Source: http://rx.ph.lacounty.gov/RxCannabis0918
Timestamp: 2019-04-18 13:29:00+00:00

Document:
Cannabis is the scientific name for marijuana. Cannabis contains a variety of active compounds, including cannabinoids. For the purposes of this article, cannabis refers to the plant and the products derived from the plant, whereas cannabinoid refers to the specific group of active compounds.
In this article, medicinal cannabis will be used to refer to cannabis use that is either recommended by a physician or initiated by a patient to treat a medical condition. The term non-medicinal cannabis will be used to refer to the use of cannabis for the purpose of seeking a pleasurable effect or “high.” Non-medicinal use is preferred over the term recreational use because recreation is associated with healthy practices, such as physical activity.
See the UCLA Cannabis Research Initiative terminology webpage for a glossary of terms associated with cannabis.
Despite the growing trend of cannabis legalization, cannabis and one of its main active compounds, Δ9-tetrahydrocannabinol (THC), remain federally classified as Schedule I drugs under the U.S. Controlled Substances Act.4 Schedule I drugs, which include heroin and LSD, are defined as having a high potential for abuse and no currently accepted medical use.5 There are significant federal research restrictions on Schedule I drugs.
There are several medical and legal considerations health care providers should be aware of regarding cannabis.
Anyone age 21 years of age or older can legally purchase cannabis in California without a physician’s recommendation.2 However, there are reasons that patients may want a physician’s recommendation for cannabis, such as to seek medical guidance or to obtain a Medical Marijuana Identification Card.
Patients aged 18 years and older,9 as well as emancipated minors, can legally purchase and use cannabis in California for medicinal use with a physician’s recommendation.
Pediatric patients under 18 years of age can also legally use cannabis for medicinal purposes if they have a physician’s recommendation. In order to purchase the pediatric patient’s medicinal cannabis, the child’s adult primary caregiver must have a Medical Marijuana Identification Card on the child’s behalf.10,11 Note: A minor who is a parent of a qualified patient can be designated the primary caregiver and obtain a Medical Marijuana Identification Card to purchase cannabis for that child.
In LA County, Medical Marijuana Identification Cards are issued exclusively by the LA County Department of Public Health12,13,14 and are valid up to one year.15 A physician recommendation is required to obtain a card.16 These cards provide exemption from certain sales taxes17 and are required to obtain medicinal use cannabis for minors. In addition, the cards authorize the use, possession, and transport of medicinal cannabis in California.11 See the California Cannabis Health Information Initiative’s “Medicinal Use Cannabis” fact sheet for more information.
As cannabis remains illegal at the federal level, cannabis use and/or possession, whether medicinal or non-medicinal, may incur federal consequences. In the case of immigration status, current or past cannabis use may impact immigration status.18 See the Immigrant Legal Resource Center’s "Immigrants and Cannabis” fact sheets, which are available in multiple languages.
There are currently four FDA-approved cannabinoids available in the United States.
*In June 2018, the FDA approved Epidiolex (purified CBD) for the treatment of seizures associated with two rare and severe forms of pediatric epilepsy, Lennox-Gastaut syndrome and Dravet syndrome, in patients two years of age and older.19 All CBD products other than Epidiolex remain Schedule I. Epidiolex is the first cannabis-derived product to be approved by the FDA. The other FDA-approved drugs are synthetic and not cannabis-derived.
Data are limited regarding drug interactions associated with cannabis use. However, there are potential drug interactions based on the known metabolism of the primary cannabinoids in cannabis.
In 2017, The National Academies of Sciences, Engineering, and Medicine (NASEM) published a landmark review titled “The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research” that summarized available scientific research regarding the potential therapeutic effects and health risks of cannabis and cannabinoids.29 NASEM presented nearly 100 conclusions that are summarized in the review.30 The major findings are summarized below.
* Cannabis refers to smoked/vaporized cannabis, which contains many active cannabinoid compounds.
** Oral cannabinoids refer to pharmaceutical preparations of individual cannabinoids. This does not include edibles or other oral forms of cannabis available in dispensaries.
Though clinical trials have shown that cannabis is effective at reducing pain symptoms in adults, the efficacy and safety of current forms of cannabis and cannabinoids available in U.S. dispensaries remains unclear. Given that pain is the most commonly cited reason for medicinal cannabis use by patients,29 it is likely that more adults will self-treat their chronic pain with cannabis. However, whether cannabis should be considered as a non-opioid therapy for chronic pain remains unclear despite recent reports suggesting that cannabis administration may reduce the use of opioid-based pain medications.31 Clinicians caring for patients with chronic pain should ask them directly about cannabis use (see “Asking Patients About Cannabis Use”), provide appropriate education, and monitor for misuse and drug interactions.
To ascertain the impacts of non-medicinal cannabis use on health, NASEM reviewed epidemiologic studies investigating the associations and risk factors of smoked cannabis and various health conditions. The table below features the key highlights regarding these health effects. Bolded findings had the most significant evidence base for harm.
Smoking cannabis during pregnancy is linked to lower birth weight in the offspring.
The relationship between smoking cannabis during pregnancy and other pregnancy and childhood outcomes is unclear.
Recent cannabis use impairs performance in the cognitive domains of learning, memory, and attention. Recent use may be defined as cannabis use within 24 hours of evaluation.
A limited number of studies suggest that that impairment persists in the cognitive domains of learning, memory, and attention in individuals who have stopped smoking cannabis.
Cannabis use is likely to increase the risk of developing schizophrenia and other psychoses in predisposed individuals – the greater the use, the higher the risk.
For individuals diagnosed with bipolar disorders, near daily cannabis use may be linked to greater symptoms of bipolar disorder than among non-users.
Regular cannabis use is likely to increase the risk of developing social anxiety disorder.
Greater frequency of cannabis use increases the likelihood of developing problem cannabis use.
Initiating cannabis use at a younger age increases the likelihood of developing problem cannabis use.
Cannabis use is likely to increase the risk of developing other substance use disorders (other than cannabis use disorder).
It is unclear whether cannabis use is associated with COPD, asthma, or worsened lung function.
There is a lack of data on the effects of cannabis or cannabinoid-based therapeutics on the human immune system.
NASEM found significant evidence of adverse effects associated with non-medicinal cannabis use across many health categories. In particular, cannabis users are at a higher risk of motor vehicle crashes and substance use disorders. In pregnancy, cannabis use is linked to low birth weight in infants. In addition, cannabis use during adolescence is associated with substantial risks including addiction and adverse impacts on academic achievement, employment, and social functioning.
It is important for healthcare providers to ask their patients about cannabis use in a non-judgmental manner, and to provide unbiased and evidence-based information. A question such as, “Are you using any cannabis or cannabis products such as marijuana, hemp, THC, or CBD?” may be included in a patient intake form and/or asked in-person. Affirmative answers should be followed up with questions about how they consume the products and the frequency of use. Due to the association between addiction and cannabis, providers are encouraged to ask cannabis users if they think their cannabis use is causing problems. If the patient responds affirmatively and is amenable to treatment, a referral for substance use disorder treatment is generally warranted. See supplemental article, “Screening for Cannabis Misuse and Substance Use Disorders,” for screening tools and treatment referral information.
Cannabis products can be legally obtained from licensed dispensaries. Patients should be advised that higher levels of THC are found in some of the newer cannabis products such as dabs, vape oil, and/or edibles.
In addition to cannabis plants, hemp plants are a source of naturally occurring CBD. CBD derived from hemp is sold widely throughout the U.S. and consumers may not associate it with cannabis. Hemp-derived CBD products sold outside of dispensaries are not regulated like cannabis-derived CBD products sold in dispensaries and thus may not contain the levels of CBD advertised or may contain contaminants. Patients known to use CBD/hemp should be monitored for potential drug interactions.
It is important to assess the patient’s utilization of synthetic cannabinoids (also known as synthetic marijuana, Spice, K2, and other names). Despite the name, these synthetic psychoactive drugs are not cannabis, are not sold in licensed cannabis dispensaries, and tend to have unpredictable and significantly more dangerous and life-threatening effects than cannabis.42 Synthetic cannabinoids may be sold as liquids for vaping or sprayed on dried plant material to be smoked and are often marketed as herbal or liquid incense. All non-prescription synthetic cannabinoids are illegal in the U.S. See the CDC webpage “Synthetic cannabinoids: What are they? What are their effects?” to learn more about synthetic cannabinoids.
It is important that healthcare providers are prepared to discuss the risks of cannabis use and how adults can use cannabis responsibly, if they choose to use it. Below are key counseling points with links to more detailed information and resources.
COUNSELING POINT: Cannabis use is discouraged among women who are pregnant, breastfeeding, or contemplating pregnancy.
COUNSELING POINT: Protect infants and children from cannabis exposure including secondhand smoke and unintentional poisoning from edibles and other products such as patches and tinctures.
Advise patients to store all cannabis products in a locked area, out of a child’s view and reach, and in the original child-resistant packaging from the dispensary.
COUNSELING POINT: It is illegal for anyone under 21 years of age to smoke, consume, buy, or possess non-medicinal cannabis. Cannabis has several negative effects in youth.
COUNSELING POINT: Do not drive when under the influence of cannabis.
Driving while under the influence (DUI) of cannabis is unsafe and illegal. Cannabis use prior to driving increases the risk of being involved in a motor vehicle crash.43,44 Studies show that cannabis impairs psychomotor skills, lane tracking, and cognitive functions.43,45 Impaired drivers may be arrested and convicted for DUI, regardless of the substance causing the impairment (e.g., cannabis, alcohol, prescription medications, street drugs).
COUNSELING POINT: Be aware of high levels of THC.
Many cannabis plants now have higher amounts of THC and newer methods of consuming cannabis (e.g., dabbing, vaping, and/or consuming edibles) tend to deliver higher doses of THC into the body, which increases risk of impairment, acute psychosis, and poisoning.
COUNSELING POINT: Be aware of synthetic cannabinoids (e.g., K2, Spice, Kush).
Synthetic cannabinoids are not cannabis and are often more dangerous.
COUNSELING POINT: Be aware of contaminants in cannabis products.
Advise patients to only purchase cannabis products from licensed dispensaries.
COUNSELING POINT: Be aware that there are legal limits for medicinal and non-medicinal cannabis use, and that penalties are associated with exceeding limits. Limits are higher for medicinal use.
Website: Let’s Talk Cannabis: What’s Legal?
COUNSELING POINT: Be aware that cannabis may impact immigration status.
Cannabis is still illegal at the federal level and may have repercussions on immigration status for patients.
The wide availability of cannabis is a significant public health concern, particularly for vulnerable populations such as adolescents and pregnant women. Though evidence is limited for the impact of cannabis on most conditions, research in adults suggests clinical benefit for three conditions: chronic pain, chemotherapy-induced nausea and vomiting, and spasticity due to multiple sclerosis.
The MBC has issued guidelines for the recommendation of cannabis for medicinal purposes, while allowing physicians to use their clinical judgment to decide on the appropriateness of medicinal cannabis for their patients. However, cannabis has been associated with an array of harmful health effects and may cause certain drug interactions. Therefore, medical providers should routinely ask patients about their use of cannabis and be prepared to have informed conversations with patients about the possible health effects of cannabis and illegal synthetic cannabinoids. Finally, providers should stay abreast of the ever-growing body of research on cannabis, as the evidence of the health impacts of cannabis use is sure to evolve and expand.
Common cannabis-related terminology, general information about cannabis and its compounds, and information about current cannabis research.
Information about NIDA’s role in providing cannabis for research, general information about cannabis and its compounds, summary of research, and statistics.
Information on uses, side effects, interactions, and dosing of cannabis/cannabinoids.
A one-credit CME course offered by the District of Columbia Department of Health that provides evidence-based information on the safety profile of medicinal cannabis. Includes common contraindications, adverse effects, and drug interactions. Download the slides or visit the website to access the course.
Helpline for patients, families and all health care providers. Experts in poisoning information tailor advice based on the patient’s medical history and specific exposure. Advise patients to program the Hotline phone number into their phones so that it is readily available in the event of unintentional ingestion and/or cannabis overdose.
Variety of resources including consumer, patient, and youth fact sheets.
Information on prevention and the County’s specialty substance use disorder treatment system and services.
Patient resources, FAQs and statistics.
Information about documentation needed to obtain a voluntary medical marijuana identification card, fees, office locations, and appointment information.
Information regarding the implementation of the County’s cannabis policies and regulations.
State Marijuana Laws in 2018 Map. Governing. http://www.governing.com/gov-data/state-marijuana-laws-map-medical-recreational.html. Accessed May 11, 2018.
Title 21 Code of Federal Regulations. Part 1308: Schedules of Controlled Substances. §1308.11 Schedule I.(d)(31). https://www.gpo.gov/fdsys/pkg/CFR-2018-title21-vol9/pdf/CFR-2018-title21-vol9-chapII.pdf. Accessed May 18, 2018.
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California Health and Safety Code. § 11362.71. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC&sectionNum=11362.71. Accessed August 31, 2018.
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Medical Marijuana Program. Medical Marijuana Program Information. Los Angeles County Department of Public Health. http://publichealth.lacounty.gov/eh/SSE/MedicalMarijuana/. Accessed August 31, 2018.
California Revenue and Taxation Code § 34011 (f). https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=RTC&sectionNum=34011. Accessed August 31, 2018.
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FDA approves first drug comprised of an active ingredient derived from marijuana to treat rare, severe forms of epilepsy. [news release]. Silver Spring, MD: U.S. Food and Drug Administration; June 25, 2018. https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm611046.htm. Accessed July 12, 2018.
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National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids, Committee’s Conclusions. http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2017/Cannabis-Health-Effects/Cannabis-conclusions.pdf. Published January 2017. Accessed May 2, 2018.
Phase-in of Required Laboratory Testing. California Department of Consumer Affairs, Bureau of Cannabis Control. https://bcc.ca.gov/about_us/documents/17-261_required_testing_chart.pdf. Accessed August 31, 2018.
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National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids, Chapter Highlights. http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2017/Cannabis-Health-Effects/Cannabis-chapter-highlights.pdf. Published January 2017. Accessed May 17, 2018.
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Kay Hooshmand, DO, MPH (UCLA); Jo (Mulun) Huang (UCLA); Gina Johnson, BS (UCLA); Dan Li, BA (UCLA); and Kelly Yeo, BS (UCLA).
Rosemary Flores, MD (Permanente Medical Group); Jaime Gonzalez, MD (Vituity Emergency Medicine); Michelle Ann Higley, MD; Kay Hooshmand, DO, MPH, (UCLA); Nalini Nauth Otello, MD, FAAP (Permanente Medical Group); and Celina Barba-Simic, MD, (Burbank Emergency Medical Group and Providence Saint Joseph Medical Center).

References: §1308
 § 2525
 v. 
 § 11362
 § 34011
 § 5715