Marijuana for Epilepsy in Adults 1 2 3

Marijuana for Epilepsy in Adults 1. 2. 3. 4. Dr Richard Mc. Lachlan‐ London Dr Mac Burnham‐ Toronto Dr Jose Tellez‐Zenteno‐ Saskatoon Dr Mark Sadler‐ Halifax

CFPC Co. I Templates: Slide 1 Faculty/Presenter Disclosure • Faculty: Mc. Lachlan, Burnham, Tellez, Sadler • Relationships with commercial interests: Burnham‐ CBD/THC for animal studies from Tilray, Blue Mountain and Cann. Science

CFPC Co. I Templates: Slide 2 Disclosure of Commercial Support • This program has received financial support from no one in the form of nothing. • This program has received in-kind support from no one in the form of nothing. • Potential for conflict(s) of interest: – The presenters have received nothing from anyone whose product(s) are being discussed in this program. – Many organizations might benefit from the sale of a product that will be discussed in this program: marijuana.

CFPC Co. I Templates: Slide 3 Mitigating Potential Bias • I have nothing to do with this (honest!):

Summary 1. Marijuana is not as harmful as regulators would have you believe. 2. Medical marijuana may be beneficial for a number of neurological conditions. 3. Attitudes are changing (back). Mc. Lachlan RS. Can J Neurol Sci. 2015; 42(2): 88 -91

Pubmed Citations

Politically Correct Position AMA: “Cannabis is a dangerous drug and as such is a public health concern. “ 2013 Am Coll Ped: “Marijuana is addicting, blah, blah…. ” 2014 CMA: “We have several causes for concern…. ” 2014 CPSO: Physicians prescribing marijuana: “are advised to proceed with caution. ” 2015

Survey‐ Epilepsia 56: 1‐ 6, 2015 (n=529)

Marijuana • • • Cannabis Hemp Marihuana Pot Grass Weed Hashish Ganja etc

Cannabis • • 1 to 5 m weed out of central asia Grows in sunlight, needs little water Many varieties Also called hemp Related to hop plant Leaves/stems/flowers= marijuana Resin= hashish Hashish oil

Plant Derived Intoxicants Tobacco Poppy Coca Cannabis Grain Grape Nicotine Heroin, opium Cocaine Marijuana Beer, whisky Wine

Chemical Constituents of C Sativa • • • Delta‐ 9‐tetrahydrocannabinol (THC) Cannabidiol (CBD) Cannabinol Cannabidivarin >100 other cannabinoids >400 other chemical compounds CB 1 CB 2?

History of Cannabis • Used for centuries • 1850‐ 1920: tobacco, alcohol, opium, cocaine, etc all used widely but not marijuana • 1920‐ 30: X X

Marijuana Tax Act 1937 ($100/ounce sold) • Mainly used by blacks and hispanics • Dupont, WR Hearst, etc lobbied to ban hemp • FBN‐ drug causes criminal behaviour and insanity (Harry Anslinger) • Hollywood‐ Reefer Madness, etc • AMA against bill Cannabis, A History. M Booth, 2003

Canadian Legislation 1923 Narcotic Drug Act includes “Indian hemp” 1922 “Marijuana‐ the new menace” ‐ “weed of madness”, a poison that induces “hellish agonies” ‐ Snowbird “a man who snuffs cocaine” ‐ Prolific Germans, Russians and Chinamen will “wrest the leadership of the world from the British. ” http: //archive. org/stream/The. Black. Candle/Murphy. Black. Candletoronto 1922#page/n 212/mode/1 up

Canadian Gov’t Position 2016 “ The government of Canada does not endorse the use of marijuana. ” Health Canada But may be changing…. .

In favour of legalization of marijuana in Canada • • 1975 1995 2001 2012 • 2013 (USA) 26% 31% 47% 58%

Growops London/Toronto 2016 (Housecreeps)

2016 US State Laws

US Gov’t Position- Illegal 1. Marijuana use is associated with dependence, respiratory and mental illness, poor motor performance, and impaired cognitive and immune system functioning, among other negative effects. 2. Marijuana intoxication cause distorted perceptions, difficulty in thinking and problem solving, and problems with learning and memory. 3. Studies have shown an association between chronic marijuana use and increased rates of anxiety, depression, suicidal thoughts, and schizophrenia. 4. Other research has shown marijuana smoke to contain carcinogens and to be an irritant to the lungs. Marijuana smoke, in fact, contains 50‐ 70 percent more carcinogenic hydrocarbons than does tobacco smoke. Fact sheet, Executive Office of the President, 2010

US Government vs Science • Office of National Drug Control Policy “Marijuana smoke, in fact, contains 50‐ 70 percent more carcinogenic hydrocarbons than does tobacco smoke. ” (Fact sheet citing 1975 botany book chapter) • “The accumulated weight of evidence implies far lower risks for pulmonary complications of even regular heavy use of marijuana compared with the grave pulmonary consequences of tobacco. ” Ann Am Thorac Soc. 2013 ; 10: 239‐ 47

How addictive is it? Ranking of addictiveness 1. 2. 3. 4. 5. 6. Nicotine Heroin Cocaine Alcohol Caffeine Marijuana 32% 22% 17% 15% 9% http: //www. tfy. drugsense. org/tfy/addictvn. htm Expert Opin Drug Saf. 2011; 10(5): 675 -685.

How safe is it? • • • Strychnine Nicotine Caffeine ASA THC LD 50 1 mg/kg 50 mg/kg 200 mg/kg 1270 mg/kg

Medical Uses of Cannabinoids Acne, Addiction/Withdrawal, ADD/ADHD, AIDS/Wasting Syndrome, ALS, Alzheimer’s, Antibiotic Resistant Infections, Anorexia, Anxiety, Arteriosclerosis, Arthritis, Asthma, Autism, Bipolar, Cancer, Cardiovascular/Heart disease, Colitis/Crohn’s Disease, Depression, Diabetes, Endocrine disorders, Epilepsy/Seizure, Fibromyalgia, Glaucoma, Huntington’s disease Inflammation, Irritable Bowel, Kidney Disease, Liver/Bile Duct disease, Metabolic syndrome, Migraine, Mood disorders, Motion Sickness, Multiple Sclerosis, Nausea, Neurodegenerative illnesses, Neuropathic Pain, Obesity, Obsessive. Compulsive Disorder, Osteoporosis, Parkinson’s, PTSD, Prion infection/Mad Cow disease, Psychosis/Schizophrenia, Rheumatism, Skin conditions, Sleep disorders, Spinal cord injury, Stress, Traumatic Brain Injury, Stroke http: //projectcbd. org/

Marijuana and Neurological Disorders • • Multiple sclerosis Muscular dystrophy Epilepsy ALS Spinal cord disease Traumatic brain injury GBM • Alzheimers, Parkinsons, Huntingtons • Stroke • Migraine • Neuropathic pain • Prion disease Pharmacol Reviews 2006; 58: 389 -462

Epilepsy Treatment 1885 • • • (Gowers Neurology textbook) Treatment Efficacy Bromide +++ Digitalis + Belladonna + Cannabis + Zinc/iron + Opium ‐ Arsenic ‐ Turpentine ‐ Mistletoe ‐

Health Canada Category 1 1. Any symptom treated as part of compassionate end‐of‐life care 2. Symptoms related to specific medical conditions, namely: ‐severe pain and/or persistent muscle spasms from multiple sclerosis, spinal cord injury, or spinal cord disease ‐severe pain, cachexia, anorexia, weight loss, and/or severe nausea from cancer or HIV/AIDS infection ‐severe pain from severe forms of arthritis ‐seizures from epilepsy Category 2 A debilitating symptom that is associated with a medical condition or it’s treatment, other than those described in Category 1.

Marijuana in Canada 2016 • 35 licensed producers (eg Tilray, Mettrum, etc) • 100 s of unlicensed dispensories (eg MOMs) • • • PRE‐ROLLED JOINTS‐ high, medium, intro grade HASH OIL GELS/GELATIN CAPSULES • • COOKIES‐ PEANUT BUTTER SKOR, CHOCOLATE CHIP BROWNIES RICE KRISPY TREATS PURE FUDGE SQUARES • • GUMMY CANDY SUCKER

Marijuana Use in Adults Admitted to a Canadian Epilepsy Monitoring Unit • 27 item questionnaire over 14 months • 292 patients median age 36 years, 58% female • Epilepsy 190, PNES 64, both 26, unknown 12 Massot‐Tarrús A, Mc. Lachlan RS. Epilepsy&Behaviour 2016

Results (n=280) Marijuana ever Marijuana current Using weekly/daily EMU 57. 4% 36. 4% 72% Smoke joints Gov’t approved 84. 7% 6% Canada* 24. 8% 8. 8% 34. 6% * Ogborne et al. CMAJ 2000; 162(12): 1685‐ 6

How effective is marijuana in helping your seizures?

Effect on stress

Information Sources • Health Canada marijuana website • Canadian Consortium for the Investigation of Cannabinoids • International Cannabinoid Research Society • Dr Google

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