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EVERYTHING YOU NEED TO KNOW ABOUT MEDICAL CANNABIS
As with all modern medicines, our understanding of cannabis and its benefits has deepened over time thanks to groundbreaking advancements in research and technology. Trilogy is committed to the ongoing education of our team to ensure they have the knowledge and resources to inform and provide you with the best possible experience. Download our Patient and Doctor brochures.
How Does Cannabis Work?
The endocannabinoid system (ECS) is a group of receptors that make up a very complex regulatory system throughout the human brain, body, central and peripheral nervous systems. The ECS creates and maintains internal stability (homeostasis) in humans (and fish, birds, mammals, amphibians, and reptiles) by adjusting the flow of neurotransmitters and regulating bodily functions, including appetite, sleep, emotion, and movement. Cannabinoids (THC, CBD, CBN, THCa etc.) are the chemical compounds produced by the cannabis plant that interact with the existing network of ECS receptors throughout the human body. Plant-based cannabinoids (phytocannabinoids) mimic the cannabinoids naturally produced by our bodies and can stimulate the ECS in the same way, helping to restore internal balance. The chemical compounds in cannabis act on all parts of the body- not just the brain, and researchers believe this is why cannabis is so effective in treating so many different ailments.
Read more about cannabinoids and the endocannabinoid system in the questions below.
What are Cannabinoids?
Cannabinoids are the active chemical compounds in the cannabis flower that give the plant its medicinal benefits and provide relief to an array of symptoms including pain, nausea, anxiety, and inflammation. Of these compounds, tetrahydrocannabinol (THC) and cannabidiol (CBD) have been studied most extensively.
Cannabinoids work by imitating naturally produced compounds in our bodies called endocannabinoids which are essential to maintaining our internal health by helping cells communicate with each other. When a patient consumes cannabis, the cannabinoids bind to receptors in our brain (called CB-1) and body (CB-2). Our brains have far more cannabinoid receptors than any other type of neurotransmitter. “They are concentrated in regions responsible for mental and physiological processes: the hippocampus (memory), cerebral cortex (higher cognition), the cerebellum (motor coordination), the basal ganglia (movement), the hypothalamus (appetite), the amygdala (emotions) and elsewhere.” CB2 receptors are prevalent throughout the immune and peripheral nervous systems including the gut, spleen, liver, heart, kidneys, bones, blood vessels, lymph cells, endocrine glands and reproductive organs. The CB1 receptors mediate physical and psychoactive effects while CB2 regulates inflammation and immune response. Cannabis is such a versatile medicine because it acts everywhere, not just in the brain. (Martin A. Lee, Project CBD.)
Cannabis contains more than 100 types of cannabinoids which all have different effects depending on which receptors they bind to. Each product and strain has a unique cannabinoid profile that can be used to target specific symptoms and provide different types of relief.
Ask our Trilogy experts which types of cannabinoids are best to treat your symptoms so we can recommend an appropriately suited product.
What are Phytocannabinoids?
Phytocannabinoids are compounds found in plants (phyto-) that interact with our internal endocannabinoid system. The majority of phytocannabinoids are found in the cannabis sativa species but have also been identified elsewhere in the plant kingdom, including piper nigrum (black pepper) and echinacea purpurea (purple coneflower).
When heated, cannabinoids go through a process called decarboxylation, which transforms them into neutral cannabinoids wide possess a variety of physiologic effects. None have been found to be toxic or capable of causing serious injury or death from overdose.
Delta-9-tetrahydrocannabinol (THC) is the most well-known and studied phytocannabinoid. THC is the predominant cannabinoid in most strains of medical cannabis and is responsible for the plant’s psychoactive effects and many medicinal properties. THC has proven effective in treating pain, inflammation, nausea, anxiety, itching, seizures, and much more. THC works by activating cannabinoid receptors in the brain (CB1) and central nervous system (CB2), mimicking the function of the natural endocannabinoids our bodies produce to regulate physiology and maintain health.
“Like endocannabinoids, the effects of THC vary in different bodily tissues. In the brain, THC can protect neurons, promote cell growth, regulate neuroplasticity (a process involved in learning and forgetting), and cause psychoactive effects including euphoria, changes in memory, mood, coordination, and perception.” (Healer.com)
Tetrahydrocannabinolic acid, THCa is a non-psychoactive cannabinoid found in raw and live cannabis. When you smoke or vaporize the cannabis flower, the heat converts THCa into THC through a process called decarboxylation.
Little research has been done but preliminary studies suggest that THCa will play a pivotal role in cannabis medicine as the industry advances. Some of the potential benefits studies are finding include: “Anti-inflammatory properties for treatment of arthritis and lupus; Neuroprotective properties for treatment of neurodegenerative diseases; Anti-emetic properties for treatment of nausea and appetite loss; Anti-proliferative properties noted in studies of prostate cancer.” (Leafly.com
Raw cannabis products including some transdermal patches deliver THCa’s benefits without the psychoactive effects. Trilogy’s team is dedicated to continued education and we will inform our patients as more research and more THCa products become available.
Research into Cannabidiol (CBD) has transformed the perception of medical cannabis. While THC is the dominant psychoactive component of cannabis, CBD provides an equally broad range of medical and therapeutic applications with none of the psychoactive effects. All cannabis plants have both THC and CBD cannabinoids, though in varying ratios and growers now intentionally breed species that are high in CBD and low in THC. “CBD has been shown to relieve anxiety, depression, pain, seizures, psychosis, inflammation, spasms, nausea, and more.” (Healer.com)
CBD does not interact with the CB1 and CB2 receptors in the same way that THC does, though it can modify the effects that other substances have on these receptors. Combining CBD and THC is shown to decrease the psychoactivity and other side effects of THC while enhancing some of THC’s medicinal benefits.
The Endocannabinoid System
Israeli pharmacologist and professor of Medicinal Chemistry, Raphael Mechoulam is widely acknowledged as the “father of cannabinoid medicine.” He was the first person to isolate and synthesize phytocannabinoids CBD and THC in 1963-65 in his laboratory at the Hebrew University of Jerusalem. In 1992, Mechoulam and colleagues found a naturally occurring neurotransmitter, or “endocannabi-noid,” and in 1995, discovered a second major endocannabinoid that attaches to both the CB1 and CB2 receptors. The discovery of the endocannabinoid system has impacted nearly every area of medicine and sparked extensive studies into the pharmacological, biochemical, and clinical effects of cannabis. Mechoulam’s discovery and subsequent study of the endocannabinoid system and its clinical applications were documented in the 2009 biopic, The Scientist.
The endocannabinoid system (ECS) has been described as the “supercomputer that regulates homeostasis [internal stability] in the human body.” Endocannabinoid receptors are found throughout the brain and in every major organ, connective tissue, gland and immune cell of every Endocannabinoids and their receptors are present in fish, reptiles, earthworms, leeches, amphibians, birds and mammals —every animal except insects. vertebrate species on the planet. The ECS is believed to be one of the most important physiological systems involved in maintaining and regulating human health.
There are three basic components to the ECS: cannabinoid receptors on the surface of cells, endocannabinoids that trigger the receptors, and hydrolytic enzymes that break down endocannabinoids after they are used. Endocannabinoids are molecules produced by the body’s cells that act very similarly to THC and the other phytocannabinoids (including CBD and THCa), facilitating communication between different types of cells. The cannabinoid system performs different tasks in each tissue with the goal of maintaining internal homeostasis.
Learn more about the endocannabinoid system and how it works here: https://www.leafly.com/news/science-tech/what-is-the-endocannabinoid-system
Ways to Consume Cannabis
There is no “best” or “correct” method of consuming cannabis. Each method has different medicinal effects, benefits, drawbacks, and clinical utility depending on the patient and their specific situation.
The beneficial compounds in cannabis can be administered by inhaling smoke or vapors, ingesting cannabis added to food or drink, swallowing capsules, taking liquid extracts such as tinctures or oils absorbed through the mouth or swallowed, or applying cannabis lotions, salves or patches to the skin.
INHALATION: ONSET 1-5 MINUTES, DURATION 1-6 HOURS
The effects of inhaling cannabis are felt almost immediately making it easy for users to judge their correct dosage. This is an ideal delivery for patients with nausea, vomiting, or other conditions that make swallowing difficult. Conversely, inhaled cannabis does have a risk of cardiovascular side effects, effects last for a shorter duration than other methods and may have a higher potential for abuse.
SMOKING is the most traditional method of cannabis use and works well for many patients. Inhaled cannabis transforms into a gaseous form, passing into the lungs and adhering to the lining of the nasal passages through which the cannabinoids enter directly into the bloodstream, resulting in almost immediate onset. The heat and smoke created by burning cannabis can irritate the respiratory tract and lungs, potentially worsening conditions such as asthma and COPD— this can be avoided by vaporization. The smoke itself does contain carcinogenic (cancer-causing) substances, but long-term heavy cannabis smokers have shown no increased risk of lung cancer, likely due to cannabis’ anti-cancer properties offsetting the carcinogens in the smoke.
VAPORIZING is considered to be the healthiest way to inhale cannabis. The vaporizer heats the herb between 300-400 degrees Fahrenheit; just hot enough to release the medicinal substances into a vapor without burning the plant material. Vapor preserves the smell and flavor of the cannabis without the heat that irritates the throat and lungs.
TOPICAL (EXTERNAL USE ON SKIN): ONSET AND DURATION VARIES
Cannabis topicals including lotions, salves, balms, sprays, and patches help alleviate localized pain, soreness, cramping, muscle spasms, inflammation, itching, and various skin conditions, including psoriasis and eczema.
Cannabis-infused topicals work by binding to a network of CB2 receptors found throughout the body and are activated either by the body’s naturally-occurring endocannabinoids or by cannabis compounds known as “phytocannabinoids” (THC, CBD, THCa). Topical use of cannabis does not produce psychoactive effects because cannabinoids can’t breach the bloodstream. However, high THC “Transdermal” patches are designed to deliver cannabinoids to the bloodstream and could have “full body” psychoactive effects that may be more effective in treating chronic pain. Different topicals have different benefits depending on the cannabis strain, how they are processed, and added ingredients such as other herbs and essential oils.
LIQUID CANNABIS EXTRACTS: ONSET 10-45 MINUTES, DURATION 2-8 HOURS
Cannabis tinctures are alcohol-based cannabis extracts. Tinctures provide one of the easiest and most versatile delivery methods and works well for a variety of patients, especially those who want to avoid inhalation. Liquid extracts are absorbed directly through the mucous membrane under the tongue or can be swallowed. They are convenient, discreet, and easy to dose correctly. Liquid medicines do have some challenges: active constituents can settle to the bottom of the bottle, To use a cannabis tincture, start with 1mL under your tongue and hold for 1-2 minutes before swallowing (Brushing your teeth beforehand can increase blood flow in the mouth and speed the onset.) If you’d like a stronger effect increase to 2mL the next day and so on until you find the volume that works for you. Effects vary if held in the mouth vs. swallowing. Alcohol tinctures may be inappropriate for people with a history of alcohol abuse. If the tincture irritates your mouth, add the liquid to a small amount of warm water first – this will evaporate some of the alcohol and dilute the rest, preventing that burning sensation.
INGESTION: ONSET WITHIN 1-2 HOURS, DURATION 4-12 HOURS
Before being consumed, cannabis must be heated (decarboxylated) to convert the cannabinoids into their active form. After decarboxylation, cannabis can be added to a variety of foods, beverages, and capsules.
When swallowed, cannabis is absorbed through the gastrointestinal tract and metabolized in the liver. This process can produce different therapeutic effects than other methods of delivery. It can take much longer to feel the effects after ingesting cannabis (which makes it difficult to find the optimal dosage), but their duration is often significantly longer. Many users report feeling a stronger psychoactive effect, while others report less psychoactivity. The GI tract is a highly sensitive organ and absorption of cannabinoids can vary from one day to the next depending on the amount of food consumed that day, sleep, or stress.
It is not dangerous to overdose on edible cannabis, but the effects of consuming too much can be unpleasant.It is best to start with a very small amount, then repeat the dose after 2-3 hours if needed. Patients new to medical cannabis should begin treatment with other delivery methods before ingesting cannabis.
RECTAL: ONSET AND DURATION VARIES
Patients who prefer not to or are unable to inhale or swallow cannabis, can use cannabis suppositories to treat conditions in the pelvis and low back. Likely due to the cannabis not being metabolized in the liver, some patients report rectal administration as less-psychoactive than ingesting. There is wide variability in absorption of rectal cannabis and the form of the suppository can make a significant difference.
What are Cannabis Flowers?
Cannabis plants can be male, female, or both (hermaphrodite), but only females produce the large, fragrant flowers that are trimmed into buds, cured and smoked. Male plants pollinate the females causing them to produce seeds so the males are eliminated from a harvest so that the female plants can produce the potent, seedless, cannabinoid-rich flowers we consume. The flower’s fragrance comes from the plant’s terpenes — these sweet, fruity, floral, earthy, piney or musky scented oils are secreted by the cannabis plant and give each strain their characteristic smells.
What are Terpenes?
Originally developed by plants as a protection against predators, terpenes are fragrant oils that give cannabis (and many other herbs, fruits, and plants) its diverse aromatic characteristics. The cannabis flower secretes these pungent oils in the same glands, called trichomes, that produce THC, CBD, and other cannabinoids.
Like cannabinoids, terpenes bind to receptors in the brain and can modify how much THC passes through the blood-brain barrier. Terpenes have also been found to influence neurotransmitters like dopamine and serotonin and may offer additional medical value as they mediate how the body interacts with other cannabinoids.
The effects vary from terpene to terpene but their beneficial qualities can be damaged if heated past their boiling point. To ensure you’re preserving the full benefit and flavor of your terpenes, use a ‘low-heat’ device such as a variable temperature vaporizer pen or adjustable eNail.
Over 200 different terpenes have been identified in the cannabis plant, and every strain has its own unique terpene profile. These are the 7 primary terpenes that occur most commonly:
Also found in conifer trees, orange peels, turpentine, pine needles, rosemary, dill, basil, and parsley, pinene has a distinct pine aroma. An effective antiseptic, pinene can be used to treat asthma, affect alertness, memory retention, and offset some THC effects. High Pinene Cannabis Strains include: Jack Herer, Chemdawg, Bubba Kush, Trainwreck, Super Silver Haze.
A terpene that occurs in highly fragrant plants and herbs such as mangoes, hops, bay laurel leaves, thyme, lemongrass, and basil. An antioxidant and anticarcinogenic with a musky, herbal aroma laced with clove, earth, citrus, and tropical fruit. Known for its sedative “couchlock” effect, myrcene is relaxing, good for muscle tension, sleeplessness, pain, inflammation, and depression. High Myrcene cannabis strains include: Pure Kush, El Nino, Himalayan Gold, Skunk #1, White Widow
A distinct citrus aroma found in fruit rinds, rosemary, juniper, and peppermint. Limonene is an effective mood elevator and stress reliever with antifungal, anti-bacterial, anti-carcinogenic properties. It may also dissolve gallstones, treat gastrointestinal complications, heartburn, and depression. High Limonene cannabis strains: OG Kush, Super Lemon Haze, Jack the Ripper, Lemon Skunk.
Caryophyllene is a spicy, peppery terpene found in many different edible plants like oregano, basil, hops, and rosemary and spices like black pepper, cloves, and cinnamon. Caryophyllene is often used in topicals and salves because of its anti-inflammatory properties and may be used to treat arthritis, ulcers, autoimmune disorders, and other gastrointestinal complications. High Caryophyllene cannabis strains: Hash Plant
Also known as levomenol, bisabolol is produced by the chamomile flower and has been widely used in the cosmetics industry. In cannabis, bisabolol displays anti-inflammatory, anti-irritant, antioxidant, antimicrobial, and analgesic effects. High Bisabolol cannabis strains include: Harle-Tsu, ACDC, Pink Kush, Headband, OG Shark, Rockstar, and Master Kush.
Found in many flowers and spices including lavender and coriander, linalool has a light floral and citrus aroma. Like lavender, linalool produces a calming effect and can be used for its sedating, anti-anxiety, anticonvulsant, and antidepressant effects. High Linalool cannabis strains include G-13, Amnesia Haze, Lavender, LA Confidential
A subtle earthy, woody aroma that occurs naturally in clove, basil, and hops. In cannabis, humulene is found to suppress hunger. Humulene’s other potential effects include: anti-bacterial, anti-inflammatory, and anti-tumor.High Humulene cannabis strains: White Widow, Girl Scout Cookies, Headband, Pink Kush, Sour Diesel, and Skywalker OG.
What are Concentrates?
Cannabis concentrate technology uses today’s most advanced cannabis extraction and refinement techniques.There are many types of concentrates including kief, hash, butane hash oil (BHO), CO2 oil, tinctures, shatter and wax. In general, a concentrate refers to any product obtained through an extraction process.Most concentrates are extracted using a solvent like butane, CO2, hydrocarbons, propane, or ethanol alcohol. Solventless extracts are made using water (hash) or heat (rosin).
Solvents strip the active compounds (THC, CBD) from the cannabis plant, leaving behind a highly potent, cannabinoid-packed product. Extracts vary in consistency but most are used for vaporization and dabbing.
The most important distinction between cannabis flowers and concentrates is potency. Average bud potency ranges between 10-25% THC, while a concentrate typically falls between 50-80%. There are also CBD-rich concentrates that are non-psychoactive and can deliver all the medicinal benefits of extracts without the high. When consuming concentrates, always start with a low dose and increase slowly once you understand your tolerance.
What is a Vaporizer Cartridge?
Pre-filled vape cartridges are widely popular for their ease of use, functionality, and portability. They are known by several names: pre-loaded cannabis oil vape cartridges, hash oil vape pens, or disposable wax pens. Vaporizers heat cannabis just hot enough to extract beneficial compounds but below the temperature of combustion. For health-conscious consumers, this is the best method of delivery as it is gentle on the lungs but can still deliver a powerful dosage.
Most cartridges are formatted to fit a 510 threaded standard vaporizer battery and require little effort and zero maintenance aside from occasionally charging the battery. Their sleek design is discreet, produces no noticeable odor and dosage is easily controlled with inhalation.
Pre-filled cartridges are typically filled with cannabis distillates which are less viscous, do not require cutting agents, and contain higher cannabinoid purity. Cartridges are available in indica, sativa, hybrid and high-CBD strains.
How to Choose the Right Strain for You
Every patient responds differently to cannabis. You will likely need to test out a few varieties in a safe and comfortable environment in order to find the medicine that works best for you. Most patients eventually find 2-3 different strains that work well for different purposes, such as one for daytime and one for sleep.
Medical cannabis strains have four major categories: indica, sativa, hybrid indica/sativa, and high-CBD. A patient suffering from fatigue or depression may use a sativa during the day, and another treating pain and insomnia will likely choose an indica strain at nighttime. High-CBD strains offer little to no psychoactive effects and may be preferred by patients treating seizures, anxiety, pain and some other disorders.
CANNABIS SATIVA strains are tall plants with narrow leaves. Buds often having a spicy or floral fragrance. These varieties tend to be more mentally stimulating, more energetic and euphoric. They can help treat nausea, stimulate appetite, ease headaches, depression, and fatigue. Although side effects are uncommon, because of its stimulating effects sativa strains are more likely to cause or worsen anxiety or paranoia.
CANNABIS INDICA strains are shorter, bushier plants. Flowers are often characterized by an intense sour or fruity fragrance. Indica varieties are typically relaxing and sedating, helping more with pain, anxiety, muscle spasms, and insomnia.
HYBRID INDICA/SATIVA strains are most common and have been cross-bred to achieve more synergistic qualities. Depending on the sativa-indica ratio, hybrid strains can help target multiple symptoms, for example; relaxing the body without the sedative feeling.
CBD-RICH strains are specifically bred to produce high levels of the cannabidiol (CBD) and low levels of the psychoactive chemical, THC. CBD has many medicinal properties, including anti-anxiety, anti-inflammatory, anti-tumor, anti-seizure, and pain relief. Strains with high levels of CBD produce little or no psychoactivity, making them desirable for young patients or those who want the medical benefits without getting “high.”
Trilogy’s experienced team can provide you with personalized recommendations on cannabis strains and cannabinoid ratios/dosages for your condition.
How to Minimize Adverse Effects
Finding your optimal dosage is the most important factor in minimizing side effects. Our experts at Trilogy will advise on consumption and help guide you safely through the selection of appropriate cannabis strains and forms for your needs— but there are guidelines you must follow at home to ensure that your experience is positive and therapeutic.
Dehydration is one of the most common causes of side effects in patients using cannabis. Ensuring that you are drinking an adequate amount of water every day (68-135 ounces) is an effective and inexpensive way to improve your health and mitigate cannabis side effects.
MINDSET AND SETTING
A patient’s state of consciousness and surrounding environment can significantly influence their experience with cannabis. if you’ve experienced anxiety, panic, paranoia, or confusion after taking cannabis, or are relatively new to cannabis, we recommend only using it in a familiar and comfortable setting. Stressful environments are more likely to trigger adverse effects in cannabis users.
Prior to consuming cannabis, take a few minutes to observe your current inner state. Are you breathing deeply? What is your mood? Ask yourself what you hope to get out of this experience. “Cannabis can stimulate neuroplasticity, the process of making new neural connections that are involved in learning and the sometimes-unconscious adoption of new thought and behavioral patterns.” (Healer.com) Setting positive intentions can help to improve the way you think and feel even after the cannabis wears off.
MINDFUL CONSUMPTION OF FOOD
Patients who have trouble controlling their appetite after using cannabis can mediate cravings by consuming cannabis after meals or keeping healthy snacks in easy access. Patients may also find that cannabis enhances the sensory experience of eating food— use this as a way to be more mindful and savor every bite. To savor each bite, try chewing each piece of food 15-20 times before swallowing.
CARDIOVASCULAR SIDE EFFECTS
If you often experience lightheadedness after standing, or racing or irregular heartbeats, use a delivery method with a slower onset, such as tincture. Take small doses at a time and wait 2-3 hours before taking a second dose. If you continue to experience symptoms, consult your healthcare provider.
How to Become a Maryland Medical Cannabis Patient
For information on how to register as an adult (18 years or older) medical cannabis patient or as a caregiver for a minor patient, please visit: http://mmcc.maryland.gov/Pages/process_to_obtain.aspx
“Any Maryland resident whose physician recommends medical cannabis as a treatment option for a qualifying medical condition is eligible to register with the Maryland Medical Cannabis Commission (MMCC) as a patient. Qualifying medical conditions include cachexia, anorexia, wasting syndrome, severe pain, severe nausea, seizures, severe or persistent muscle spasms, glaucoma, post-traumatic stress disorder (PTSD) and chronic pain.”
For more information visit: http://mmcc.maryland.gov/Pages/patients.aspx
Links to Additional Resources and Studies
The Society of Cannabis Clinicians is a fountain of information about medical cannabis research and has compiled a thorough list of resources for patients seeking additional information and access to peer-reviewed studies. Visit their Patient Resources page here: http://cannabisclinicians.org/patient-resources/
For information on cannabis myths and facts, Dr. Dustin Sulak has published an interesting article on Healer.com https://healer.com/marijuana-myths-cannabis-facts/