the body can produce cannabinoids on its own. This endocannabinoid system comprising of CB1 & CB2 receptors is a signalling system central to homeostasis. Reference: Green Leaf Options Endocannabinoids bind to the receptors to down-regulate neural pain signals and inflammatory responses.

CB1 receptors are mostly found in the brain and CNS and appear to affect cognitive function. CB2 receptors are mostly found in the immune system. THC mainly attaches to CB1 receptors, producing the psychoactive euphoric "high" of cannabis. CBD does not bind strongly to either receptor but interacts with other pathways such as activating serotonin receptors and encourages higher levels of endocannabinoids such as anandamide, our "happy molecule".

THC is more euphoria-producing so very useful for any painful condition, while CBD is more focus-producing so is more useful in ADD, bipolar, PTSD etc.

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Routes of administration

Bongs

Cannabinoids need to be heated to become active. Traditionally, people smoked cannabis using a pipe or bong. This burns the cannabis. Cannabis smoke delivers 50-70% more carcinogenic hydrocarbons than tobacco smoke and a higher risk of cardiac arrhythmias.

Cannabis oils

Although there are a variety of oral options, OILS are the most widely used form of medicinal cannabis. Oils can be made with a variety of THC to CBD ratios. Sprays can be more convenient to administer (personal preference and cost). Juicing & teas do not allow adequate decarboxylation of raw plant to activate the cannabis.

Cannabis creams

Topicals may help for localised symptoms. Suppositories may be useful for patients with cancer, gastro-intestinal symptoms and in young children or the elderly.

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Oil versus vaping (inhaling)

Graph comparing oil and vape effects

This chart illustrates the different duration of effects between oral and inhaled cannabis. The oral dosing takes longer to start working but lasts much longer, whereas vaping gives an instant effect but wears off quickly. It is thus possible to use a combination of products – oil for the baseline effect and vaped for breakthrough symptoms, especially with respect to pain and corresponds to long and short-acting opiates.

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Suitability

Medicinal cannabis may not be suitable for everyone:

  • Medicinal cannabis products containing THC are often not appropriate for patients who:
    • Have a previous psychotic or concurrent mood or anxiety disorder
    • Are pregnant or planning on becoming pregnant or breastfeeding
    • Have unstable cardiovascular disease as it may worsen arrythmia
    • Cannabis should be avoided in patients with severe cardiovascular, immunological, liver or kidney disease, especially in acute illness

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Side-effects

  • Medicinal cannabis can have side-effects, but these are generally mild. Notably, there were actually no significant differences between the side-effects reported by people receiving medical cannabis and those who received either placebo or nothing at all -
    • Tiredness
    • Dizziness
    • Psychological effects, especially in adolescents
    • Dry mouth
    • Changes in memory
    • Other physical effects (hypotension - low BP, tachycardia - rapid heart rate)
    • Tolerance can develop quickly
    • Dependence has been reported, estimated at 1:10 illicit users
    • A very small number of patients develop Cannabinoid Hyperemesis Syndrome (CHS), basically an allergy to cannabis.
    • I have had one patient on high dose of THC develop gynaecomastia (enlarged breasts) but he may have had other contributing factors including other medications. Opioids are also reported to sometimes have this side-effect.
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    Warning re driving

    Beware of driving while using medicinal cannabis.
    While it is legal to take it for medical purposes, current Victorian law still prohibits driving while there is any THC in your body. For a detailed review, see the video. Of course, regardless of what medication you take, do not drive or operate machinery if you feel impaired.

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      OIL Dosing schedule

      Starting medicinal cannabis oil - start low, go slow, stay low

      Take the oil in your cheek or under the tongue using the supplied measuring syringe, although you can just swallow it. Start with 0.25ml at night for 3 nights, then increase to twice daily dosing for another 3 days.
      Increase the evening dose to 0.4ml for 3 nights, then to 0.4ml twice daily.
      In Summary (Daily Schedule):

      DAY AM PM (about 2 hours before bedtime)
      1 - 3 0 0.25ml
      4 - 6 0.25ml 0.25ml
      7 - 9 0.25ml 0.4ml
      10 - 12 0.4ml 0.4ml

      Do not expect to have a full effect at this dose, unless you're quite lucky! You now need to decide when in the day you need more (if you do), so you can increase by 0.2ml sometime in the day (morning, middle of the day or night) every 2-3 days.

      People typically end up needing somewhere between 1.6ml per day up to 2ml per day in divided doses. At 1.6ml per day, a bottle lasts about a month. Some people need significantly more but this can get expensive.
      This can be:
      0.4ml in the morning (some people want less) and 0.6-1.2ml at night
      0.4-0.5ml 3 times a day
      0.6 – 1.0ml twice a day
      What works for you is the correct dose. Take it slowly.

      Review in a week. After a month, the ratio may need to be tweaked. Build up the cannabis dose first then gradually reduce opioids etc. Don't come off routine medications suddenly, but many patients find they can reduce their use of pregabalin, benzodiazepines and even opioids. Discuss any intended changes with the doctor.

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      Intra-buccal Spray

      Cheek spray

      NanoCelle® - THC and CBD NanoCelle® delivery platform is the application of nanotechnology to enhance drug delivery and hence efficacy. NanoCelle® creates nano-sized water-soluble particles of active pharmaceutical ingredients such us THC and CBD that optimises dose requirements. Provides faster and more effective drug absorption. Improves drug bioavailability (amount of drug molecule e.g THC/CBD that reaches systemic circulation). The NanoCelle® delivery route of administration is to spray inside of the cheek allowing direct access to the body’s systemic circulation system via the facial lymphatics.

      NanoCelle graphic

      The NanoCelle™ water soluble nanoparticle cannabis‐based medicine clinical studies in cancer bone pain has shown:
      Pain reduction by 40% in metastatic cancer patients
      Same THC plasma levels (blood stream)
      Higher CBD plasma levels (blood stream)
      when compared to the only TGA approved cannabis-based medicine.
      The level of current evidence on medicinal cannabis efficacy is low-moderated, and further research is needed for the safety of patients.

      For patients prescribed this product, here is a video detailing its use.

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      Vaping dry flower

      Some dry herb vaporisers

      Vaporisation heats the cannabis leaf (don't put oil in the device!) at 160-230°C which is lower than smoking, thus higher bioavailability and fewer harmful effects (takes out the cancer-causing by-products of burning cannabis). Effects are generally felt within minutes and last up to 2-3 hours. The higher the temperature, the stronger the effect. It generally uses plant leaves which are rich in THC, the psychoactive component. Different strains are available.

      Volcano vaporiser

      Indica strains are more physically sedating, so better for relaxing or a nightcap before bed.
      Sativa strains tend to deliver more energising effects so are better with physical activity, social events and creative projects. Hybrid strains are a combination from the result of crossbreeding cannabis strains. In addition, the terpenes contribute to the entourage effect. You may need to experiment with several products to see which works best for your needs. We can offer you a choice and recommendations.

      A selection of vapourisers are available at varying prices. The cheaper portable ones may be more convenient but tend to use up more of the product. Desktop models such as the Volcano may work out cheaper in the long run for regular use. Most vapourisers use 0.25 gram per use.

      You can download a Vaporisation Guide which, although provided by one company, is appropriate to most flower products. There are also many sites on the internet with instructions about vaping cannabis. Below are some:

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      Vape cartridges

      Vape cartridges (mCARTs) are a distillate (liquid concentrate of flower extract) that is an alternative to flower for those patients who don’t like to vapourise flower, is less conspicuous in that it has almost negligent odour when vaped and very little vapour when exhaled. The cartridges contain 500mg of distillate, with each 3 second inhalation utilising 5mg, so a total of about 100 doses. When writing a script, most prescribers write a 3 second inhalation TDS, for example, with most patients actually using PRN (if you're the average patient who uses the cartridge for about 2 weeks, you inhale about 6 times per day). Since most patients find it difficult to time a 3 second inhalation, it is probably easier to take 3 x 1 second inhalations for each dose. The vapouriser used for cartridges is different to the one used for flower. The mCART vaporiser (Jupiter L6 Silo) has an RRP of $50 (at time of writing). If you have your own vape (for nicotine for example), if it has a 510 thread, which most do, then you don’t necessarily need to purchase a new cartridge vapouriser. The onset of action is rapid (5-15 minutes), just like flower, and its duration 2-4 hours. The other thing to keep in mind is that the mg active in the cartridges seems to have more punch, so can’t be directly compared to flower.

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      Preparing for your first medicinal cannabis appointment

      When you are coming for your appointment, please bring a summary of your medical condition, including previous and current treatments. What symptoms do you want to relieve? Ideally write these points down and bring the list with you. You should also download and complete the I'm new to the practice patient form. Finally, it may not be possible to fully fix the problem, and, at present, the cost of the medicinal cannabis can be significant - up to about $200 per month.

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      Some evidence-based research

      You may be interested in some of the following material:

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