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Cannabis and Cannabinoids Education:
a tool to change medical practice
R a q u e l P e yr a u b e , M D
r p e y r a u b e @ i c l o u d . c o m
Jan 19th, 2019
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✓ The pilot of the education program for physicians has been
sponsored by public agencies and private companies that
will be mentioned at the end of the presentation
✓ No other conflicts to declare for this activity
Conflict of Interest
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✓ Increasing availability
✓ Widely spread but not always of good quality, accurate,
reliable
✓ More patients and clinicians trying these treatments
✓ “Medical advise” from suppliers, Internet blogs and forums
✓ Also “hopes traffickers”
Availability of information
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Monitor Cannabis Uruguay Survey 2017
Interest in Medical Cannabis
2.7%
1.2%
6.2%
12.4%
18.4%
24.1%
30.1%
0.0% 10.0% 20.0% 30.0% 40.0%
Other
Personal interest, curiosity
Recommendation of health personnel
Recommendation of relatives / friends
I studied about the positive effects on thedisease
Only to take less medication
Conventional treatment did not havesatisfactory results
Why did you become interested in this type of treatment?
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MC recommendation for health conditions
Monitor Cannabis Uruguay Survey 2017
45.8%
24.9%
12.3%
5.2%
5.0% 3.8%
3.0%
Who suggested you use cannabis as medicine?
I myself
Family members / friends
People I know
Physician
Another Health professional
Media
DK/NA
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✓ Access to information
- Internet: 56.2%
- Health professionals: 11.9%
- Only 10.6% of the reported ongoing treatments were
recommended by a physician
- 57% of the interviewees haven’t consulted a physician after
getting the information
Getting information
Monitor Cannabis Uruguay Survey 2016-2018
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✓ Consultation and medical follow up:
- 31% of interviewees reported that were already using cannabis
for medicinal purposes:
44.8% self-medication
27.6% as a medical suggestion
17.2% by peer recommendation
10.3% by domestic growers or growshops
- 58.6% of them said they were doing the treatment without
medical supervision
Getting information
Monitor Cannabis Uruguay Survey 2016-2018
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✓ Reasons for not consulting a medical doctor
- They think their doctor is not trained to follow these treatments: 23%
- They are not prepared to discuss with their doctors: 9.5%
- Their doctors don’t support cannabis treatments: 9.5%
- It’s not an appropriate matter to discuss with a doctor: 8.4%
- They fear rejection: 4.2%
Getting information
Monitor Cannabis Uruguay Survey 2016-2018
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✓ 57% of cases the medical consultation did not take place due to
barriers in the doctor-patient relationship
✓ 40% of the respondents that were already using cannabis for medical
purposes were approved by their doctors
✓ 45% of the interviewees reported adverse reactions from their
doctors: disapproval , ignorance, skepticism, indifference
Consultation with a MD
Monitor Cannabis Uruguay Survey 2016-2018
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✓ 45% of the interviewees reported adverse reactions from their
doctors:
- disapproval 17%
- ignorance 10%
- skepticism 15%
- indifference 8%
Consultation with a MD
Monitor Cannabis Uruguay Survey 2016-2018
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25% of the respondents!
How many people are thinking or interested
in MC treatments?
Monitor Cannabis Uruguay Survey 2017
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✓ Not prepared for clinical interventions with cannabis and
cannabinoids-based medicines
✓ Not having accessed to reliable, science-based, relevant
clinical information
✓ Subject not studied at the Medicine School
Interviews to clinicians and MS faculty
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The Questions
Patients
- Potential benefits in different
diseases
- Compatibility and interactions
with conventional treatments
- Indication or not during
pregnancy and breast-feeding
- Evidence of the efficacy
- Evidence of treatment safety
- Potential benefits to their ailments
- Compatibility with conventional
treatments
- During pregnancy?
- Results
- Side/Adverse effects
Doctors
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1. Neurology:
- Epylepsi
- Neurodegenerat ive
- Tourette syndrome
2. Gastroenterology & Nutr i t ion:
- Crohn & EII
- Nauseas & Vomits
- Anorexia - Cachexia
3. MH d isorders and Addict ion
- PTSD
- Anxiety/Depression
- Addict ion
- Insomnia
- TEA
4. Pa in:
- Chronic
- Neuropathic
- Metastat ic
- Migraine
- F ibromyalgia
- Rheumatic d iseases
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5. Autoimmunity:
- Lupus
- RA
- Thyroidi t is (Hashimoto)
- Diabetes Type I
- Raynaud syndrome/disease
- Others
6. Oncology & Pal l iat ive care:
- Chemotherapy (s ide effects & opt imiz ing resul ts)
- Cancer (not alone)
- HID-AIDS and Wast ing syndrome
- Terminal states
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7. Dermatology
- Psoriasis
- Acne
- Dermatit is
8. Ophthalmology:
- Glaucoma (open angle)
- Diabetic ret inopathy
- Neurodegenerative
9. Bone conditions:
- Osteoporosis
- Bone fractures (?)
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The Questions
Patients’
- Potential benefits in different
diseases
- Compatibility and interactions
with conventional treatments
- Indication or not during
pregnancy and breast-feeding
- Evidence of the efficacy
- Evidence of treatment safety
- Potential benefits to their ailments
- Compatibility with conventional
treatments
- During pregnancy?
- Results
- Side/Adverse effects
Doctors’
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¬ Pharmacodynamic
¬ Pharmacokinetic
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✓ With other sedative drugs enhancing central effects: sedation
and impairment of motor performance
✓ Psychostimulants can reduce cannabinoids action
✓ Warning: drugs and substances with positive chronotropic and
inotropic effects (hypertension and tachycardia)
Cannabis & Cannabinoides
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Cannabis & Cannabinoides
2017
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Cannabis & Cannabinoides
2017
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• From mild to moderate
• No lethal cases reported with exclusive use of cannabis and in healthy
people (different from the illicit market synthetic cannabinoids)
• Easily reversible by reducing doses or associated medication
• Take into account the biphasic / bimodal effect: dose response curve
Cannabis Medicinal – Aspectos Clínicos
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✓ Euphoria
✓ Fatigue
✓ Sedation and drowsiness
✓ Dizziness
✓ Sickness
✓ Tachycardia / Bradycardia
✓ Hyper or arterial hypotension
✓ Orthostatic hypotension
✓ Bronchodilation
✓ Dry mouth and reduction of
lacrimation
✓ Muscle relaxation
✓ Disorders of coordination
✓ Memory and concentration
disorders
✓ Psychotomimetic effects
✓ Immobilization simulated
catatonia
✓ Increase in appetite
✓ Hyperemesis
✓ Hypoglycemia
✓ Dependence
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And also…
Patients’
- Any specific information or clinical
aspects to request?
- Routes of administration
- Smoking?
- Doses
- Products and formulations
- Treatment monitoring
- Access to safe products
- Bibliography (reliable clinical
information)
- I will be stoned?
- Is it a lifelong treatment?
- Is it a curative treatment?
- Is it possible to interrupt the current
treatment or reduce doses?
- What happens when cannabinoids-
based treatment is interrupted?
- To quit the treatment, should the doses
be reduced slowly?
Doctors’
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- I will be stoned?
- Is it a lifelong treatment?
- Is it a curative treatment?
- Is it possible to interrupt the current treatment or reduce doses?
- Shall I become an addict? Dependency?
- What happens when cannabinoids-based treatment is interrupted?
- To quit the treatment, should the doses be reduced slowly? Withdrawal
syndrome?
Patients’
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Doctors’
Any specific information or clinical aspects to request?
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The clinical interview
1. General features of any other clinical record
2. Diagnosis, Treatment/s (past and current) & Reason for consultation
3. Personal and family pathological antecedents (general and MH)
4. Why cannabis? What led the patient to consider cannabis-based treatment.
Expectations & prejudices
5. Prior and present experience with cannabis (adult use/medicinal)
6. Education of patients and close relationships
7. The prescription: doses, formulation and compounds, routes of
administration
8. Treatment follow-up
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Doctors’
- Routes of administration?
- Doses?
- Products and formulations?
- Treatment monitoring?
- Access to safe products?
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Doctors
Bibliography (reliable information)
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4cdc
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4cdc
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Education
✓ General public
✓ Medical education
The Answers
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✓ General public education
- Systematized and specialized education web platforms
- Public personalized face-to-face approaches
- Educational campaigns
- Medical doctors consultation (?)
Contents endorsed by scientific associations or being duly accredited by
bibliography
The Answers
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✓ Medical education
- Inclusion of the ECS and its modulation in the official
programs of the medicine schools:
(physiology, pharmacology, neurology, dermatology,
oncology, gastroenterology, immunology, etc.)
- Education programs of the scientific societies
- Continuing medical education programs
The Answers
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✓ Medical Training Course: The Pilot
Goals:
- Training a generation of clinicians with academic standard
- Providing basis for the design of a medical education
program at medicine schools
- Recruiting medical doctors
- Improving doctor-patient relationship
Medical education
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T course
- 7 modules in 70 hours
- Modulated interactive lectures
- Clinical cases discussions (most frequent pathologies)
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Some features
Methodology: Interactive modulated lectures (modules 1 to
6) and workshop for clinical
discussions(module 7)
Website
Simultaneous translation
Bibliography: Handbooks and 3 articles provided by the
responsible of the topic
Evaluation: Pre and post course
Other
Medical education
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The course:
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Acknowledgments
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Raquel Peyraube , MD
rpeyraube@ic loud .com
Danke schön!
Grazie mille!