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Physician Guide to Cannabis-Assisted Opioid Reduction Prepared by Adrianne Wilson-Poe, Ph.D. Distributed by Congressman Earl Blumenauer

Physician Guide to Cannabis-Assisted Opioid Reduction
Prepared by Adrianne Wilson-Poe, Ph.D.
Distributed by Congressman Earl Blumenauer
Cannabis reduces opioid overdose mortality.
• In states with medicinal cannabis laws, opioid overdoses drop by an average of 25%. This effect gets
bigger the longer the law has been in place. For instance, there is a 33% drop in mortality in California,
where compassionate use has been in place since 1996 (1).
• This finding was replicated by Columbia’s school of public health, using a completely different analysis
strategy (2).
Cannabis reduces opioid consumption.
• Cannabis is opioid-sparing in chronic pain patients. When patients are given access to cannabis, they
drop their opioid use by roughly 50%. This finding has been replicated several times from Ann Arbor to
Jerusalem (3, 4).
• This opioid sparing effect is accompanied by an enhancement of cognitive function once patients begin
cannabis therapy: this effect is most likely due to the fact that patients reduce their opioid use (5).
• Cannabis use is associated with a reduction in not only opioid consumption, but also many other drugs
including benzodiazepines, which also have a high incidence of fatal overdose. In states with medicinal
cannabis laws, the number of prescriptions for analgesic and anxiolytic drugs (among others) are
substantially reduced (6). Medicare and Medicaid prescription costs are substantially lower in states
with cannabis laws (7).
Cannabis can prevent dose escalation and the development of opioid tolerance.
• Cannabinoids and opioids have acute analgesic synergy. When opioids and cannabinoids are
coadministered, they produce greater than additive analgesia (8). This suggests that analgesic dose of
opioids is substantially lower for patients using cannabis therapy.
• In chronic pain patients on opioid therapy, cannabis does not affect pharmacokinetics of opioids, yet it
still enhances analgesia. This finding further supports a synergistic mechanism of action (9).
• Pre-clinical models indicate that cannabinoids attenuate the development of opioid tolerance (10, 11).
Cannabis, alone or in combination with opioids, could be a viable first-line analgesic.
• The CDC has updated its recommendations in the spring of 2016, stating that most cases of chronicpain
should be treated with non-opioids (12).
• The National Academies of Science and Medicine recently conducted an exhaustive review of 10,000+
human studies published since 1999, definitively concluding that cannabis itself (not a specific
cannabinoid or cannabis-derived molecule) is safe and effective for the treatment of chronic pain (13).
• When 3,000 chronic pain patients were surveyed, they overwhelmingly preferred cannabis as an opioid
alternative (14).
o 97% “strongly agreed/agreed” that they could decrease their opioid use when using cannabis
o 92% “strongly agreed/agreed” that they prefer cannabis to treat their medical condition
o 81% “strongly agreed/ agreed that cannabis by itself was more effective than taking opioids
Cannabis may be a viable tool in medication-assisted relapse prevention
• CBD is non-intoxicating, and is the 2nd most abundant cannabinoid found in cannabis. CBD alleviates
the anxiety that leads to drug craving. In human pilot studies, CBD administration is sufficient to
prevent heroin craving for at least 7 days (15).
• Cannabis users are more likely to adhere to naltrexone maintenance for opioid dependence (16).
Bibliography and References Cited
1. Bachhuber MA, Saloner B, Cunningham CO, Barry CL. Medical cannabis laws and opioid analgesic overdose
mortality in the United States, 1999-2010. JAMA Intern Med. 2014;174(10):1668-73. doi:
10.1001/jamainternmed.2014.4005. PubMed PMID: 25154332; PMCID: 4392651.
2. Kim JH, Santaella-Tenorio J, Mauro C, Wrobel J, Cerda M, Keyes KM, Hasin D, Martins SS, Li G. State Medical
Marijuana Laws and the Prevalence of Opioids Detected Among Fatally Injured Drivers. Am J Public Health.
2016;106(11):2032-7. doi: 10.2105/AJPH.2016.303426. PubMed PMID: 27631755; PMCID: PMC5055785.
3. Boehnke KF, Litinas E, Clauw DJ. Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a
Retrospective Cross-Sectional Survey of Patients With Chronic Pain. J Pain. 2016;17(6):739-44. doi:
10.1016/j.jpain.2016.03.002. PubMed PMID: 27001005.
4. Haroutounian S, Ratz Y, Ginosar Y, Furmanov K, Saifi F, Meidan R, Davidson E. The Effect of Medicinal Cannabis
on Pain and Quality-of-Life Outcomes in Chronic Pain: A Prospective Open-label Study. Clin J Pain.
2016;32(12):1036-43. doi: 10.1097/AJP.0000000000000364. PubMed PMID: 26889611.
5. Gruber SA, Sagar KA, Dahlgren MK, Racine MT, Smith RT, Lukas SE. Splendor in the Grass? A Pilot Study
Assessing the Impact of Medical Marijuana on Executive Function. Front Pharmacol. 2016;7:355.
doi:10.3389/fphar.2016.00355. PubMed PMID: 27790138; PMCID: PMC5062916.
6. Bradford AC, Bradford WD. Medical Marijuana Laws Reduce Prescription Medication Use In Medicare Part D. Health
Aff (Millwood). 2016;35(7):1230-6. doi: 10.1377/hlthaff.2015.1661. PubMed PMID: 27385238.
7. Bradford AC, Bradford WD. Medical Marijuana Laws May Be Associated With A Decline In The Number Of
Prescriptions For Medicaid Enrollees. Health Aff (Millwood). 2017;36(5):945-51. doi: 10.1377/hlthaff.2016.1135.
PubMed PMID: 28424215.
8. Roberts JD, Gennings C, Shih M. Synergistic affective analgesic interaction between delta-9-tetrahydrocannabinol and
morphine. European journal of pharmacology. 2006;530(1-2):54-8. Epub 2005/12/27. doi:
10.1016/j.ejphar.2005.11.036. PubMed PMID: 16375890.
9. Abrams DI, Couey P, Shade SB, Kelly ME, Benowitz NL. Cannabinoid-opioid interaction in chronic pain. Clinical
pharmacology and therapeutics. 2011;90(6):844-51. Epub 2011/11/04. doi: 10.1038/clpt.2011.188. PubMed PMID:
22048225.
10. Wilson AR, Maher L, Morgan MM. Repeated cannabinoid injections into the rat periaqueductal gray enhance
subsequent morphine antinociception. Neuropharmacology. 2008;55(7):1219-25. doi:
10.1016/j.neuropharm.2008.07.038. PubMed PMID: 18723035; PMCID: 2743428.
11. Smith PA, Selley DE, Sim-Selley LJ, Welch SP. Low dose combination of morphine and delta9- tetrahydrocannabinol
circumvents antinociceptive tolerance and apparent desensitization of receptors. European journal of pharmacology.
2007;571(2-3):129-37. Epub 2007/07/03. doi: 10.1016/j.ejphar.2007.06.001. PubMed PMID: 17603035; PMCID:
2040345.
12. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016.
MMWR Recomm Rep. 2016;65(1):1-49. doi: 10.15585/mmwr.rr6501e1. PubMed PMID: 26987082.
13. NASEM. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for
Research. Washington (DC) 2017.
14. Reiman A, Welty M, Solomon P. Cannabis as a Substitute for Opioid-Based Pain Medication: Patient Self Report.
Cannabis Cannabinoid Res. 2017;2(1):160-6. doi: 10.1089/can.2017.0012. PubMed PMID: 28861516; PMCID:
PMC5569620.
15. Hurd YL, Yoon M, Manini AF, Hernandez S, Olmedo R, Ostman M, Jutras-Aswad D. Early Phase in the Development
of Cannabidiol as a Treatment for Addiction: Opioid Relapse Takes Initial Center Stage. Neurotherapeutics.
2015;12(4):807-15. doi: 10.1007/s13311-015-0373-7. PubMed PMID: 26269227; PMCID: PMC4604178.
16. Raby WN, Carpenter KM, Rothenberg J, Brooks AC, Jiang H, Sullivan M, Bisaga A, Comer S, Nunes EV. Intermittent
marijuana use is associated with improved retention in naltrexone treatment for opiate-dependence. Am J Addict.
2009;18(4):301-8. doi: 10.1080/10550490902927785. PubMed PMID: 19444734; PMCID: PMC2753886.

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Peter Homberg is Partner and Head of the German Life Sciences Practice at Dentons, one of the top 10 global law firms present in more than 50 countries. He and his colleagues advise on Germany’s new regulations regarding the legalization of cannabis for medical use.

There are many unusual questions to be asked, so this time we caught up with a very different kind of expert: Peter Homberg is Partner and Head of the German Life Sciences Practice at Dentons, one of the top 10 global law firms present in more than 50 countries. He and his colleagues advise on Germany’s new regulations regarding the legalization of cannabis for medical use.

Peter, the effect and use of cannabis are highly controversial. What is the significance of cannabis for medical purposes and what does the legalization mean for patients?

Before the law was liberalized, patients who suffered from certain diseases, like multiple sclerosis, cancer or chronic pain, could only use cannabis if they had applied for a specific exemption at the Federal Institute for Drugs and Medical Devices (BfArM). As regulations were extremely strict, only a few hundred patients were granted the permission to use the cannabis plant for medicinal purposes.

So what does it do? The plant is famous for containing THC, short for tetrahydrocannabinol, which binds to specific cannabis receptors (CB) in the central and peripheral nervous systems. The activation of CB1 in the spinal cord, for instance, reduces the perception of pain. In terms of medical use this means that cannabis can give relief to people suffering from cancer, multiple sclerosis, chronic pain and other serious diseases

The change in law means that patients can now receive a prescription from their doctor. If the doctor decides that there are no therapeutic alternatives to alleviate the patient’s suffering, the prescription allows the patient to obtain cannabis at the pharmacy. Although the restrictions have been lifted slightly, these processes are still strictly controlled by the BfArM.

The change in German law means that cannabis can now be prescribed as a pain killer by GPs
What is the current state of affairs in regards to legislation and what is the legal process for obtaining a license to cultivate cannabis?

With the legalization of cannabis, the BfArM established a cannabis agency within the institution to organize and control the cultivation of cannabis for medical use. As a result, a public tender has been released, and numerous companies have applied for the cultivation license.

Companies have to abide to strict guidelines to obtain a cultivation license
Of course, the process is taking much longer than expected, as this is a totally new field and the BfArM is asking for very specific qualifications: A company needs to have had some kind of past experience with cannabis products, they have to own indoor premises for the cultivation of the plants and have specific security measures in place in order to qualify.

Although we don’t have companies in Germany that have experience with growing cannabis, we do have some that have imported the plants from outside of Germany. They have significant experience in handling the product, be it through packaging or security measures.

For example, here in Germany there is a subsidiary of a larger Canadian company that has been producing the plants to a large extent. So this is a great advantage for them as they can build on their experience in Canada and fulfil the necessary requirements to qualify as legal cultivators.

You’ve been able to legally smoke weed in the Netherlands since the 1970’s, other countries like Italy and Denmark liberalized the medical use years ago. Germany seems quite slow in catching-up, why is that?

The legalization of cannabis for medical use in Germany occurred through a chain of unforeseeable events
Germany has one of the strictest narcotic drugs laws in Europe. In my opinion, if the German Federal Administrative Court hadn’t made a very specific decision, then the changes in legislation would never have been made. But through a chain of unforeseeable events, the following occurred:

One of the patients who had received the exemption from the BfArM, started growing his own cannabis at home, stating that the exemption included not only the purchase, but also the cultivation of cannabis. When BfArM sent him a cease and desist order, he took the issue to court.

In the last instance, the court ruled in his favour. This meant that all people who had previously received an exemption from BfArM would be able to legally grow cannabis at home. As this ruling would have resulted in a loss of control by the BfArM and in extension the government, cannabis was legalized for medical use and the complete control over cultivation and distribution returned to the government.

What role is Dentons playing in this whole transition process?

First and foremost we have been informing our international clients on regulatory issues and the new legislation in Germany. With cannabis everything is new, it’s a completely new field and different from any other topic in the life sciences.

THC – tetrahydrocannabinol – binds to specific cannabis receptors in the central and peripheral nervous systems
We have an international cannabis group at Dentons that is at the forefront of current affairs and keeps up to date on the topic. Our work includes regulatory advice, mergers and acquisitions and intellectual property. For instance, we have advised clients, one of them a large Canadian company, on the acquisition of a cannabis distributor in Germany to get a strong foothold in the country and on the European market.

In future, we will also have to handle various disputes. It will be very interesting to see how they evolve, how to handle them and their outcome. If one company, for example, receives the permission to cultivate cannabis in Germany and others don’t, then these decisions will certainly be challenged.

What can Germany… what can Europe learn from Canada?

Canada is well ahead in the use of cannabis for medicinal purposes. What is happening in Germany now is following the Canadian pattern: Today, we have a tender in the public procurement field that came from BfArM. It invited qualified companies to put forward their bid on specific cannabis plants in order to sell these to BfArM. In turn, BfArM will sell these plants to the pharmacies. Like in Canada, a government controlled process.

Germany can learn from Canada in issues of quality control as well. BfArM wants to overlook the cultivation and distribution process, because patients have to be able to count on a high quality product. Quality control includes specific laboratories, which check the type of insecticides or pesticides used or how much THC a plant contains.

There is much to learn from the Canadians, such as quality control, and cultivation and distribution processes
How do you see this niche developing from a legal but also from a medical perspective? What do you personally hope to see happen?

Our clients hope to see a greater liberalization, also for casual use. In my opinion this is not going to happen neither in Germany, nor in other countries in Europe. Nevertheless, more countries in the world are considering the medical use of cannabis and consequently, investors are looking into it as they expect a significant growth in the market.

We will also see a certain amount of effort put into research. With this new kind of liberalisation the indications that qualify for cannabinoid treatment have to be defined. Today we know that cannabis can help patients with for example chronic pain, cancer or multiple sclerosis, but in future we may discover more indications that will qualify for the treatment with cannabis.

“Germany has one of the strictest narcotic drugs laws in Europe”
Accordingly, the group of patients who can use cannabis as a medicinal product will grow. But the market in Germany is very competitive, so it will be interesting to see how companies and institutions will position themselves on the market to get a piece of the cake that is bound to become larger and larger every year.

Personally, I am glad that cannabis has been made available as a medicinal product for people who suffer severe pain. For many it is the best painkiller with less side effects than other drugs.

Want to learn more about the legal aspects of cannabis as a medicinal product? Visit Dentons here!

Images via Miss Nuchwara Tongrit, Africa Studio, Shutterstockphoto3, Zerbor/Shutterstock

What you need to Know about the Legalization of Cannabis for Medical Use


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The Ministry of the Interior writes in his reply that in 2015 there were 1736 alcohol deaths in Bavaria, six more than in the previous year. Of these 123 were between 25 and 44 years old and two were under 25 years. Men were affected in about two-thirds of alcohol-related deaths. In addition, according to the Ministry, deaths are attributable to alcohol consumption, which is an accompanying factor, for example, in certain cancers. The Landesamt für Gesundheit und Lebensmittelsicherheit (German Health and Food Safety Authority) therefore assumes around 12,000 deaths per year.

09/15/2017
Oans, zwoa, totgsuffa
Every year there are over 1700 alcoholic beverages in Bavaria. Young people drink again less – more for this

What would happen if not alcohol, but cannabis the Volksgestge number 1? Two and a half weeks at the Oktoberfest from the teenager to the retiree, over the course of the evening, several grams of grass would be ordered, look at each other in the light of the light of the joint and danced to the latest Wiesn hits. What is unimaginable with cannabis is normal with alcohol. In Germany 74,000 people die each year from the effects of alcohol abuse.

More than every second of the 11 to 17-year-olds have already drunk alcohol, 13 percent have a drunken at least once a month, 4500 children and adolescents have to be admitted to the hospital every year. “In Bavaria around 270,000 people are dependent on alcohol,” write Katharina Schulze and Ulrich Leiner (both Greens) in their request. They wanted to know from the state government the consequences of alcohol consumption in Bavaria.

The Ministry of the Interior writes in his reply that in 2015 there were 1736 alcohol deaths in Bavaria, six more than in the previous year. Of these 123 were between 25 and 44 years old and two were under 25 years. Men were affected in about two-thirds of alcohol-related deaths. In addition, according to the Ministry, deaths are attributable to alcohol consumption, which is an accompanying factor, for example, in certain cancers. The Landesamt für Gesundheit und Lebensmittelsicherheit (German Health and Food Safety Authority) therefore assumes around 12,000 deaths per year.

Not to mention the people who were killed under the influence of alcohol in the wheel. Their number rose by nine to 58 persons from 2015 to 2016, the number of injured persons by 31 to 2616. And the dead will probably be no less. According to the epidemiological search survey in Bavaria, 17.4 percent of adults drink alcohol at high risk – especially younger people. Nearly 37 percent are between 18 and 24, while the 60 to 64-year-olds are just under six percent. Here, too, men are particularly affected.

Alcohol abuse leads to violence and high economic costs

Alcohol abuse does not only affect the drinkers themselves. The economic costs of alcohol-related diseases in Germany are estimated at more than 26 billion euros. On the other hand, income from the state is derived from alcohol-related taxes of just 3.2 billion euros. In addition, there are social consequences, such as violence among alcohols. In one third of all violence in Bavaria alcohol was involved. The attacks of drunders on the police and rescue service have increased in comparison with the previous year to nearly all Bavarian police droids. Overall, the number of suspects who have committed criminal offenses rose by 1800 to 41 430 compared to the previous year. Some of the drunken accused were not yet 14 years old.

The Minister of Interior Minister Joachim Herrmann (CSU) can not say whether local alcohol bans can help to reduce the rate of crime development. An increasing number of municipalities and cities would, however, issue such decrees. “Thus,” […] can effectively reduce […] regulatory disorder and offenses committed under influence of alcohol, “the reply says.

The Ministry of Health praises itself for having further increased the starting age for the first consumption of alcohol by means of prevention programs such as “Strong Will Instead of Proliferation” or the “HaLT” action. In fact, teens drink less alcohol. The proportion of those who have consumed cannabis in the last 12 months has risen by four to 22 per cent, according to the Munich Institute of Therapies Research. Kiffen instead of drinking on the Wiesn – perhaps it is nevertheless no utopia. (David Lohmann)

INFO: Alcohol Consumption
Alcohol has a long history in Bavarian culture: it is both a pleasure and a drug. According to science, there is no alcohol consumption without a health risk. Recommended quantity for women: You should not drink more than 12 grams of pure alcohol per day, which is about 0.3 liters of beer or 0.15 liters of wine or sparkling wine or about four centiliters of an alcoholic drink such as liqueur, corn or vermouth. Recommended quantity for men: You should not drink more than 24 grams of pure alcohol per day, which is about 0.6 liters of beer or 0.3 liters of wine or sparkling wine or about eight centiliters of liquor.

Advice for women and men: The German headquarters for addiction recommends to abstain from alcohol on at least two to three days a week. Risks: In the long term, there is a risk of becoming dependent. In case of excessive consumption, alcohol can cause severe cardiovascular disease, liver disease and various types of cancer. Renouncement: For health reasons people should stay sober when they take medication. Pregnancy: If a drinking mother becomes an alcohol, it may interfere with the babies’ baby’s development and cause premature birth or premature birth. Children and adolescents: For them alcohol can have serious consequences for the developing organism, starting with a blood alcohol value of 0.5 per thousand, there is the danger of becoming unconscious.

http://www.bayerische-staatszeitung.de/staatszeitung/landtag/detailansicht-landtag/artikel/oans-zwoa-totgsuffa.html


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Quotes

“We do not want individuals prosecuted—we want the industry to be accountable. This industry—starting from the top — should be systematically shut down.”

– Kevin Sabet, president of Smart Approaches to Marijuana, during a phone conference discussing the Cole Memo

“The President has told me he is a strong supporter of medicinal marijuana. He has launched a just war on opioids which he has correctly said is the real drug abuse crisis today.”

– Roger Stone, in a prepared statement in which he also apologizes for referring to a number of black Americans as “negro”

“If I hadn’t begun self-medicating with [cannabis], I would have killed myself. The relief isn’t immediate. It doesn’t make the pain disappear. But it’s the only thing that takes the sharpest edges off my symptoms…But I live in fear that I will be arrested purchasing an illegal drug. I want safe, regulated medical cannabis to be a treatment option.”

– Thomas James Brennan, a former sergeant in the Marine Corps who wrote an op-ed for the New York Times, “Make Pot Legal for Veterans With Traumatic Brain Injury“

“People who use medical marijuana to treat arthritis are literally burning joints to soothe their burning joints.”

– a “shower thought” from reddit user furiouspasta

“The dumbest purchase I ever made…hmm…dumbest purchase I ever made…I think it was when I bought what was supposed to be five dollars worth of pot in the village, way, way, way back, and the guy who got it for me got oregano. And I bought myself an envelope full of oregano.”

– David Crosby, founding member of both The Byrds and Crosby, Stills & Nash, during an impromptu call into The Best Show after “these pruciferous [which isn’t a word] people on Twitter” kept asking him to call in

[The idea of legalized recreational marijuana] “makes the hair stand up on the back of my neck.”

– US Attorney General Jeff Sessions addressing an audience at the National Alliance For Drug Endangered Children in Wisconsin


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Deutsche Bahn: Cannabis medicine at railway stations is permitted – from DHV

https://hanfverband.de/nachrichten/news/deutsche-bahn-cannabismedizin-auf-bahnhoefen-ist-erlaubt Published: 24 August 2017 – 11:08By: Florian Rister

Can cannabis patients take their medicine at stations? Are you allowed to smoke cannabis in designated smoking areas? These questions have not only been concerned with many affected and even railway workers since the amendment of the Act in March. The DHV has followed up at the German Railroad and received answers!

We are currently aware of a case in which a cannabis patient was given a ban on smoking in the smoking area of ​​a station due to the smoking of cannabis. It seemed all the more exciting to get an official statement from Deutsche Bahn. Because by the re-classification of medical cannabis as a classic Annex III narcotic, this actually corresponds to the same status as many other drugs also. It is therefore not surprising that the Deutsche Bahn provides in its opinion: Legal cannabis medicine prescribed and taken is permitted at railway stations, also smoked in the smoking zone!

Here are our related questions and the complete answers from DB:

1.) The building rules for DB stations prohibit “trade with and consumption of drugs and narcotics”. Does this apply in principle to prescribed anesthetics from Appendix III BtmG?

On the basis of the relevant legal bases, such as the BGB (German Civil Code) as well as other sources, the building rules for passenger stations reflect the conditions of use of all station visitors. The control content is based on the faulty behavior of station attendants perceived on the spot and are intended to ensure that all station visitors behave equally and in a manner which is reckless in DB’s railway stations. The regulation you referred to relates, as in the BtmG, to the anesthetics of Appendix III in principle. The exception to this is provided by medically prescribed anesthetics, which were prescribed by a physician according to the provisions of the BtmG §13 (1). In this case, we believe that the intended use, Which is detectable by the corresponding prescriptions. This means in practice, as long as pharmacies documented the entitlement to the funds from Annex III to prove and consumers according to the enclosed medical regulation the legal authority to the consumption of the anesthetics can prove and from consumption no danger for the life and / or the safety of the Railway undertakings, this is not prohibited by the rules of the DB railway stations.
2.) Can patients with a prescription for cannabis take this orally in railway stations or other premises of the DB, eg as a drop, drink or pastry?

Provided that the requirements of § 13 (1) are met and the consumer can prove this and does not create any danger to life or limb through the use, the consumption is permitted in public areas of the passenger stations. For non-public areas of DB or third parties in the station, eg travel centers, office complexes or even rental units in railway stations, the respective responsible owners can define different regulations at their own discretion. This is beyond the competence of DB Station & Service AG.
3.) Can patients with a prescription for cannabis smoke this in designated smoking areas on DB stations?

If the requirements of § 13 para. 1 are fulfilled and the consumer is able to prove this and the risk of death is not a risk to life and limb, the patient may smoke in the designated smoking areas of the DB Cannabis stations by means of smoking. Provided that he does so in a provocative manner or for other station visitors of an inconvenient form, we reserve the right to use the relevant safety authorities as the owner of the house. If a consumer is unable or can not prove his right to use against our employees or on behalf of the DB companies on demand, we reserve the right to initiate domestic measures and to contact the relevant safety authorities to clarify the facts.
Subjects:
German Hemp Association
Cannabis as medicine
Panorama & Strange
Germany – General information
Special Topics:
start page
Cannabis as medicine law (2016)


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The chairman of the German Association for Cannabis as Medicine Dr. Franjo Grotenherman, has entered an “indefinite” hunger strike until Germany “decriminalize all citizens who need cannabis to treat their serious diseases.”

On August 17, 2017, I entered an indefinite hunger strike. The objective of refusing to accept any food is to decriminalize all citizens who need cannabis to treat their serious diseases.

On March 10, 2017, a much-debated law on cannabis as a medicine went into effect in Germany. It was the declared aim of the legislature to allow all patients who need a therapy with cannabis medicines to do so. The law, however, proves itself in practice as bureaucratic. Therefore, a treatment with cannabis and cannabinoids is unattractive for doctors who in principle support such therapy. Many patients do not find a doctor who allows them legal access to the needed treatment.

The legislator has taken a great step into the right direction. However, many patients are still dependent on a still as illegal regarded treatment. They face criminal sanctions. This is no longer acceptable. Therefore a basic clarification in the narcotics law must be established. The prosecution of patients to whom a doctor has certified the need for a therapy with cannabis must end.

Already today, the German Narcotics Law allows prosecutors to stop a criminal case in the case of a „minor debt“. This possibility is mainly applied in cases of possession of small amounts of cannabis. I urge that criminal proceedings should in principle also be stopped if accused citizens need cannabis for medical reasons. The need for a cannabis therapy should not be judged by the judiciary, a government agency or a health insurance company, but, as with other medical treatments, also by a doctor.

I also strongly support the uncomplicated access of patients to standardized preparations from the pharmacy. In this respect, it is necessary to improve the existing law. However, the prosecution of the remaining losers of the legal situation must also be ended. I am not aware of a convincing argument by which patients‘ prosecution can be maintained. A corresponding amendment to the Narcotics Act is, therefore, logical and unavoidable.

Franjo Grotenhermen, born in 1957, studied medicine in Cologne. Medical practice in Rüthen (NRW) with a focus on therapy with cannabis and cannabinoids. Grotenhermen is the chairman of the German Association for Cannabis as Medicine (ACM), Executive Director of the International Association for Cannabinoid Medicines (IACM) and Chairman of the Medical Cannabis Declaration (MCD), as well as author of the IACM-Bulletin, which is available in several languages ​​on the website of the IACM. Grotenhermen is an associate of the Cologne nova-Institut in the department of renewable resources and author of numerous articles and books on the therapeutic potential of cannabis and cannabinoids, their pharmaco logy and toxicology. Among others, since 2008 he has been an expert on debates in the Health Committee of the German Bundestag on the medical use of cannabis products, most recently in September 2016.

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Cannabis And The Elderly: A Neurophysiological And Pharmacological Review

by Gaurav Dubey

The elderly population, a term which is generally agreed to mean any individual age 65 or older, is a uniquely diverse and often complex demographic to treat

The aging baby boomers now include many frail and elderly individuals, as Knickman and Snell put in their 2002 review discussing, among several items, “the potential burden an aging society will place on the care-giving system and public finances” (Knickman & Snell, 2002).

Devastating neurodegenerative illnesses such as Alzheimer’s Disease and Parkinson’s disease, as well illnesses such as cancer and chronic pain are more prevalent in older populations and require a multimodal treatment approach. Such treatment can involve hospice care when patients are diagnosed as “prospectively dying” and are the often given very high doses of narcotics, such as morphine, to help ease this pain (Ber-sala et al., 2013) (Scitovsky, 2005).

However these powerful comfort drugs carry serious side effects that can be incredibly detrimental to one’s quality of life (Meier, 20111). A study by Ber-sala and colleagues, however, is one among several emerging studies that also indicate significant alleviation of symptoms in the elderly upon cannabis consumption (Ber-sala et al., 2013). I have discussed previously works that clearly demonstrate the efficacy of cannabis in the treatment of various disorders such as Alzheimer’s and Chronic Pain, conditions with a high prevalence in the elderly population. To this end, this article will focus on a new 2017 study by Katz and colleagues that demonstrably shows the utility and efficacy of cannabinoids in the elderly while using other related and supporting data (Katz et al., 2017). Providing safe, effective and therapeutic care for our senior citizens and adequate end of life care for hospice patients is the hallmark of a successful healthcare system and compassionate society. As such, further investigation into cannabis and cannabinoids for the elderly population is a vital responsibility for the medical community and it’s healthcare providers.

The elderly population, which is steadily increasing in numbers, is the demographic with the highest prevalence of disease and suffering (Parker et al., 1997). The need for adequate care and allocation of resources to treat this diverse population presenting with an even more diverse palette of pathologies is a critical one. Elderly patients typically consume a large amount of prescription drugs, all with varying risk and side effect profiles (Katz et al., 2017).

“Comfort Drugs” used in hospice care, such as hydrocodone, morphine and fentanyl, while generally effective at treating pain, can cause significant drowsiness and even respiratory depression, leading to death, upon overdose (Chau et al., 2008). Chau’s study also describes how normal physiologic aging can significantly alter the pharmacokinetic mechanisms of such drugs in the elderly population, which requires even greater care by the prescribing physician (Chau et al., 2008). With the mounting clinical evidence regarding the efficacy of cannabis to treat a wide variety of pathologies, including many that significantly affect the senior population, special attention should be given to the potential of adding cannabis to the arsenal of drugs to help treat the elderly.

When used simultaneously with opioids, “cannabinoids have been shown to successfully lead to a greater cumulative relief of pain” leading to patients using fewer opiods and experiencing fewer side effects (ref). Perhaps more fascinating from a neuropharmacological standpoint is the fact that cannabinoids seemed to also “prevent the development of tolerance to and withdrawal from opiates” and is even able to essentially cause a weaker dose, that wasn’t working as efficaciously for pain relief for the patient before, to become effective once again (Lucas, 2012). The reduced side effect and high safety profile both present cannabis as a compelling alternative or adjunct to these drugs as well.

In a new 2017 review analyzing clinical evidence for the utilization of cannabinoids in the elderly by Katz and colleagues, the beneficial effects of cannabis in the elderly is implicated by just some of the major conditions cannabis is known to effectively treat in the elderly: Dementia, Parkinson’s Disease, Alzheimer’s Disease and Cancer (Katz et al., 2017).

pensioner cannabis

Image credit- Mass Roots

Furthermore, in discussing the safety of cannabis, Katz and colleagues state, “Cannabinoids present a relatively safe profile of action in elderly patients. Hence, cannabinoid treatment should be considered more readily when other options fail, even in cases of scarce data” (Katz et al., 2017). In fact, I strongly believe that due to the relative safety of cannabis (no reported overdoses/deaths), it should often be considered a first line treatment if possible, over the use of an opioid analgesic, for instance, which carries significantly greater risks. In a population that is often already overmedicated, the possibility of using cannabis, a compound known to be relatively safer than some of the other drugs used to treat chronic pain and illness, should be seriously considered as a mainstay treatment as more data becomes available (Katz et al., 2017).

Indeed, my article regarding cannabis use reducing the individual consumption of prescription drugs speaks to this point well.

As mentioned above, cannabis has been identified to have beneficial and therapeutic properties for several diseases with high prevalence in the elderly. One such condition that cannabis has been indicated for is Alzheimer’s Disease (AD). Indeed, Volicer et al. demonstrated in a placebo-controlled crossover-designed study that treatment with a THC analogue (Dronabinol) attenuated behavioral disturbance in Alzheimer’s patients (Volicer et al., 1997).

While critics of this study claim the lack of quantitative data make the results difficult to adequately validate, a systematic review by Woodward and authors, reporting on “the largest studied cohort of dementia patients treated with Dronabinol to date”, was able to confirm these findings. They reported that Dronabinol could serve as an efficacious “adjunctive treatment for neuropsychiatric symptoms in dementia” (Woodward et al., 2014).

Furthermore, Katz and colleagues, in reviewing this clinical data, concluded that cannabinoids seem to be a safe and effective treatment for therapy “to manage behavioral disturbances in patients” (Katz et al., 2017). Neurodegenerative disorders such as AD are debilitating and often require a multidimensional approach to treatment. Similar challenges arise when considering Parkinson’s disease, another common neurodegenerative illness prevalent in the elderly.

Parkinson’s Disease (PD) is another illness commonly associated with elderly patients and is primarily characterized by death of dopamine neurons in the substantia nigra. It often presents with symptoms such as: tremor, rigidity, gait abnormality and non-motor related clinical symptomology (Katz et al., 2017).

While the etiology of PD is still largely unknown, emerging research has uncovered that our own endocannabinoid system seems to play a significant role in the mechanism of the illness (Katz et al., 2017). This is pharmacologically fascinating as there is a lack of CB1 receptors (one of two main cannabinoid receptors in the body/brain) in the dopaminergic nigostriatal (this is spelt correctly?) neurons that are being damaged due to this serious illness.

canada cannabis

It’s currently presumed this occurs due to the fact that the endocannabinoid system modulates GABA and glutamate transmission (two other major neurotransmitter systems in the brain not part of the endocannabinoid system) (Katz et al., 2017). The ability of our own intrinsic endocannabinoid system to play a key role in the mechanisms of this disease holds promise for the future treatment of PD with cannabis.

A common feature of both PD and AD along with other neurodegenerative disorders prevalent in the elderly is dementia, a debilitating phenomenon that has shown significant receptivity to the therapeutic applications of cannabis (Walther & Halpern, 2010). In regards to PD, cannabis has been shown to provide “significant amelioration also in rigidity, tremor, bradykinesia, pain and sleeping problems with no significant adverse effect” (Lotan et al., 2014). Furthermore, a small cohort of 22 PD patients treated with cannabis and surveyed 30 minutes after use reported “a significant improvement of 9.9 points in the mean score Unified Parkinson’s Disease Rating Scale (P<0.0001)” (Katz et al., 2017).

Another common morbidity and co-morbidity among the elderly population is cancer. Chemotherapy is a common mainstay of cancer treatment and is well known to carry seriously averse side effects that are difficult to manage for patients. A recent 2016 review by Dr. Abrams states “Cannabis is useful in combatting anorexia, chemotherapy-induced nausea and vomiting, pain, insomnia, and depression” induced by chemotherapy (Abrams et al., 2016).

In a study with 211 patients, of which 131 had a second, follow-up interview, “all cancer or anticancer treatment-related symptoms showed significant improvement (P < 0.001). Aside from memory lessening in patients with prolonged cannabis use, “no significant adverse events” were reported (Ber-sala et al., 2013). Having worked in an oncology ward for 4 summers and in my training as an EMT in Miami-Dade, I’ve personally witnessed the immense suffering of cancer patients. It’s difficult not to want to provide anything and everything to assist them, especially if they are in their final years and moments before the inevitable. Narcotics such as morphine for pain and adderall to combat the drowsiness from the morphine are common balancing acts in regards to hospice care medications.

As stated by Nersesyan & Slavin, “Stimulants such as methylphenidate or caffeine can increase alertness in patients who are experiencing somnolence on a dose of morphine that provides sufficient pain control” (Nersesyan & Slavin, 1998). With cannabis having a significantly lower side effect profile and a lower chance of adverse drug events as mentioned above, it is time to seriously consider easy access of cannabis to elderly patients suffering from these conditions, especially those in hospice care. Perhaps the pharmacokinetic mechanisms of the drug are not completely understood, however, enough compelling data exists, combined with the fact there has never been one singlepurported overdose/fatality from cannabis that serious consideration need be given to this modality of treatment.

cannabis weight loss

The safety profile of cannabis next to some of the other drugs used to treat this patient population isn’t even comparable when considering potential for fatalities (that already occur every day) from opioids alone. For this and so many other reasons, it’s time to make a change.

So why restrict access to cannabis if it is beneficial for elderly and it improves their quality of life? Ber-sala, in his study, states that cannabis induced relief of symptoms in their study may in part be due to its euphoriant properties. He points out that, “from a medical point of view, the general improvement in the level of distress is important as an end-point for palliative studies, and the cause is less important (Ber-sala et al., 2013).

There is no doubt that the use of potent narcotics such as morphine and hydromorphine create powerful and potentially addicting “highs” as well, but their use is often times warranted in this situation. Thus, holding cannabis to a different standard due to this side effect is in fact holding a double standard and disrespecting science and evidence. In fact, if you’re sick and dying of cancer on your deathbed, the idea of “feeling good” is a powerful one I think many people, especially those in the medical profession, can relate with.

Another reference in regards to cannabis in popular culture is the “munchies”, essentially, the appetite-stimulation effects of cannabis use. While the data is scarce on this topic in the elderly, preliminary findings show promise (Katz et al., 2017). A few small studies (<40 people) using Dronabinol as a treatment found small changes in weight gain or increased consumption of food over shorter time intervals (Katz et al., 2017). Furtherore, when considering the “entourage effect” (define that) and the beneficial effects of, for instance, Sativex (a 1:1 THC:CBD ratio, whole plant cannabis formulation) over other synthetic cannabinoid compounds such as Dronabinol and Marinol, it begs the question about whether whole plant cannabis formulations would be even more beneficial to patients over synthetics compounds (Russo, 2008).These results call for further investigation as proper nutrition is vital to this population of patients.

The stigmatization of the “high” of cannabis and the social satire of the “muchies” can often detract from the medical necessities of these effects for cancer patients, many of whom report as truly depending on these characteristics of cannabis to help them through such illnesses (Waissengrin et al., 2015). Overwhelming data shows this population could potentially benefit greatly from cannabis use and only more research and more science can help change public perception.

The elderly population is one that suffers from an increased prevalence of a variety of severe pathologies, not the least of which including neurodegenerative disorders, cancer and chronic pain. A recent 2016 study found that “medical expenses more than double between ages 70 and 90” and that “ the government pays for over 65 per cent of the elderly’s medical expenses” (De Nardi et al., 2016). If the effects of cannabis can be reproduced in bigger trials, FDA approved treatments and therapies that are efficacious and successful can be implemented, healthcare costs and the benefit to society overall could improve. With a healthcare crisis already underway in our country, perhaps a paradigm shift such as this one is a promising one. Maybe the question we should be asking is not “can we afford to do this?” but rather, “can we afford not to?”

[Featured image credit- Endoca]

Gaurav Dubey | August 15, 2017 at 1:14 pm | Tags: Cannabiscannabis elderlyCannabis studyMedical Cannabis studyPensioners | Categories: FeaturedHealth | URL: http://wp.me/p8nEcz-H9
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