Cannabis safety for practitioners of Chinese and Integrative medicine

Medical Cannabis therapeutics for Chinese Medicine Practitioners	Dr. Noelle Potash Dac. Lac, MSMCT
what is my cannabis use doing to my body from a TCM perspective?
History	10,000 year old clay jars filled with cannabis
	2500 year old mummy with breast cancer buried with cannabis
	2500 year old tombs containing cannabis
	Scythians- nomadic people spread the knowledge of how to use cannabis throughout Asia.
Medicinal value	2700 BCE -1900 ce, recognized as medicine throughout Asia
	2000 BCE- Ayurvedic, Persian, and Chinese medical physicians use for gout, epilepsy, pain, infectious disease.
	200 BCE-1900 Ce- used in Americas and Europe for pain, cough, tumors, 100 papers published.
	1914-2000 declared criminal activity.
Cultivation 4 subtypes of cannabis sativa	Narrow leaf-hemp (sativa)
	Narrow leaf-drug (sativa)
	Broad leaf-hemp (indica)
	Broad leaf-drug (indica)
	ID of different cultivars is based on leaflet size and now in modern times, Phyto cannabinoid ratios.
	Classifying the plant into 2 or 3 types (Indica/sativa/ruderalis) does a disservice to the complexities of the plant and makes it really hard to predict therapeutic outcomes.
Cannabis use origins: China	Psychoactive type cannabis was found n northwest province of Xinjiang and the southwest province of Yunnan
	Documented Chinese uses start over 2000 years ago with the first mention of medical uses in the Pen T’ao Ching in 2737 BCE.
	the people of Guangxi provence continue to use cannabis in their daily food intake for “longevity”.
Many Names:	Ma Fen: Immature flower
	Ma Fen is acrid, Balanced. Treats the 7 damages, disinhibits the five viscera, precipitates the blood and cold qi.
	Taking to much of it may make one behold ghosts and run frenetically about.
	Protracted (for a long time or longer than expected) taking may enable one to communicate with the spirit light and make the body light.
	The seed is sweet and balanced. It mainly supplements the center and boosts qi.
	Protracted taking may make one fat, strong, and never senile.
	Ma Bo, the hemp spike, grows in rivers and valleys. (not/confuse with the Fructificatio Lasiosphaerae)
	Mahua- mature cannabis flower. (not/confuse with the Madhuca longifolia)
Divine Farmers materia Medica	Mafen: It is toxic, breaks accumulations, relieves impediments and disperses pus.
The Great Encyclopedia of Chinese Medicinals	Mahua: dispels wind, relieves pain, settles tetany.
	Indications: Bi syndrome, gout, withdrawal, Mania, insomnia, panting, and cough.
Yao Wu Tu Kao: illustrated analysis of medical substances.	Cannabis moves blood since it descends blood and cold qi.
	Uses: headache, menstrual pain, irregularities, itching, convulsions, anemia, and dry cough.
Classical Combos (Dui Yao)	Mahua and Cao Wu for severe tetany, wind-bi syndrome.
	Mafen, Shichang Pu, Gui Jiu (dysoma) for seeing ghosts. 100 days of a morning pill to see ghosts.- Li Shizhen
	Mahua and Ren shen (ginseng): forgetfulness. “know the affairs of the world and the 4 directions”. Dementia, Foggy headedness, memory loss. Happiness in heart.
Classical formulations	Mafei powder: Hua tuo’s formula for sedation, analgesic, and surgery
	Da ma Ren jiu: Mafen and Maziren preparation into wine.
	Shui Sheng San: cannabis and daturia. Stupor or slumber for moxa on the skin.
	Lu rong: aids cannabis. Young horn of deer.
	Sun Sumiao: took the leaves and juiced them to add into a liniment for broken bones.
	“Eradicates hidden wind inside the body”. For hard to treat Wind-Bi syndrome.
Changes over time	1995 to 2000: THC 4 to 8% TCH in cannabis
	2000 to 2015: 8 to 12% THC in cannabis
	Chemotype I: THC > CBD
	Chemotype II: THC = CBD
	Chemotype III: THC < CBD
Endocannabinoid system	1992 when researching effects of THC
	The body’s homeostasis system, nervous system, immune system, brain and gut axis, affects everything.
	More than receptors: enzymes, ligands (molecule or atom which binds to a protein like o2, dopamine, insulin), receptors to hormones and neurotransmitters
	Endocannabinoidome: extends to our microbiome
	Found in all vertebrates, throughout whole body.
	Helps us to adapt to environment, stressors, hormones.
Endocannabinoids: 2 Main:	2-arachidonoylglycerol (2-AG)
	Arachidonoyl ethanolamine (AEA)
	synthesized on demand. Metabolized by FAAH (AEA) and MAGL (2-AG)
8 other lesser understood endocannabinoids
Endocannabinoid receptors	CB1: in the CNS, brain and organs
	CB2:in spleen, periphery, immune system, skeletal system
other receptors in the endocannabinoid system	GRP18, GRP119, GRP55
other affected:	5HT (serotonin), TRPV1, PPARa
Locations	CB1: brain, CNS, heart, lungs, digestive organs, skeletal, adipose tissue, blood vessels, eyes.
	CB2: brain, periferial tissues, immune system, spleen, thymus
	GRP18: brain, spine, skin, lymph, intestines, appendix, kidneys, lungs, reproductive organs, immune system.
	GRP55: brain, intestines, lungs, pancreas, liver, urinary system, adrenals, adipose tissue, muscle, endothelial, immune cells.
	GRP119: colon, ileum, pancreas, B-cells, islets of langerhans, stomach
	TRPV1: Chondrocyt4es, brain neurons, epothelial cells, smooth muscles, mast, dendritic, lymphocytes, osteoclasts, hepatocytes, myotubes, fibroblasts, pancreatic B-cells.
	5HT Serotonin: cortex, hippocampus, nucleus accumbens, substantia nigra, ventral tegmental area, brain stem, PNS, enteric nervous system of GI, urinary tract
	PPARa: duodenum, heart, kidney, liver, skeletal, adipose, adrenal gland, brain, intestines, kidney, liver , lung, skeletal, spleen.
	Cannabis really affects everything! More research is needed.
Retrograde signaling (the Yin and Yang)	DSI depolarization induced suppression of inhibition aka pro-excitatory
Regulate neurotransmitter.	DSE depolarization induced suppression of Excitation aka pro-inhibitory
	DSI inhibits GABA and promotes Glutamate: yang more energy
	DSE inhibits Glutamate and promotes GABA: yin more rest and digest.
Endocannabinoid Deficiency and Excess	Deficiency: lower than normal endocannabinoid concentrations. Congenital, acquired through injury or chronic disease effect. Linked to migraine, fibromyalgia, IBS.
	Excess: Overactive CB1 receptor signaling promotes obesity, insulin resistance, dyslipidemia, obesity and metabolic disorders.
	def: sleep issues, mood, neurological dysfunction, pain intolerance
	excess- inflammatory state, excess GABA, fat storage, increase appetite, memory impairment, slow wound healing, BP issues
Phytocannabinoids
THC	CB1 agonist
	Induces DSE
	Biphasic (too little or too much can cause different reaction) can be opposite of GABA; insomnia, heart palpitations, excited.
	Positive Allosteric modulator to glycine receptors
	Psychoactive
CBD	Negative allosteric modulator CB1
	Negative allosteric modulator 5HT3 (nausea and moods in gastro system)
	Agonist 5HT1A (moods like depression)
	Positive Allosteric modulator to glycine receptors
	Psychoactive (still changes brain functions, perceived reality, moods, brain).
CBG	partial agonist CB2, (more in skeletal, joints). Increase GABA
	Negative allosteric modulator CB1
	Induces DSE
	5HT1A antagonist
CBN	Weak partial agonist CB1 and CB2
	Product of THC degradation. Sedating. Less psychoactive, sleepy, sedated.
CBC	Weak partial agonist CB1 and CB2
	Agonist 5HT1A (help moods like depression and anxiety)
	FAAH inhibitors lead to increase AEA. Increase own endocannabinoids.
THCV (raw plant)	Agonist and Antagonist to CB1 Receptors
	Biphasic (too little or too much can cause different reaction) can be opposite of GABA; insomnia, heart palpitations, excited.
	Found in raw cannabis
	Great for overactive ECS
Terpenes the essential oils/hormones of the plant
Pinene (upward)	smell: pine trees
	Effect: mix of calming and energizing
Limonene (upward)	smell: citrus
	effect: energizing mood and uplifting, mental clarity.
Mycene (descending)	woody/musky
	effect: sedating, calming both shen and nerve type pain
Linalool (inward)	smell: floral
	effect: calm shen and nerves
Trans/Beta-Caryophyilene (outward, cooling, expelling)	smell: spicy
	effect: anti-inflammatory, pain relief
Flavonoids	to utilize flavonoids , must eat or drink them
	Cannaflavin A: antioxidant, anti-parasitic, anti-inflammatory, neuroprotection, binds with viral protein
	Cannaflavin B; anti-cancer (pancreatic), Leishmaniasis
	Cannaflavin C: anti-parasitic
	Diabetics benefit from Flavonoids.
THC
Qi/nature	Hot/drying
Flavor	bitter, acrid
Organ affnity	Liver, Stomach, Heart
Directions	Ascending, descending, outward
Indications	Liver yang rising, blood stasis, qi stasis, shen disturbance
	Trauma, pain, mood irregularities, menstrual irregularities, insomnia, anorexia, brain disorders
Cautions/contraindications	Yin xu, blood Xu
	Paranoia, anxiety, palpitations, increased rate rate, somnolence, lethargy
Dosage	start 1-5mg. 2.5 to 5mg is effective.
CBD
Qi/nature	cooling/moistening
Flavor	sweet, slight bitter
Organ affnity	Liv, Stomach, Heart
Directions	Descending, inward
Indications	Liver yang rising, internal wind, Liver yin def., Stomach Yin def. , shen disturbance
	Tics, tremors, spasms, pain, insomnia, anorexia, mood irregularities
Cautions/contraindications	Caution in cold patients
	too much can cause diarhea, drowsiness, decrease short term memory
Dosage	start 5-10mg, up to 10-40mg
THCV (raw plant)
Qi/nature	Cool
Flavor	bitter, acrid
Organ affnity	Liv, Stomach, Spleen
Directions	ascending, outward
Indications	Stomach heat, spleen Qi xu, Liver heat, Liver qi stagnation, food stagnation
	Excessive appetite, fatigue, foggy thinking
Cautions/contraindications	Yun xu
	palpitations, ungrounded feeling.
Dosage	5-7mg, low dose more effective
CBG
Qi/nature	neutral, cool, drying
Flavor	bitter, acrid
Organ affnity	Large intestines, Stomach, kidneys, lung
Directions	Outward, descending
Indications	Moves Qi and blood, stops pain, drying
	Bone and joint inflammation, assists bone matrix, Bi syndrome, intestinal inflammation, abdominal pain, anti-parasite/microbial
Cautions/contraindications	Blood xu
	excess can cause dizziness, diarrhea, headaches, dry mouth
Dosage	5-10mg. 10-40mg effective.
CBN
Qi/nature	Neutral, warm, moistening
Flavor	bitter, sweet
Organ affnity	Liver, spleen, stomach
Directions	descending
Indications	Harmonize liver and stomach, nourish stomach, Liver yin def.
	Anorexia, insomnia
Cautions/contraindications	Inconclusive, decrease in eosinophils in animal studies
Dosage	15-40mg
CBC
Qi/nature	Neutral, moistening
Flavor	bitter, sweet
Organ affnity	Liv, stomach, kidney
Directions	descending
Indications	Harmonize liver and stomach, nourish yin of liver and kidneys
	Joint deformation, abdominal pain, nausea, osteoporosis, liver yang rising symptoms
Cautions/contraindications	inconclusive
Dosage	5mg-25mg
Administration routes
Inhalation	onset: 1-15 minutes
	duration: 2-4 hours
Oral	onset: 30-180 min
	duration: 5-8 hours
Oral/mucosal	onset: 15-20 minutes
	duration: 4-6 hours
Transdermal (patch)	onset: 15-20 minutes
	duration: 6-12 hours
Topical	onset: 20 minutes
	duration: 2-3 hours
Rectal	onset: variable
	duration: variable
Certificate of Authenticity (COA)	Cannabis is a soil remediator and can absorb heavy metals
	Minimize the possibility of contamination
	Get a COA if possible unless you know the grower.
	Growing your own, use organic products.
other considerations	patients with lung disease should not smoke
	Pediatrics, no THC
	Not recommended in Pregnancy, crosses the placenta
	Edibles enhance strength of THC
	patients with kidney disease, liver disease, IBD have slower absorption/excretion
Cannabis metabolism	THC and CBD affect psychiatric, cardiovascular drugs, immunotherapy. caution/contraindication
Cannabis in the clinic	common to see stagnation in middle jiao
	can contribute to heart-kidney disharmony
	may present with excess damp- swollen tongue, dark, pulse slippery
	smoking high does: heat and phlegm
	CUD: cannabis hyper-emesis syndrome
Cannabis hyperemesis Syndrome	abdominal pain, cramping, uncontrolled vomiting
(seen in chronic users)	symptoms relieved by hot showers
	vomiting stops when they stop using
Cannabis Use Disorder (CUD)	large amounts of use over long period of time
	unsuccessful attempts to cut down
	too much time recovering from use
	failing in school, work, and home to overuse.
	social and interpersonal problems
	psychological problems worsening from use
	high tolerance, withdrawal symptoms stop after quitting.
	Mood disorders, suicidal ideation, depressive symptoms.
	patients need to be monitored for mood disorders and pathological changes.
Neurological considerations	CB1 are highly concentrated in CNS and brain, affects neurology
	THC has direct affinity to CB1 in areas of brain associated with mood, cognition, memory, motor coordination, hunger.
	CBD affects neurology more indirectly. Interacts with serotonin, affects mood, reduces anxiety and depression.
	Cannabis can potentiate the effects of antidepressant, anxiety and epileptic medication. Drowsiness, poor memory/concentration, dizziness, increaes paranoid.
	Cannabis can increase mood disorders like anxiety, depression, mood, memory, and motivation.
	Can lower motor skills, lower coordination.
	Risk of schizophrenia in those with family history of psychosis.
	Reduced attention span, decreased cognitive and motor skills, ataxia, aphasia, unusual perceptions (hallucinations), anxiety.
Cardiovascular considerations	Cannabinoids can have a effect on blood pressure and heart rate
	those with heart rate abnormalities (sick sinus syndrome) , supra ventricular tachycardia, Atrial fibrillation, advised not to exercise on THC until after 1-3 hours.
	interferes with cardiovascular medications, decreases platelets, increasing INR (clotting time), need to consult with doctor on cannabis use.
Oncology considerations	Cannabis can have anti-tumor effect but can also increase growth and spread.
	Can worsen symptoms like tachycardia, respiratory distress, panic attacks, hypotension, syncope, mood/psychotic disorders.
	Infection risk in immuno-compromised and hepatic damaged patients.
	May increase tumor growth in HPV and neck squamous cell carcinoma, increase testicular tumor.
	Cannabis can interfere in CYP450 enzyme and interfere in immune system.
Pulmonary considerations	contaminants with smoking: cardon monoxide, ammonia, nitrosamines, tars are release and carcinogenic.
	Decreased pulmonary function with inhaled cannabis causing cough, increased mucus, chest tightness, wheezing can exacerbate asthma, COPD, and lung illnesses.
	Contaminant in poorly grown cannabis like mold, mildew, pesticides, heavy metals and irritate and worsen lungs.
	has a negative effect on the adaptive immunity of the lungs. More susceptible to infections. Immunocompromised should not smoke.
Gastrointestinal considerations	CHS- cannabis hyperemesis syndrome: vomiting, nausea
	IBD treatment with cannabis has adverse effects: headache, dizziness, drowsiness, nausea. Helpful in Oncology nausea, but worse for gastrointestinal diseases.
	CBD has been shown to increase hepatic injury and elevated transaminase in those with hepatic conditions.
	CBD has potential to increase weight-loss, should be used with caution with those who are taking drugs that reduce mineral and nutrient absorption.

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