Medical Cannabis: Toward a New Policy and Health Model for an Ancient Medicine

Clinical Benefits and Safety of Medical Cannabis Products: A Narrative Review on Natural Extracts

Interest in medical cannabis and cannabis-based medicinal products (CBMPs) has increased greatly in recent years. Two cannabinoids are of principal importance; delta-9-tetrahydrocannabinol (∆9-THC), the primary psychoactive component, and also cannabidiol (CBD), considered non-intoxicating. Each has distinct mechanisms of action and different therapeutic potentials. CBMPs differ in their ∆9-THC and CBD components; predominantly ∆9-THC, balanced formulations with equivalent ∆9-THC and CBD elements, and CBD-predominant products. In this narrative review, we evaluate the published evidence for the clinical benefits of CBMPs and overall benefits in well-being. We also review the overall safety profile and discuss the potential for dependence with CBMPs. Evidence can be drawn from a wide range of randomized and other controlled studies and from observational real-world studies. Most data from observational registry studies are supportive of ∆9-THC-based products (∆9-THC-predominant or balanced CBMPs) in the management of chronic neuropathic pain. Balanced products are also effective in reducing spasticity in multiple sclerosis. Most CBMPs show benefit in providing symptomatic benefits in reducing anxiety, nausea, and in improving sleep, but the place of specific products is more subtle, and choice guided by specific circumstances. Symptomatic improvements are accompanied by improved quality of life and well-being. Safety data indicate that CBMPs are generally well tolerated in most patients without specific contraindications. The majority of adverse effects are non-serious, and transient; most are principally associated with ∆9-THC and are dose-dependent. In contrast to recreational cannabis use, there is little evidence from clinical studies that CBMPs have any potential for dependence.

The Association of Medical Cannabis Use with Pain Levels and Opioid Use in Illinois' Opioid Alternative Pilot Program

OBJECTIVE

The state of Illinois' Opioid Alternative Pilot Program (OAPP) is the first and only official harm-reduction program in the US to address the opioid crisis via facilitation of safe and legal access to medical cannabis. This study evaluates the association of medical cannabis use with pain level and frequency of opioid use in the first cohort of OAPP participants in 2019.

METHODS

A survey was sent OAPP enrollees between February and July 2019. Cannabis users (n = 626) were compared to non-users (n = 234) to determine whether there was an association between cannabis use and self-reported (a) pain level and (b) frequency of opioid use. Backward stepwise regression models were used.

RESULTS

A total of 860 participants was included in the analysis. Overall, 75% of the study sample reported pain as their primary medical symptom, and 67% of cannabis users reported having a disability. The mean difference in pain level between cannabis users and non-users was 4.5 units (on a 100-point scale) higher among cannabis users than non-users (p = 0.03); and cannabis use was statistically associated with pain level. High-frequency opioid users had lower odds of reporting cannabis use within the past year than low/no opioid users.

CONCLUSIONS

Although there was a statistical association between cannabis use and pain, the difference of 4.5 points in pain level between users and non-users was too small to reflect a clinically meaningful relative difference. This study may provide useful information to providers and clinicians about how the OAPP and similar programs may reduce opioid use and improve health outcomes.

A three-years survey of microbial contaminants in industrial hemp inflorescences from two Italian cultivation sites

BACKGROUND

The use of industrial Cannabis sativa L. for recreational, cosmeceutical, nutraceutical, and medicinal purposes has gained momentum due to its rich content of valuable phytochemicals, such as cannabidiol (CBD) and cannabigerol (CBG). However, there are concerns regarding the risk of microbial contamination in plants grown outside controlled environments. Microbes associated with hemp can be either epiphytes or endophytes and may pose a risk of infectious illness for humans.

METHODS

Seven Italian hemp genotypes, including Bernabeo, Carmagnola, Carmaleonte, Codimono, CS, Eletta Campana, and Fibranova, were cultivated in two distinct geographic locations, Catania and Rovigo, for three consecutive years from 2019 to 2021. Total aerobic microbes (TAMC), total combined yeasts/moulds (TYMC), the presence of bile-tolerant Gram-negative bacteria, and the absence of Escherichia coli and Salmonella spp. were evaluated and compared. The main phytocannabinoid content was measured and correlated with microbial contamination.

RESULTS

Most samples analyzed in this study did not meet the European Pharmacopoeia microbiological limits. The detection of potential pathogens, such as E. coli and Salmonella spp., in the samples indicates that the use of inflorescences may represent a possible source of infection. Microbial contamination varied among harvesting seasons and production sites, with agroclimatic conditions influencing microbial load and composition. The presence of potentially pathogenic bacteria was less associated with seasonal climate variability and more likely affected by sporadic contamination from external sources. CBD concentration exhibited a negative correlation with bile-tolerant Gram-negative bacteria and total yeasts/moulds levels. Samples with lower CBD content were more contaminated than those with higher CBD levels, suggesting a potential protective effect of this phytochemical on the plant.

CONCLUSIONS

The threshing residues (inflorescences, floral bracts, and leaves) of industrial hemp varieties represent a valuable product and a source of beneficial phytochemicals that warrants further exploration. While post-harvest sterilization methods may reduce microbiological risks, they may also degrade heat- and light-sensitive bioactive phytochemicals. The most promising strategy involves implementing best agronomic practices to maintain healthy and uncontaminated cultures. Rigorous monitoring and quality certification protocols are essential to mitigate the microbiological risk associated with the consumption of hemp-derived products.

Global patterns in small-scale cannabis growers' distribution practices: Exploring the grower-distributor nexus

BACKGROUND

While the supply of cannabis is commonly assumed to be dominated by criminal gangs, a sizable share of the domestic cannabis supply is provided by small-scale growers. This article examines the nature and scope of small-scale growers' distribution practices, with a particular focus on cross-country differences and variations between different types of grower-distributors, i.e., "non-suppliers", "exclusive social suppliers", "sharers and sellers" and "exclusive sellers".

METHODS

Based on a large convenience web survey sample of predominantly small-scale cannabis growers from 18 countries, this article draws on data from two subsamples. The first subsample includes past-year growers in all 18 countries who answered questions regarding their market participation (n = 8,812). The second subsample includes past-year growers in 13 countries, who answered additional questions about their supply practices (n = 2,296).

RESULTS

The majority of the cannabis growers engaged in distribution of surplus products, making them in effect "grower-distributors". Importantly, many did so as a secondary consequence of growing, and social supply (e.g., sharing and gifting) is much more common than selling. While growers who both shared and sold ("sharers and sellers"), and especially those who only sold ("exclusive sellers"), grew a higher number of plants and were most likely to grow due to a wish to sell for profits, the majority of these are best described as small-scale sellers. That is, the profit motive for growing was often secondary to non-financial motives and most sold to a limited number of persons in their close social network.

CONCLUSION

We discuss the implications of the findings on the structural process of import-substitution in low-end cannabis markets, including a growing normalization of cannabis supply.

Medical cannabis use in Australia: consumer experiences from the online cannabis as medicine survey 2020 (CAMS-20)

Background

Australia has had a framework for legal medicinal cannabis since 2016, yet prior online surveys in 2016 and 2018 indicated that most consumers continued to use illicit medical cannabis products. Regulatory data indicate an increase in the prescription of medicinal cannabis since 2019, and this survey examines consumer experiences of prescribed and illicit medical cannabis (MC) use in Australia.

Methods

A cross-sectional anonymous online survey was administered September 2020 to January 2021. Recruitment via social media, professional and consumer forums, and medical practices. Participant eligibility: ≥ 18 years; used a cannabis product for self-identified medical reason(s) in the past year, and resident in Australia. Outcome measures included consumer characteristics, conditions treated, source and patterns of MC use, and perspectives on accessing MC.

Results

Of the 1600 participants (mean age 46.4 ± 14.3 years, 53% male), 62.4% (n = 999) reported using only illicit and 37.6% (n = 601) used prescribed MC in the past year. MC was used on a median of 28 (IQR: 12, 28) of the past 28 days and cost $AUD 74 ± 72 weekly (median = $40, IQR: $7, $100). Prescribed participants were more likely to treat pain conditions than those using illicit MC (52% v 40%, OR = 1.7, 1.3–2.1) and less likely to treat sleep conditions (6% v 11%, OR = 0.5, 0.3–0.8), with mental health conditions also a common indication in both groups (26%, 31%). Prescribed MC was consumed predominately by oral routes (72%), whereas illicit MC was most commonly smoked (41%). Prescribed MC was ‘mainly THC’ (26%), ‘equal THC/CBD’ (40%), ‘mainly CBD’ (31%) and ‘uncertain’ (3%), while 34% of those using illicit MC were ‘uncertain’ of the cannabinoid profile. Cost and difficulties finding medical practitioners to prescribe remain significant barriers to accessing prescribed MC, and few (10.8%) described the existing model for accessing prescribed MC as ‘straightforward or easy’.

Conclusions

There has been a notable shift from illicit to prescribed MC by many consumers compared to prior surveys. Consumers using prescribed MC reported a range of advantages compared to illicit MC, including safer routes of administration, and greater certainty regarding access and composition of products.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00666-w.