Medicinal cannabis for psychiatry-related conditions: an overview of current Australian prescribing

NSW cannabis medicines advisory service retrospective enquiry analysis to inform clinical guidance resource development

BACKGROUND

An innovative New South Wales government funded statewide Cannabis Medicines Advisory Service (CMAS) operated between January 2018 and June 2022. The service provided comprehensive patient-specific and evidence-based information to support health professionals in prescribing and patient care decisions. This study aimed to describe real-world data collected by CMAS.

METHODS

A sub-set of de-identified, patient-specific enquiries collected between January 2021 and June 2022 (n = 123/567; 21.7%) were analyzed using R version 4.2.1. Diagnosis, indication, and comorbidities were coded using Medical Dictionary for Regulatory Activities (MedDRA) terminology.

RESULTS

Most patient-specific enquiries from medical practitioners were from general practitioners (n = 103/123; 83.7%). Female (n = 53/123; 43.1%) and male (n = 59/123; 48.0%) patients were similarly represented. Sex was not specified for 8.9% (n = 11/123) of patients. The mean age of patients was 52.1 years (range <10-90). The most common three diagnoses were osteoarthritis, anxiety, and chronic pain. Indications that were most frequently reported included chronic pain, anxiety, back pain, non-neuropathic pain, and insomnia. Comedications were most commonly non-opioid and opioid analgesics and antidepressants. Most practitioners were considering prescribing a cannabidiol (CBD) product for their patient. Cannabinoid composition selection guidance provided by CMAS was predominantly (delta-9-tetrahydrocannabinol) THC:CBD ~1:1, followed by CBD-only products. CMAS was contacted by health professionals regarding the management of potential adverse events for five patients.

CONCLUSION

The findings of this study shed light on the information medical practitioners were seeking to inform their clinical decision-making about medical cannabis and can inform the development of clinical guidance resources.

High Prescribing: A Case Study of High-Potency Medicinal Cannabis Inducing Psychosis

Introduction: There has been a recent significant increase in medical cannabis prescribing in Australia despite weak evidence for its effectiveness in treating the most common indications. Concern has been raised about the potential harms of inappropriate prescription of cannabis; however, there have been no prior published cases of psychosis secondary to medicinal cannabis in Australia. Case Presentation: We present a case of a 21-year-old Indigenous male with psychosis following switching from illicitly obtained cannabis to prescription cannabis, which resulted in Othello delusions towards his partner, violence towards her and ultimately an attempt to end his life. Discussion: Cannabis use is linked to the development of a psychotic illness whether it is prescribed or obtained illicitly. People who are prescribed cannabis are also at an elevated risk of developing cannabis use disorder (CUD). Cannabis prescribers need to screen for risk factors of drug-induced psychosis such as a family member with a psychotic illness, review patients regularly and provide harm minimisation advice to prevent damage from their prescription. Conclusion: There are clear dangers to overprescribing medicinal cannabis and the care that needs to be taken by prescribers to avoid them. There is a need for a change in the regulation of cannabis prescribing in Australia. Further research is warranted on the effects of the increase in prevalence of cannabis prescribing.

Cannabinoids in the Treatment of Selected Mental Illnesses: Practical Approach and Overview of the Literature

Although an increasing number of patients suffering from mental illnesses self-medicate with cannabis, current knowledge about the efficacy and safety of cannabis-based medicine in psychiatry is still extremely limited. So far, no cannabis-based finished product has been approved for the treatment of a mental illness. There is increasing evidence that cannabinoids may improve symptoms in autism spectrum disorder (ASD), Tourette syndrome (TS), anxiety disorders, and post-traumatic stress disorder (PTSD). According to surveys, patients often use cannabinoids to improve mood, sleep, and symptoms of attention deficit/hyperactivity disorder (ADHD). There is evidence suggesting that tetrahydrocannabinol (THC) and THC-containing cannabis extracts, such as nabiximols, can be used as substitutes in patients with cannabis use disorder.Preliminary evidence also suggests an involvement of the endocannabinoid system (ECS) in the pathophysiology of TS, ADHD, and PTSD. Since the ECS is the most important neuromodulatory system in the brain, it possibly induces beneficial effects of cannabinoids by alterations in other neurotransmitter systems. Finally, the ECS is an important stress management system. Thus, cannabinoids may improve symptoms in patients with mental illnesses by reducing stress.Practically, cannabis-based treatment in patients with psychiatric disorders does not differ from other indications. The starting dose of THC-containing products should be low (1-2.5 mg THC/day), and the dose should be up-titrated slowly (by 1-2.5 mg every 3-5 days). The average daily dose is 10-20 mg THC. In contrast, cannabidiol (CBD) is mainly used in high doses>400 mg/day.

Effects of cannabidiol on psychosocial stress, situational anxiety and nausea in a virtual reality environment: a protocol for a single-centre randomised clinical trial

INTRODUCTION

The non-intoxicating plant-derived cannabinoid, cannabidiol (CBD), has demonstrated therapeutic potential in a number of clinical conditions. Most successful clinical trials have used relatively high (≥300 mg) oral doses of CBD. Relatively few studies have investigated the efficacy of lower (<300 mg) oral doses, typical of those available in over-the-counter CBD products.

METHODS

We present a protocol for a randomised, double-blind, placebo-controlled, parallel-group clinical trial investigating the effects of a low oral dose (150 mg) of CBD on acute psychosocial stress, situational anxiety, motion sickness and cybersickness in healthy individuals. Participants (n=74) will receive 150 mg of CBD or a matched placebo 90 min before completing three virtual reality (VR) challenges (tasks) designed to induce transient stress and motion sickness: (a) a 15 min 'Public Speaking' task; (b) a 5 min 'Walk the Plank' task (above a sheer drop); and (c) a 5 min 'Rollercoaster Ride' task. The primary outcomes will be self-reported stress and nausea measured on 100 mm Visual Analogue Scales. Secondary outcomes will include salivary cortisol concentrations, skin conductance, heart rate and vomiting episodes (if any). Statistical analyses will test the hypothesis that CBD reduces nausea and attenuates subjective, endocrine and physiological responses to stress compared with placebo. This study will indicate whether low-dose oral CBD has positive effects in reducing acute psychosocial stress, situational anxiety, motion sickness and cybersickness.

ETHICS AND DISSEMINATION

The University of Sydney Human Research Ethics Committee has granted approval (2023/307, version 1.6, 16 February 2024). Study findings will be disseminated in a peer-reviewed journal and at academic conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12623000872639).

Impacts of supplementing Cannabis sativa byproducts during the transition period on behaviour, feed consumption, constipation levels, colostrum production and piglet performance in hyperprolific sows

In the modern swine industry, inflammation and pain in sows after farrowing represent a crucial animal welfare concern. Cannabis sativa, a medicinal plant, has analgesic, anti-inflammatory and antipyretic properties and is rich in fibre. The objective of this study is to examine the impacts of supplementing sows with Cannabis sativa byproducts during transition periods (7 days before and after farrowing) on various aspects including postpartum behaviour, feed intake, constipation, farrowing duration, colostrum yield and piglet performance. The experiment involved a total of 100 Landrace × Yorkshire sows. The sows were distributed according to parity numbers into two groups, i.e., control (n = 54) and treatment (n = 46). The control group was provided with a lactation diet at 3.0-3.5 kg per day for a period of 7 days before and after farrowing. The treatment groups received the same quantity of the diet but with an additional supplementation of 150 g/d of Cannabis sativa byproduct. The byproduct was analysed and contained 0.24 % (w/w) cannabidiol (CBD), resulting in a daily intake of 360 mg of CBD per sow. The conventional lactational diet had a dietary fibre content of 4.3 %, whereas the diet supplemented with Cannabis sativa byproduct had a higher dietary fibre content of 16.9 %. Video cameras were used to observe and document the behaviour of sows within the initial 24 h after farrowing. The duration in which sows engaged in activities such as sleeping, sitting, standing, feeding and nursing their piglets was quantified. Additionally, the rectal temperature of the sows was measured, and a temperature equal to or exceeding 39.5 °C was considered indicative of fever. The faecal score of the sows was assessed, and a faecal score of ≤2 was classified as constipation. On the third day postpartum, the proportion of sows with fever in the treatment group was lower than that in the control group (20.0 % and 38.9 % respectively, P = 0.051). Sows receiving supplementation with Cannabis sativa byproducts exhibited increased durations of standing and feeding compared to those in the control group (P < 0.05). Notably, overall, sows without constipation issues spent more time consuming feed than those experiencing constipation (P = 0.006). The prevalence of constipation was significantly lower in the treatment group compared to the control group (17.4 % and 81.5 %, respectively, P < 0.001). Furthermore, the postpartum sows demonstrated increased feed intake following supplementation with Cannabis sativa byproducts (P < 0.05). Sow colostrum yield, piglet colostrum intake, piglet mortality and other piglet traits did not differ between the control and treatment groups (P > 0.05). In conclusion, supplementing Cannabis sativa byproducts during the transition periods in peri-parturient sows under tropical conditions resulted in a reduction in constipation issues and improved sow activities, such as increased time spent standing and consuming feed within the first 24 h postpartum.