Pharmacists and the future of cannabis medicine

Assessment of education in a community hospital on healthcare providers' knowledge of and attitudes toward medical marijuana

INTRODUCTION

Although medical marijuana usage continues to become more socially acceptable and is increasingly regarded as a legitimate treatment alternative for certain medical conditions such as cancer and epilepsy, stigma remains.

METHODS

This study examined whether offering an educational session addressing several key aspects of medical marijuana (e.g., pharmacology, legality) to healthcare providers in a community hospital setting improved knowledge about and/or altered attitudes toward marijuana use. This information was collected through administration of pre- and post-education session surveys. Multiple choice questions were utilized to assess knowledge of marijuana pharmacotherapy, pharmacodynamic interactions, and regulations, whereas descriptive analyses via Likert-scale questions determined attitudes toward medical marijuana. A secondary outcome entailed analysis of drug interactions with marijuana users via retrospective chart review.

RESULTS

A total of 43 healthcare providers participated in the study. There were statistically significant increases in healthcare provider knowledge post-education session across multiple occupations (physician, P < .01; nurse, P < .001; pharmacist, P < .01; and nurse technician, P < .05). A total of 72 patients (83%) who self-reported marijuana use for medical or recreational purposes had a potential drug-drug interaction with marijuana.

CONCLUSIONS

As both medical and recreational marijuana continue to become legalized across the United States, formal education surrounding marijuana use and laws becomes increasingly important for healthcare providers and can be highly effective in preventing misinformation.

Changes in Arkansans' attitudes toward pharmacist involvement and regulation of medical cannabis following its availability in Arkansas

BACKGROUND

Pharmacists are likely to encounter questions from patients regarding medical cannabis (MC). This serves as an opportunity for pharmacists to provide reliable medical information about MC dosing, drug interactions, and impact on preexisting health conditions.

OBJECTIVES

This study examined changes in perceptions of the Arkansan community toward MC regulation and pharmacist involvement in MC dispensing after MC products became available in Arkansas.

METHODS

A longitudinal, self-administered online survey was conducted in February 2018 (baseline) and September 2019 (follow-up). Baseline participants were recruited through Facebook posts, emails, and printed flyers. Participants from the baseline survey (N = 1526) were invited to participate in the follow-up survey. Paired t tests were used to determine changes in responses, and multivariable regression analysis was used to identify factors associated with follow-up perceptions.

RESULTS

Participants (n = 607, response rate 39.8%) started the follow-up survey, resulting in 555 usable surveys. The largest group of participants was 40-64 year old (40.9%). The majority were female (67.9%), white (90.6%), and reported past 30-day cannabis use (83.1%). Compared to baseline, participants preferred less regulatory control of MC. They were also less likely to agree that pharmacists helped improve MC-related patient safety. Participants favoring less MC regulation were more likely to report 30-day cannabis use and perceived cannabis to have low health risk. Past 30-day cannabis use was also significantly associated with disagreement that pharmacists improve patient safety and are well-trained to provide MC counseling.

CONCLUSION

After MC product availability, Arkansans' attitudes changed toward less MC regulation and less agreement with the pharmacist's role in improving MC safety. These findings call for pharmacists to better promote their role in public health safety and demonstrate their knowledge concerning MC. Pharmacists should advocate for an expanded, active consultant role in dispensaries to improve safety of MC use.

Measuring the diversity gap of cannabis clinical trial participants compared to people who report using cannabis

Little is known about the demographics of people who use cannabis, including how use trends within population subgroups have evolved over time. It is therefore challenging to know if the demographics of participants enrolled in cannabis clinical trials are representative of those who use cannabis. To fill this knowledge gap, data from the National Survey on Drug Use and Health (NSDUH) on "past-month" cannabis use across various population subgroups in the United States was examined from 2002 to 2021. The most notable increases in "past-month" cannabis use prevalence occurred in those aged 65 and older (2,066.1%) and 50-64-year-olds (472.4%). In 2021, people reporting "past-month" cannabis use were 56.6% male and 43.4% female. Distribution across self-reported race and ethnicity was 64.1% White, 14.3% Black, 14.1% Hispanic, and 3.1% more than one race. And many ages were represented as 24.4% were 26-34, 24.1% were 35-49, 22.4% were 18-25, and 17.6% were 50-64 years old. To understand if these population subgroups are represented in cannabis clinical trials, participant demographics were extracted from peer-reviewed clinical trials reporting on pharmacokinetic and/or pharmacodynamic models of cannabis or cannabinoids. Literature was grouped by publication year (2000-2014 and 2015-2022) and participant prior exposure to cannabis. Results identified that cannabis clinical trial participants are skewed toward overrepresentation by White males in their 20s and 30s. This represents structural discrimination in the research landscape that perpetuates social and health inequities.

A cross-sectional survey exploring the knowledge, experiences and attitudes of Australian pharmacists toward medicinal cannabis

BACKGROUND

Australian pharmacists currently dispense a wide range of prescription-only cannabis-based medicines. Recent regulatory changes will expand the role of pharmacists, allowing certain low-dose cannabidiol products to be supplied without a prescription in pharmacies. This harmonises Australia with many other countries where cannabidiol products are readily available to consumers.

AIM

To examine Australian pharmacists' experience, knowledge and attitudes towards medicinal cannabis and their preparedness to supply over-the-counter low-dose cannabidiol products.

METHOD

We conducted a cross-sectional study using a 51-item on-line questionnaire that was informed by previous surveys of health professionals and assessed for face validity. Australian pharmacists were recruited to complete the survey between May and December 2021, primarily through professional pharmacy organisations. Pharmacists were included in the final dataset if they completed the demographic characteristics section and at least one additional section of the questionnaire. Data were analysed using descriptive and relational statistical tests.

RESULTS

There were 272 attempts to complete this survey and 217 responses included in the final dataset. Over half of the respondents (60.0%, 130/217) had dispensed at least one medicinal cannabis prescription during their career and 58.5% (127/217) had received at least one medicinal cannabis enquiry in the last fortnight. Only around half (53.9%, 117/217) felt comfortable supplying medicinal cannabis products and fewer (39.3%, 79/201) were confident discussing cannabis-related enquiries. More than half of the respondents (58.7%, 118/201) supported the provision of low-dose cannabidiol products through pharmacies. Two-thirds (67.8%, 80/118) of respondents achieved relatively low scores (< 60%) in the knowledge component of the survey. Most respondents (94.2%, 178/189) endorsed a need for further training in this area.

CONCLUSION

Australian pharmacists tended to support medicinal cannabis availability and improved access to low-dose cannabidiol products via pharmacies. However, results highlight a need for improved training and education of pharmacists around cannabis-based medicines.

Deletion of Cryab increases the vulnerability of mice to the addiction-like effects of the cannabinoid JWH-018 via upregulation of striatal NF-κB expression

Synthetic cannabinoids have exhibited unpredictable abuse liabilities, especially self-administration (SA) responses in normal rodent models, despite seemingly inducing addiction-like effects in humans. Thus, an efficient pre-clinical model must be developed to determine cannabinoid abuse potential in animals and describe the mechanism that may mediate cannabinoid sensitivity. The Cryab knockout (KO) mice were recently discovered to be potentially sensitive to the addictive effects of psychoactive drugs. Herein, we examined the responses of Cryab KO mice to JWH-018 using SA, conditioned place preference, and electroencephalography. Additionally, the effects of repeated JWH-018 exposure on endocannabinoid- and dopamine-related genes in various addiction-associated brain regions were examined, along with protein expressions involving neuroinflammation and synaptic plasticity. Cryab KO mice exhibited greater cannabinoid-induced SA responses and place preference, along with divergent gamma wave alterations, compared to wild-type (WT) mice, implying their higher sensitivity to cannabinoids. Endocannabinoid- or dopamine-related mRNA expressions and accumbal dopamine concentrations after repeated JWH-018 exposure were not significantly different between the WT and Cryab KO mice. Further analyses revealed that repeated JWH-018 administration led to possibly greater neuroinflammation in Cryab KO mice, which may arise from upregulated NF-κB, accompanied by higher expressions of synaptic plasticity markers, which might have contributed to the development of cannabinoid addiction-related behavior in Cryab KO mice. These findings signify that increased neuroinflammation via NF-κB may mediate the enhanced addiction-like responses of Cryab KO mice to cannabinoids. Altogether, Cryab KO mice may be a potential model for cannabinoid abuse susceptibility.

Attitudes and Knowledge Regarding the Therapeutic Use of Cannabinoids among Community Pharmacists: A Pilot Cross-Sectional Study in Amman, Jordan

There is an increasing interest in the therapeutic use of cannabis worldwide, with a number of cannabinoid-derived drugs currently approved by the Food and Drug Administration (FDA) for certain indications. This study was conducted via a printed questionnaire and aimed to explore the attitudes and knowledge regarding the therapeutic use of cannabis and cannabinoids among community pharmacists residing in Amman, Jordan. The results revealed a neutral to low agreement level regarding the medical usefulness of cannabis; however, a higher agreement level was observed for FDA-approved cannabinoid-derived drugs. The majority of the participants reported that they did not learn enough regarding cannabinoids, do not adequately remember what they have learned, and do not actively look for information after graduation. The average percentages of correct identification of cannabis/cannabinoid FDA-approved drug indications, common adverse effects, interacting drugs, and cautions/contraindications were 40.6%, 53%, 49.4%, and 57.3%, respectively, with an overall correct identification rate of 51.1% of the participants. In conclusion, the results indicate an inadequate level of knowledge with a significant room for improvement regarding the various aspects of cannabinoid pharmacology.

Pharmacy undergraduate programs: Development of an adaptive curriculum for student success

Objectives

Applicants for graduate work in Pharmacy on paper appear competitive, but upon entering a Doctor of Pharmacy (PharmD) program many students struggle with course work, course load, and pharmacologic topics in their first-year studies. In addition to math and science, undergraduate candidates need to have skills that enable them to be adaptable and creative learners. The Pharmacy Undergraduate Program (PUP) at the University of Southern California (USC) has been attentive to these educational needs. In this manuscript we will show how our program has been successful in generating well-prepared and successful candidates for graduate programs (pharmaceutical, clinical, medical, and other) and employment in pharmaceutical fields.

Methods

A review of current student enrollments (N = 121), graduated student annual survey data (N = 50), student research data (N = 68), and ongoing course surveys have been used to detail information related to PUP.

Results

Students who have graduated from PUP have been successful post-graduation. Graduates of PUP have gone on to PharmD programs 44% (22/50); medical school 16% (8/50); PhD programs 24% (12/50); full-time employment 6% (3/50); internship/volunteer positions 10% (5/50); taken a gap year 4% (2/50); and MS/MA program 2% (1/50).

Conclusions

PUP has been successful in helping the admission of our students into graduate degree programs related to pharmaceutical sciences and medicine. This success can be attributed to the dynamic nature of the course offerings and the creativity of the teaching faculty, which leads to students being well-prepared to tackle the rigors of their graduate studies after leaving the program.

Description and Disposition of Patients With Cancer Accessing a Novel, Pharmacist-Led Cannabis Consultation Service

PURPOSE

The Cannabis Consultation Service (CCS) is an innovative pharmacist-led resource at the Sunnybrook Odette Cancer Centre. Its mandate is to provide education and guide patients through access and appropriate use of high-quality plant-derived cannabinoids (PDCs). Our objective was to describe the CCS, explain its processes, and characterize patient disposition with respect to use of PDCs.

METHODS

We retrospectively reviewed the charts of patients referred to the CCS from July 13, 2020, to March 05, 2021. We used descriptive statistics to report on the patient population and service metrics.

RESULTS

During the 34-week period, 96 patients accessed the CCS (median age, 61 years). The top reasons for CCS consultation were management of cancer pain, insomnia, and general interest. Medical cannabis was supported as an option in 44/96 patients. Reasons for not supporting PDC use included lack of indication, potential drug interaction/contraindication, or requiring treatment with first-line therapy. Of the 40 patients requiring a medical document, 22 initiated therapy. The most common product used was a 2:50 THC:CBD (Tetrahydrocannabinol:Cannabidiol) cannabis oil. At the date of last contact, few patients remained on therapy because of lack of benefit, patient choice, and/or hesitancy.

CONCLUSION

Despite patients with cancer having interest in seeking PDCs for symptom management, only a few initiated and continued therapy. Pharmacists have an opportunity to advise patients and the oncology team on the risks and benefits of PDCs. These results can be used to support the development of medical cannabis programs by oncology centers and focus future research priorities.

Clinical Relevance of Drug Interactions with Cannabis: A Systematic Review

Concomitant use of cannabis with other drugs may lead to cannabis–drug interactions, mainly due to the pharmacokinetic mechanism involving the family of CYP450 isoenzymes. This narrative systematic review aimed to systematize the available information regarding clinical relevance of cannabis–drug interactions. We utilized the PubMed/Medline database for this systematic review, using the terms drug interactions and cannabis, between June 2011 and June 2021. Articles with cannabis–drug interactions in humans, in English or Spanish, with full-text access were selected. Two researchers evaluated the article’s inclusion. The level of clinical relevance was determined according to the severity and probability of the interaction. Ninety-five articles were identified and twenty-six were included. Overall, 19 pairs of drug interactions with medicinal or recreational cannabis were identified in humans. According to severity and probability, 1, 2, 12, and 4 pairs of cannabis–drug interactions were classified at levels 1 (very high risk), 2 (high risk), 3 (medium risk), and 5 (without risk), respectively. Cannabis–warfarin was classified at level 1, and cannabis–buprenorphine and tacrolimus at level 2. This review provides evidence for both the low probability of the occurrence of clinically relevant drug interactions and the lack of evidence regarding cannabis–drug interactions.

THC shows activity against cultured Plasmodium falciparum

The FDA approved drug Dronabinol was identified in a previous study applying virtual screening using the haemozoin crystal as a target against malaria parasites. The active ingredient of dronabinol is synthetic tetrahydrocannabinol (THC), which is one of the major cannabinoids from Cannabis sativa. Traditional use of cannabis for malaria fever was reported in the world's oldest pharmacopoeia, dating to around 5000 years ago. In this research we report that THC inhibits β-haematin (synthetic haemozoin) and malaria parasite growth. Due the psychoactivity of THC, CBD, the other major naturally occurring cannabinoid that lacks the off-target psychoactive effects of THC, was also tested and inhibited β-haematin but showed only a mild antimalarial activity. To evaluate whether THC inhibit haemozoin formation, we performed a cellular haem fractionation assay that indicated that is not the likely mechanism of action. For the first time, the cannabinoid chemical structure is raised as a new chemical class to be further studied for malaria treatment, aiming to overcome the undesirable psychoactive effects of THC and optimize the antimalarial effects.

Cannabis and the Cancer Patient

Session 2 of the National Cancer Institute's Cannabis, Cannabinoids, and Cancer Research Workshop opened with testimony from a lymphoma survivor who detailed medicinal cannabis-related improvements in nausea, low appetite, insomnia, and mental health and the limited clinical counsel she received regarding cannabis use. Discussion next turned to the evolution of the legal landscape of cannabis in the United States, one in which state and federal laws frequently conflict and the Controlled Substance Act renders cannabis Schedule I. This legal climate creates conundrums for US medicinal cannabis researchers who contend with limited funding opportunities, avenues to source trial drug, and procedural red tape and for oncology clinicians who recommend medicinal cannabis to patients with some frequency while perceiving themselves as ill equipped to make such clinical recommendations. Ultimately, it creates challenges for cancer patients who find themselves turning to nonmedical and anecdotal information sources. The risks of cannabis use by the cancer patient were discussed next. These include infection, pharmacodynamic and pharmacokinetic drug-botanical interactions, cyclic nausea and vomiting, e-cigarette or vaping product use-associated illness, legal issues, and high cost. The session concluded with a broad survey of the research supporting oncologic cannabinoid use, conclusive evidence for chemotherapy-induced nausea and vomiting, and suggestive evidence for cancer-related pain.

Description of collaborative, fee-for-service, office-based, pharmacist-directed medical cannabis therapy management service for patients with chronic pain

BACKGROUND

Treatment with medical cannabis (MC) in the United States tends to be patient-driven in nature despite evidence that suggests that patients have remarkably poor knowledge on the medical use of this treatment modality.

OBJECTIVE

To develop and pilot a collaborative, fee-for-service (FFS), office-based, pharmacist-directed MC therapy management (MCTM) service for patients suffering chronic pain.

PRACTICE DESCRIPTION

A collaborative, FFS, office-based, pharmacist-directed MCTM service where patients are seen after a physician deems them suitable for treatment with MC. The pharmacist designs the initial treatment regimen by selecting a formulation, dose, route, and frequency of administration and then manages ongoing therapy by making regimen changes based on the patient's response, adverse effects, and financial concerns.

PRACTICE INNOVATION

The creation of a specialized service where a registered MC pharmacist is positioned in a collaborating provider's office and sees patients face-to-face for the provision of MCTM services.

EVALUATION METHODS

Patient retention, revenue generated, and ability to replicate the service were evaluated. Patient satisfaction was assessed by collecting subjective feedback on the service.

RESULTS

The pilot site that developed the service has seen 133 patients from 2016 to 2021 and has retained 89% of patients after 5 years of quarterly appointments. Patients appear willing to pay out of pocket for the service, and the revenue generated covers the pharmacist's and collaborating physician's time as well as additional overhead. The service has been replicated at 2 additional sites, and patient feedback has been positive.

CONCLUSIONS

MCTM is another useful pharmacist service that patients are willing to pay for. MCTM services decrease the collaborating provider's workload while still allowing them to offer their patients personalized treatment with MC. In our experience, the service retains patients, generates enough revenue to cover costs, can be replicated, and is well received by patients.

Analgesic Potential of Terpenes Derived from Cannabis sativa

Pain prevalence among adults in the United States has increased 25% over the past two decades, resulting in high health-care costs and impacts to patient quality of life. In the last 30 years, our understanding of pain circuits and (intra)cellular mechanisms has grown exponentially, but this understanding has not yet resulted in improved therapies. Options for pain management are limited. Many analgesics have poor efficacy and are accompanied by severe side effects such as addiction, resulting in a devastating opioid abuse and overdose epidemic. These problems have encouraged scientists to identify novel molecular targets and develop alternative pain therapeutics. Increasing preclinical and clinical evidence suggests that cannabis has several beneficial pharmacological activities, including pain relief. Cannabis sativa contains more than 500 chemical compounds, with two principle phytocannabinoids, Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD). Beyond phytocannabinoids, more than 150 terpenes have been identified in different cannabis chemovars. Although the predominant cannabinoids, Δ9-THC and CBD, are thought to be the primary medicinal compounds, terpenes including the monoterpenes β-myrcene, α-pinene, limonene, and linalool, as well as the sesquiterpenes β-caryophyllene and α-humulene may contribute to many pharmacological properties of cannabis, including anti-inflammatory and antinociceptive effects. The aim of this review is to summarize our current knowledge about terpene compounds in cannabis and to analyze the available scientific evidence for a role of cannabis-derived terpenes in modern pain management. SIGNIFICANCE STATEMENT: Decades of research have improved our knowledge of cannabis polypharmacy and contributing phytochemicals, including terpenes. Reform of the legal status for cannabis possession and increased availability (medicinal and recreational) have resulted in cannabis use to combat the increasing prevalence of pain and may help to address the opioid crisis. Better understanding of the pharmacological effects of cannabis and its active components, including terpenes, may assist in identifying new therapeutic approaches and optimizing the use of cannabis and/or terpenes as analgesic agents.

Ask Your Provider About Cannabis: Increasing Nurse Practitioner Knowledge and Confidence

Introduction:

Nurse practitioners (NPs) are authorizing providers for medical cannabis in many states, and may serve as a primary care clinician. We report findings from a nationally distributed 2-h continuing education (CE) module aimed to improve knowledge, confidence, and willingness to communicate with patients about cannabis.

Methods:

Data were electronically obtained from the CE platform pre- and post-test (n=289) and a follow-up survey sent within 3 months postcompletion (n=184, 63%). Pre- and post-testing assessed cannabis pharmacodynamics, law, evidence-based use, metabolism, pharmacokinetics, laboratory testing, adverse reactions, and drug–drug interactions. The subsequent survey asked about changes in practice behavior, including willingness and self-identified recommendations for use. Quantitative and qualitative descriptive analysis and repeated-measures analysis of variance were used to analyze CE impact.

Results:

Significant improvement in scores was noted from pretest to post-test for all content with a mean improvement of 39.3% (95% CI: 30.6–47.9%). The greatest increases were for metabolism, pharmacokinetics, and drug–drug interaction content. At follow-up, 52.2% reported that the CE changed their attitudes about cannabis and although 86% had rarely or never applied it yet in practice, 92% reported they were now likely to inquire about cannabis use in their patients and 84% were likely to counsel patients about it. Although self-identified recommendations overlapped by conditions, some were unique to CBD (complex regional pain syndrome, migraine, mood disorder, smoking cessation) and THC products (appetite, cachexia, depression, fibromyalgia, HIV, seizure disorder, stress, and weight loss). Pain was the most common condition for recommendation of both CBD and THC, followed by anxiety and arthritis.

Conclusions:

NPs gained key knowledge about cannabis, which may impact patient care and prescribing practices. The educational module resulted in more willingness to discuss and counsel patients about cannabis, even if practitioner attitudes did not change.

Δ-9-tetrahydrocannabinol dose increase leads to warfarin drug interaction and elevated INR

OBJECTIVE

We have reported a case of a drug-drug interaction (DDI) involving warfarin and Δ-9-tetrahydrocannabinol (THC) that resulted in a supratherapeutic international normalized ratio (INR) level. The purpose of this case report is to highlight the possibility of a pharmacokinetic DDI between THC and warfarin.

CASE SUMMARY

A 67-year-old Caucasian man suffering from chronic pain presented to a dispensary in Buffalo, NY, for a refill of his medical cannabis (MC). The patient asked to speak with the pharmacist, and during their discussion the patient stated that he had a supratherapeutic INR level of 5.2 measured at home with a self-test device. The patient had no evidence of bleeding, and administration of warfarin was held for 2 days before the INR level returned to a normal range. The supratherapeutic level occurred when the patient was self-titrating his dose of THC and scored an 8, or "probable," on the Naranjo Adverse Drug Effect Probability Scale.

PRACTICE IMPLICATIONS

Warfarin and cannabinoids such as THC are both metabolized by cytochrome P450 (CYP) isozymes present in the liver and gastrointestinal tract. In the case described, a dose increase of 7.35 mg THC preceded an INR elevation of 5.2, but did not result in any bleeding. These observations are suggestive of a DDI involving warfarin and THC. Clinicians involved with MC should have adequate knowledge of the drugs that act as substrates, inhibitors, and inducers of CYP enzymes, including the major cannabinoids.

Herbal Preparations of Medical Cannabis: A Vademecum for Prescribing Doctors

Cannabis has been used for centuries for therapeutic purposes. In the last century, the plant was demonized due to its high abuse liability and supposedly insufficient health benefits. However, recent decriminalization policies and new scientific evidence have increased the interest in cannabis therapeutic potential of cannabis and paved the way for the release of marketing authorizations for cannabis-based products. Although several synthetic and standardized products are currently available on the market, patients’ preferences lean towards herbal preparations, because they are easy to handle and self-administer. A literature search was conducted on multidisciplinary research databases and international agencies or institutional websites. Despite the growing popularity of medical cannabis, little data is available on the chemical composition and preparation methods of medical cannabis extracts. The authors hereby report the most common cannabis preparations, presenting their medical indications, routes of administration and recommended dosages. A practical and helpful guide for prescribing doctors is provided, including suggested posology, titration strategies and cannabinoid amounts in herbal preparations obtained from different sources of medical cannabis.