By Nikki Wilson, PharmD/MBA, Director of Pharmacy Product Development, Coventry
Marijuana, it seems, is everywhere. Nearly a dozen states have approved cannabis for recreational use and more than two-thirds have signed off on medical marijuana1. Marijuana’s active chemical components are becoming more widespread, too. Cannabidiol (CBD), which is derived from cannabis, has popped up seemingly overnight in products from skin cream to candy to dog treats. Hemp, another marijuana analog, already appears in thousands of commercial products. The number is likely to increase thanks to a recent loosening of restrictions on hemp cultivation2. With so much going on around marijuana, it makes sense to review what we know and what it might mean for workers’ compensation.
The growing popularity of various forms of cannabis increases the likelihood that their use will become a bigger consideration within workers’ comp in the coming years. Here we’ll look at some of the basics of cannabis. Then, in our next installment, we’ll dig further into some of the details around cannabis.
First off, we should define what we’re talking about. In workers’ comp, we often use the terms “marijuana” and “cannabis” interchangeably. That’s understandable given marijuana is perhaps the more commonly used term.
While marijuana is more of a slang term encompassing the plant and associated products, the term cannabis originates from the plant genus name and is what we most often find in scientific literature. Cannabis generally refers to a preparation of the cannabis plant. Cannabis is comprised of a variety of chemical components, including cannabinoids. Cannabinoids are the active chemical constituents. It’s this chemical profile — the percentage of cannabinoids in cannabis — that determines a product’s potency and effects. Therefore, the makeup of the cannabis is what matters more than the various strain names or plant species type3.
How it works
The simple question of how cannabis works gives way to an intriguing answer. The focus is often on plant-derived cannabinoids. Yet, interestingly, humans have their own cannabinoid systems. Our bodies produce what are called endocannabinoids, or endogenous cannabinoids. Humans possess two cannabinoids receptors: CB1and CB2. These receptors, found throughout the body, are where various cannabinoids can exert their effects. Depending on where in the body a receptor exists, its task varies. Regardless, in each case, the goal is balance, or homeostasis.
As an example, let’s consider the brain. CB1 receptors are located in the brain and nervous system, organs, glands, and connective tissues. These receptors are responsible primarily for regulation of cognition, memory, motor function, pain, appetite, and sedation. CB2 receptors are present on immune cells, blood-forming cells, and organs and they generally play a role in immune function.
Plant-derived cannabinoids, sometimes referred to as phytocannabinoids, affect these same systems when they are introduced to the body. It’s for this reason that medical cannabis is often used to treat pain. A snapshot of patients taking medical cannabis in Colorado and Oregon in 2016 found more than nine in 10 were attempting to alleviate severe pain4. About a quarter of patients, who were allowed to identify more than one treatment goal, said they were attempting to combat muscle spasms and symptoms of multiple sclerosis. Fending off nausea was another reason for taking medical cannabis. Fewer patients said they were hoping to find relief from post-traumatic stress disorder, cancer, and seizures and epilepsy, among others.
It’s little surprise that patients would identify varying goals when taking cannabis. Proponents point to numerous potential physiological effects that cannabis can produce. These include:
- Improving sleep
- Inhibiting seizures
- Offering neuroprotection
- Reducing anxiety
- Improving psychotropic symptoms
- Preventing nausea
- Stimulating appetite
- Reducing intraocular pressure
- Acting as a bronchodilator
- Relaxing muscles and reducing muscle spasms
- Relieving pain
- Countering inflammation
- Serving as an anti-proliferative
- Fighting viruses
Among the cannabinoids with therapeutic interest, tetrahydrocannabinol (THC) has a number of well-known characteristics such as its psychoactive, analgesic, and anti-nausea properties. Less often known is that THC is also regarded as being neuro-protective and anti-inflammatory.
CBD, by comparison, does not possess psychoactive properties because it shows little affinity for interacting with the CB1 or CB2 receptors, the body’s main cannabinoid receptors. Instead, CBD tends to bind to the TRPV1 receptor. This tendency is similar to capsaicin, the chili pepper extract that is sometimes used as a pain reliever. Because CBD alone doesn’t produce a high, it’s the subject of a good deal of research and numerous orphan drug status designation applications.
When combined with THC, CBD tends to blunt some of unwelcome side effects such as anxiety, dysphoria, panic reactions, and paranoia. At the same time, introducing CBD along with THC can improve some of the therapeutic activity of THC5.
Recreation vs. Medication
It is important to note there is not a distinct difference between recreational and medical marijuana. Most of what is used recreationally contains THC; that’s what causes the high. Cannabis used for medicinal purposes may or may not contain THC. If the product is higher in CBD or purports to be “CBD-only,” the user might not experience euphoric effects. Yet there is much variability to consider. For example, cannabinoid products that are marketed as “CBD” products are intended to have a low psychoactive response and little to no THC. If, however, the patient is obtaining cannabis from a dispensary, which would most often be the case, the amount of THC depends on the blend or the plant strain and the chemical profile. Several dispensaries list the chemical makeup — that is, the amount of THC vs. CBD, for example — on the labeling, but there is no regulation to determine accuracy.
There are a number of ways users can obtain the effects of cannabis. It can, of course, be inhaled by smoking or vaporization. It can be eaten in food or delivered through lozenges or lollipops. It can pass through skin as a topical or rectal formulation. Naturally, how the drug is taken helps determine its effects, duration, and possible side effects. For example, smoking or vaping marijuana brings an immediate reaction. By comparison, eating foods that contain marijuana slows the initial reaction through the digestion process though it lengthens the duration.
Side Effects Can Vary
Just as the ingredients and methods of taking cannabis vary, so too do the potential adverse side effects. These can include a rapid heart rate, an irregular heart rate, and hypertension. The drug can also interfere with breathing by causing lung irritation, coughing, wheezing, and production of sputum. Gastrointestinal challenges, such as nausea, vomiting, and dry mouth, can also arise. The potential neurological fallout reads like the boilerplate of a pharmaceutical commercial: Side effects can include lethargy, sedation, drowsiness, slowed reaction time, impaired motor coordination, dizziness, loss of balance, and loss of muscle control.
Also possible are decreased focus, impaired judgment, disorientation, confusion, impaired short-term memory and memory formation, recollection, red eyes, and dilated pupils. Perhaps most famously, the psychoactive side effects can include euphoria, hallucinations, anxiety, and even addiction. A rare but particularly concerning effect is referred to as cannabinoid hyperemesis syndrome in which the cannabis user experiences ongoing cyclic vomiting.
Cannabis can present further risks when combined with other drugs. It can interact with central nervous system depressants, the blood thinner warfarin, tricyclic antidepressants, antiepileptic drugs, hydrocortisone, and antibiotics, for example. Research on some of these drug interactions is lacking because cannabis remains a Schedule I Controlled Substance. This designation means it is defined as having “no currently accepted medical use and a high potential for abuse.” It is illegal at the federal level and is therefore difficult to study in the U.S. through controlled trials.
Medical providers should talk with patients to understand their histories and perhaps identify some of the potential effects that might occur. In general, for example, cannabis can exacerbate the effects of other drugs that make patients lethargic.
There are other factors to take into account. Does the patient have a history of psychosis? What about cardiovascular disease or respiratory disease? Is she pregnant? Is there a history of a substance-use disorder?
Cannabis should be considered with the same rigor as other medications in terms of potential side effects, drug interactions, and dosing levels. As with other drugs, some patients merit particular caution. These include those who are under age 25, have active mood disorders, have risk factors for cardiovascular disease, or who use high levels of alcohol or benzodiazepines.
There are other safety considerations that aren’t always in play with fully legal medications. Some of these worries are over inconsistency of the product, packaging and labeling, and quality and purity. Beyond that, improper testing can fail to account for undisclosed contents or to identify contaminants.
Variations in the percentages of a product’s composition mean one product could be very different from another that contains the same ingredients but at different levels. In fact, every dispensary’s product is different. Manufacturers might have similar dosages of THC and CBD, but the varying inactive ingredients could potentially alter absorption, distribution, and metabolism.
Next week we’ll take a closer look at some of the other unique aspects and challenges of cannabis.
3Hazekamp, A. and Fischedick, J. T. (2012), Cannabis ‐ from cultivar to chemovar. Drug Test. Analysis, 4: 660-667. doi:10.1002/dta.407, https://onlinelibrary.wiley.com/doi/abs/10.1002/dta.407
4Adapted from CDPHE, 2016; OHA, 2016
5 Russo, Ethan B. “Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects.” British journal of pharmacology vol. 163,7 (2011): 1344-64. doi:10.1111/j.1476-5381.2011.01238.x
About Nikki Wilson
Nikki is a Pharm.D. who graduated with her Doctor of Pharmacy and Master of Business Administration (MBA) from Creighton University. As a licensed Pharmacist, Nikki has over nine years of comprehensive industry experience through leadership roles overseeing prescription home delivery programs, clinical pharmacy operations and benefit management, and product development. Today, she is responsible for developing pharmacy product strategy and program capabilities at Coventry with a focus on enhancing patient safety and returning people to work, to play, and to life.
Coventry offers workers’ compensation care-management and cost-containment solutions for employers, insurance carriers, and third-party administrators. With roots in both clinical and network services, Coventry leverages more than 35 years of industry experience, knowledge, and data analytics. As a part of the specialty division of Aetna our mission is returning people to work, to play, and to life. And our care-management and cost-containment solutions do just that. Our networks, clinical solutions, specialty programs, and business tools will help you focus on total outcomes.