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CONFIDENTIAL – CDA CLINICSTM

Prescribing Doctors

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Prescr ibing medicinal cannabis

(MC) now?

Would you l ike to learn

how to prescr ibe

MC?

Do you have any pat ients to refer for medicinal

cannabis Rx?

Real ly, no pat ients? You are unique

That is a step on the r ight side of history. Please enter your contact detai ls via

CDAClinics.com.au for educat ional advice

Please send your pat ient to CDAClinics.com.au to f ind a local CDA doctor or use our telehealth

option. Please refer with a standard medical referral

YES

YES

YES

NO

NO

NO

REDISCOVERY

PROHIBITION

ANCIENT USE

Cannabis history

Sir William Brooke

O’Shaughnessy (1809 –

1889) introduced the

therapeutic use of

Cannabis to Western

Medicine after

scientifically validating its

effectiveness

From Ancient China to Ancient Greece, Cannabis

was safely used for medicine for 5000 years

At the end of Alcohol

Prohibition Mr Harry

Anslinger was facing

unemployment, but with

the backing of corporate

ties, he formed the

Federal Bureau of

Narcotics, whom focused

on prohibiting Cannabis

and spreading

propaganda about

Cannabis being a

“demon drug”

In 1964 Prof Raphael

Mechoulam first isolates

THC

The American Medical

Association of Doctors

lobbied hard to prevent

the prohibition of

Cannabis as medicine,

but facing imprisonment

abandoned the cause

In 2003 the USA

Department of Health

patented Cannabinoids as

Neuroprotectants (Brain

Protecting)

Australia became the first

whole continent to re-

legalize Medicinal

Cannabis in 2016

Prior to prohibition

Cannabis was the most

prescribed drug by

American Doctors

In 1996 California became

the first US state to re-

legalize Medicinal

Cannabis

Uruguay became the first

country in the world to re-

legalize recreational

cannabis in 2013. Canada

then legalized recreational

cannabis in 2018

LEGALISATION

CB1

receptors

Cannabinoid Type

1 (CB1) receptors

are found in the

brain and on nerve

cel ls

Act ivated CB1

receptors

downregulated the

upstream neuron

to protect the

downstream

neurons

The Endocannabinioid System

Every human has an Endocannabinoid System in their bodies

that restores homeostasis by promoting sleep, appetite, stress

reduction, modulation of pain and inflammation.

Cannabinoid compounds in Cannabis interact with the

Endocannabinoid System to produce effects

Cannabinoid Type

2 (CB2) receptors

are found in

immune system,

brain, and through

the body

Activated CB2

receptors act ivated

inf lammatory

modulat ion and

var ious other

ef fects

CB2

receptors

Other receptors are involved in the Endocannabinoid System

such as GPR18, GPR 55, GPR119, TRPV1, 5HT-3, Gly-R, PPAR

alpha and PPAR gamma

Ingesting vs Inhaling

Inhaled cannabis effects last 2 to 4 hours, which is beneficial for patients wanting to have quick on-set and quick off .

Ingested CannabisOnset in 30-90 minutes.Peak onset in 2-4 hours.Lasts 8-24 hours

Inhaled CannabisOnset within 90 seconds.Peak onset 15-30 minutesLasts 2-4 hours

Time

Onset

Ingested cannabis can have effects that last up to 24 hours, but generally effects dissipate after 12 hours meaning twice daily dosing is common.

Inhaled cannabis should be with a vapouriser set to above 185 degrees Celsius, but below where smoke or combustion occurs. After inhalation of a dose a patient should wait 10 minutes to see effects before repeat dosing.

Ingested cannabis will take up to 90 minutes to take effect, and therefore repeat dosing should only occur after this time to avoid side effects.

THC vs CBD

CBD (Cannabidiol) does not bind to CB1 receptors so is not psychoactive

at all. CBD works by inhibiting the degradation of natural endogenous

endocannabinoids, meaning the levels of endocannabinoid the body

makes are increase; making the natural endocannabinoid signalling more

effective.

THC (Tetrahydrocannabinol) binds to CB1 receptors in the brain, causing

downregulation of neuronal signals. In this way THC is considered

psychoactive, and may have effects on reducing pain, spasms, nausea,

vomiting, and improving sleep and appetite.

Cannabinoids are

metabolised by

CYP450 enzymes in

the liver and

throughout the body

Other drugs that are

also P450

metabolised should

be monitored and

adjusted

CYP450 enzyme

Metobolisation

THC CBD

The LD50 (median lethal dose) of THC is estimated at

>800mg/kg, and CBD at >1000mg/kg

THC does not cause

schizophrenia but it can

unmask it; thus

contraindicated in those

patients. Note: CBD is a

treatment consideration for

schizophrenia.

The National Academies of Sciences, Engineering and

Medicine (2017) report that cannabis has a lower risk of

dependence than coffee, alcohol, nicotine, and morphine.

Safety

There have been no recorded human deaths directly

attributable to acute cannabinoid toxicity ever

Beneficial Effects

• Analgesic• Anti-inflammatory• Anti-epileptic• Neuroprotective• Immuno-modulation• Anxiolytic• Anti-psychotic

Side Effects

CBD Effects

• Dry mouth• Fatique• Changes in

appetite• P450 inhibition• Diarrhoea

CBD

Beneficial Effects

• Anti-spasmotic• Analgesic• Anti-epileptic, in

some cases• Neuroprotective• Antiemetic• Anxiolytic, in some

cases• Decreases sleep

Apnea index and Insomnia

Side Effects

THC Effects

• Short term memory impairment

• Changes in appetite

• Nausea• Short term memory

impairment• Dizziness /

Hypotension• Anxiety / Paranoia /

Temporary Toxic Psychotic Symptoms

THC

Product Selection

CBD mitigates potential THC anxiety effects

Binds to CB1 receptors on

neurons

THC THC : CBD CBD

Increases natural Endocannabinoid

effectiveness

Neuroactive, sedating, driving

exclusion

Entourage effect of CBD with THC

Effects on CB2 receptors

1mg initiation2.5mg initiation

(total)2.5mg initiation

Max 120mg/dayMax / day

120mg : 1200mgMax 1200mg/day

Indication Consideration

Medical Marijuana Matrix

The doses above are oral

doses; Vaporised doses are

approx. half

CBD

THC

50mg

5mg

5mg 25mg

JUICERS

ANXIETY

PARKINSONS

EPILEPSY

BACK PAIN

SPASMS

SEVERE PAIN

INSOMNIA

PTSD

THC has an sedating and

neurotropic effects from 5mg

orally single dose

Always start with a low <2.5mg

dose and titrate up to the

patients symptom control

Treat the patient, not the

guideline

Eligibility

Chronic condition

lasting 3 months or

more, unless justifiable.

Medical drugs tried

but failed to resolve

indication

Medical drugs tried

with side effects

List other failed treatments e.g. Surgery,

Injections, Therapies

Clinical reviews to

stabilise, e.g. Week

1, Week 2, then

Monthly

INTENDED

MONITORING

Baseline ELFTs, and

1 month, or

stabilised dose

INDICATION

CLINICAL

JUSTIFICATION

Monitor P450 metabolised medication levels

Symptom

treatment

TGA

APPLICATION

What conditions can medicinal cannabis be

prescribed for?

“FAST TRACK” CONDITIONS• chronic pain• palliative care• epilepsy• chemotherapy induced

nausea• multiple sclerosis

ANY CHRONIC CONDITION THAT…

• has lasted 3 months or longer

• and has not responded to conventional medical treatment, or has side effects

MEDI CINA L CA NNA BI S

PRESCR I PT I ON A PPL ICATI ON

TGA SA S B & S TA TE

A PPRO VA LS

Cannabis oil is a simple and easy to administer form. You can use the

dropper cap or the provided measuring syringe to get an accurate

dosage. Patients are advised that sublingual is the best

administration. The carrier oil can be Hemp Seed Oil, Olive Oil,

Fractionated Coconut Oil (MCT) or Grapeseed Oil.

Product Forms

Cannabis f lower comes mil led and needs to be heated

and inhaled. The patent is advised to vaporise the f lower

to decarboxylate the cannabis at the correct

temperature. Inhal ing i t in this way increases the onset,

and it wears off sooner. This makes inhal ing useful for

people who need fast-act ing treatment for ai lments such

as spast ic ity.

Cannabis products come in a

variety of forms. Selection of the

product depends on the patient

condition, ease of use, dosage,

Oi l Capsu les

Typical ly preferred by people who suffer f rom respiratory

problems, young chi ldren and those who want to protect

their health, Cannabis Oil Capsules are safer and more

discreet than other forms of cannabis products. Pi l ls also

provide a exact and steady dosage and they don’t smell l ike

f lower or oi l can.

Product Forms

Crystal

Crystals are highly ref ined and the pures t fo rm of CBD. Unl ike other extracts,

crystals are at least 98% pure, meaning that no other substances are present in

your product. Crystal comes in a salt - l ike form in a smal l container and unl ike

other product forms, doesn’t need to be stored in any way.

Cor rect dos ing

Crystal are easier to dose with since they are a pure form of the cannabinoid. I f

you need to take 1 mg of CBD a day, you simply need to measure out 1 mg of

crystal , rather than having to f igure out how to ensure that you’re gett ing the

correct dosage.

Versat i l i t y

You can take i t in many dif ferent forms depending on your tastes and

preference.

A highly convenient way to take crystals is to mix with an e- l iquid for a vape pen.

There are tons of dif ferent kinds of e- l iquids avai lable, many of them containing

no nicot ine, only f lavour. You can mix up to 200 mg of crystals into 10 mg of the

e- l iquid. You wi l l need to slowly heat the mixture to al low the CBD crystals to

ful ly absorb into the l iquid. I t can then be vaped l ike any other l iquid.

You can also mix i t with many dif ferent types of oi ls. . The standard potency of

most oi l is about 10%, so you wi l l want to mix about a gram of crystals in with 10

ml of whatever oi l you are using. You wi l l need to warm the oi l enough to al low

the crystals to dissolve into the oi l . The best oi ls to use are Hemp Seed Oil or

Olive Oil .

Crystal can also be compounded into a topical cream or mixed into baking.

Fi rst t ime prescr ipt ions

For first time prescriptions (Rx) you will need to load the product into

your computers system or write it by hand on a prescription pad.

Handwritten Rx: Written in short hand and words

Computer generated: Hand written under computer text l ike an

Opiate Rx

Important!

Attach to the Rx the TGA Approval and State Approval if

applicable

Write starting / current dose and maximum titration

Write Rx as a S8 requires in your state

Important Checks

Repeats

Repeats are not allowed, however pharmacists are allowed to partially

dispense a Rx. Therefore, prescribing the max monthly amount means

a patient can collect 1 bottle/item at a time.

Pharmacists

Pharmacists will need to get in touch with our wholesaler to order the

product that you have prescribed. Pharmacists are able to make an

order on our website: CDAClinics.com.au/pharmacists

How to write a medicinal cannabis prescription.

Check DOB on RxCheck SAS # on Rx

ORAL DOSING GUIDECONDITION THC:CBD RECOMENDED DOSE

Anxiety CBD2.5mg BD, titration double dose Q3days up to

300mg BD maxChemo-induced

NauseaTHC>>CBD 2.5mg titrated up to 20mg QID reg or PRN

Chronic Pain1+:1, a cohort of

patients respond to CBD alone

2.5mg PRN titration up to max 20mg per hour and max 120mg per day

Endometriosis THC<CBD 2.5mg titrated up to 25mg QID reg or PRN

EpilepsyCBD, in resistant

cases add a little THC after CBD titration

2.5mg/kg BD, increase Q1 week by 2.5mg/kg QID to max dose of 1000mg/day

Fibromyalgia THC<CBD 2.5mg titration up to 25mg QID reg or PRNInflammatory

DiseaseCBD (some evidence for CBDA and THCA)

2.5mg titration up to 25mg QID reg or PRN

Insomnia / Sleep Disorder

THC>CBD 2.5mg Nocte, titration to max 50mg

Migraine 1:1 2.5mg titration up to 25mg BD reg or PRNMS Insomnia / Sleep Quality

1:1 2.5mg Nocte, titration to max 50mg

MS PainTHC > CBD, some respond to either

2.5mg PRN titration up to max 120mg per day

Dystonia / Spasticity

1:1 2.5mg PRN titration up to max 120mg per day

Neuropathic Pain1+:1, a cohort of

patients respond to CBD alone

2.5mg PRN titration up to max 20mg per hour and max 120mg per day

Paediatric EpilepsyCBD, in resistant

cases add a little THC after CBD titration

1mg/kg BD, increased Q1week by 1mg/kg BD to max dose of the lower of 20mg/kg/day or

1000mg/day (some studies go to 50mg/kg/day)

Palliative Care Regular Dosing

1:10 moving to 20:4 if required

2.5mg BD titrated up to 120mg per day

Palliative Care PRN Dosing

1:10 moving to 20:4 if required

2.5mg PRN titration up to max 20mg per hour and max 120mg per day

PTSD1+:1, a cohort of

patients respond to CBD alone

2.5mg PRN titration up to max 20mg per hour and max 120mg per day

Schizophrenia CBD25mg BD, titration to max 1200mg per day

(consider QID dosing)

Sleep Apnoea THC 2.5mg Nocte, titration to max 50mg

Doses above are oral. PRN = As required, BD = Twice per day, TID = Three per day, QID = 4 times per day, Nocte = Each

night, Titrate = Gradually adjust, Q2 = every 2 days.Example prescription wording: Oil 2.5 mg BD, max 10mg /day.

Prescription wording Wikipedia

VAPE DOSING GUIDECONDITION THC:CBD RECOMMENDED DOSE

Anxiety CBD1mg QID, titration double dose Q3days up to 50mg QID

max

Chemotherapy-Induced Nausea

THC>>CBD 1mg titrated up to 20mg QID reg or PRN

Chronic Pain1+:1, a cohort of

patients respond to CBD alone

1mg PRN titration up to max 20mg per hour and max 100mg per day

Dystonia / Spasticity 1:1 1mg PRN titration up to max 100mg per day

Endometriosis THC<CBD 1mg titrated up to 25mg QID reg or PRN

EpilepsyCBD, in resistant

cases add a little THC after CBD titration

1mg/kg BD, increase Q1week by 1mg/kg QID to max dose of 500mg/day

Fibromyalgia THC<CBD 1mg titration up to 25mg QID reg or PRN

Inflammatory DiseaseCBD (some evidence for

CBDA and THCA)1mg titration up to 25mg QID reg or PRN

Insomnia / Sleep Disorder

THC>CBD 1mg Nocte, titration to max 50mg

Migraine 1:1 1mg titration up to 25mg QID reg or PRN

MS Insomnia / Sleep Quality

1:1 1mg Nocte, titration to max 50mg

MS PainTHC > CBD, some respond to either

1mg PRN titration up to max 100mg per day

Neuropathic Pain1+:1, a cohort of

patients respond to CBD alone

1mg PRN titration up to max 20mg per hour and max 100mg per day

Paediatric EpilepsyCBD, in resistant

cases add a little THC after CBD titration

0.5mg/kg QID, increased Q1week by 0.5mg/kg BD to max dose of the lower of 10mg/kg/day or 500mg/day

(some studies go to higher dose)

Palliative Care Regular Dosing

1:10 moving to 20:4 if required

1mg QID titrated up to 100mg per day

Palliative Care PRN Dosing

1:10 moving to 20:4 if required

1mg PRN titration up to max 20mg per hour and max 100mg per day

PTSD1+:1, a cohort of

patients respond to CBD alone

1mg PRN titration up to max 20mg per hour and max 100mg per day

Schizophrenia CBD 5mg QID, titration to max 1000mg per day

Sleep Apnoea THC 1mg Nocte, titration to max 50mg

Doses above are for inhaled vaporizer. Product type (e.g. crystal) may require starting at 10 mg. For vapourised product focus on PRN

titration to symptom effect, e.g. 0.1g dried flower or 1mg Q10mins PRN for symptom control titration to max 2g/day. After an inhaled dose of vaporizer wait 10 mins to see if symptoms are

controlled; a repeat dose or larger dose can then be tried every 10 mins. PRN = As required, BD = Twice per day, TID = Three per day, QID = 4 times per day, Nocte = Each

night, Titrate = Gradually adjust, Q2 = every 2 days, Q10 mins = every 10 mins.Example prescription wording: (1) Flower 0.1g Q10mins PRN, max 2g/day; (2) Vape Solution 1

mg Q10 mins PRN, max 10mg /day. Prescription wording Wikipedia

CONSULTATION

COSTSCLINIC

MEDICARE

REBATE

Clinic Only

TELE

HEALTH

Application

consultation$199 $71 $199

Prescription

Collection- - -

Review / Repeat

Prescription$65 $37 $59

Approval renewal $170 $71 $99

These prices are only a guide. Each practitioner and clinic sets

their own prices dues to local overhead costs. CDA Prescriber

support allows for streamlined consultation and application.

Medicare rebates are only available with a physical clinic visit and

not available with TeleHealth or online consultations.

Patients located in a remote area without access to a prescribing

doctor may qualify for a TeleHealth Medicare rebate.

Consultation Costs

TGA SAS Portal

Clone patient

applications

Download

documentationsas.fga.gov.au

New

applications

Expiring

approval l ist

Searches e.g.

patient initials

TGA SAS Portal 2

Autogenerated prescriber info

TGA SAS Portal 3

Search “CDA”Select Medicine

Select Notify State

Select NOT SAS A

TGA SAS Portal 4

Initial to Maximum Dose

Write CDA Product Name

Supplier –Burleigh Heads

Cannabis

Indication

Clinical

justif ication

Intended

monitoring

TGA SAS Portal 5

Patient Details

Patient Class

Prescriber option State Information

Requirements

Prescriber

infomation

Patient

information

TGA SAS Portal 6

Prescription Pathway

Application consultation

Prescription collection

Review week 1

Review week 2

Monthly reviews and

prescriptions

APPEAL OR REASSESS

Declined

CLONE REAPPLICATION

TGA / STATE ASSESSMENT

Patient provides

doctor with Referral Letter

and Medical Information

Further Info Required

References

REFERENCE SOURCE

Access to medicinal cannabis products – The Therapeutic Goods

Administration

https://www.tga.gov.au/access-medicinal-cannabis-products-1

Guidance for the use of medicinal cannabis for the prevention or

management of nausea and vomiting in Australia – The Therapeutic Goods

Administration

https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-

prevention-or-management-nausea-and-vomiting-australia

Guidance for the use of medicinal cannabis in Australia: Overview – The

Therapeutic Goods Administration

https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-

australia-overview

Guidance for the use of medicinal cannabis in the treatment of chronic

non-cancer pain in Australia – The Therapeutic Goods Administration

https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-

treatment-chronic-non-cancer-pain-australia

Guidance for the use of medicinal cannabis in the treatment of epilepsy in

pediatr ic and young adult patients in Australia – The Therapeutic Goods

Administration

https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-

treatment-epilepsy-paediatr ic-and-young-adult-patients-australia

Guidance for the use of medicinal cannabis in the treatment of multiple

sclerosis in Australia – The Therapeutic Goods Administration

https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-

treatment-multiple-sclerosis-australia

Guidance for the use of medicinal cannabis in the treatment of pall iat ive

care patients in Australia – The Therapeutic Goods Administration

https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-

treatment-pall iat ive-care-patients-australia

Medicinal Cannabis - The Office Of Drug Control

https://www.odc.gov.au/medicinal-cannabis

The Health Effects of Cannabis and Cannabinoids - The National

Academies of Sciences, Engineering and Medicine

https://www.nap.edu/catalog/24625/the-health-effects-of-cannabis-and-cannabinoids-the-current-state

Update of Cannabis and its medical use - World Health Organization

https://www.who.int/medicines/access/controlledsubstances/6_2_cannabis_up

date.pdf

CDA Help Phone +61 468 459 540

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Contacts

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