Pharmacy Perspectives - Winter/Spring 2018 - 8

Medical Cannabis:
"Now that the patient count has grown and
we've been in operation for three years, it's gotten
to a point where we've been documenting our patient outcomes," Slomski said. "And when we get
a new patient, we do have a little bit of a database
where we could see, 'Okay, this patient's similar
demographic, similar symptom relief-these are
things that have worked well for other patients,' and
that allows us to make a better recommendation for
our newest patients."
"There's a lot of networking and conversations
that go on. I don't know everything, I don't claim
to know everything, but I do reach out and have
conversations with those who are more knowledgeable," Friedman said.
"The problem is standardization-every dispensary's product is different. Manufacturers may
have similar dosages of THC [tetrahydrocannabinol] and CBD [cannabidiol], but the varying
excipients may potentially alter the absorption,
distribution, and metabolism. So it's very hard to
extrapolate data in products available in various
states. But we're doing that anyway because it's
the best we have," said Melani Bersten, PharmD,
a dispensary pharmacist in Minnesota. "Similar
to when pharmacists compound medications, we
understand the basic pharmacologic properties
and hypothesize what will happen in the body.
Our only solution under the current legal restrictions is to start low and go slow and prepare
our patients for the experimental nature of the
medicine."
"As far as selecting the strains, I know what
we have in inventory. I know the species and
the ratios of the cannabinoids and I know what
they do, and I know what this patient is trying to
accomplish, and so I make my recommendations
based on that," Friedman said. "There's a little bit
of trial and error, but we try to minimize the error
and get to a benefit a lot faster than just throwing
products at them and saying, 'Hey, try this.'"

"Once I understand the patient and the medications they're on and the goal of therapy, I make
sure they understand what cannabis is and how it
can help them," Friedman said. "I go through the
different routes of cannabis administration and help
them understand the difference between sativa and
indica. I talk about the strains and the THC and
CBD ratios. So, these are quite comprehensive conversations-it's never just a 5-minute thing. There's
a lot to it."

WHO COULD BENEFIT FROM MEDICAL
CANNABIS?
Most states with medical cannabis laws limit its use
to patients diagnosed with a predefined set of qualifying conditions. Common qualifying conditions
are cancer, HIV/AIDS, multiple sclerosis, cachexia
or wasting syndrome, glaucoma, amyotrophic lateral
sclerosis (ALS), Crohn disease, and seizures. More
states are beginning to include pain, PTSD, and
problems with sleep. Some are less explicit-the
District of Columbia and California both allow use
for any condition that cannot be adequately treated
by other means and that limits a patient's ability to
perform activities of daily living.
"I did not necessarily expect the diversity of patients finding relief with medical cannabis [in New
York]. There tends to be a stigma or stereotype of
individuals who use cannabis, but we really see every
demographic and a wide variety of medical conditions," said Veselov.
But there are also patients for whom medical cannabis might not be a good choice. "One of the things
we look out for are any cardiovascular comorbidities,
because especially with the inhaled cannabis, it could
decrease blood pressure with a paradoxical increase
in heart rate. So any of our cardiovascular patients,
we're going to caution them about that," Slomski said.
"Consulting with patients on their medical cannabis requires assessing the patient's goals of therapy

CBD OIL AND THE MYTH
OF "NATURAL" CURES

"
Clinical pharmacy neurology research fellow Matt Makelky, PharmD

think in general people think that CBD and THC are
cure-alls and that because they're natural products,
they don't have drug interactions, there are no
side effects. I see it all the time online-'You have
a migraine? Try CBD oil,''You have pain, try CBD oil,'"

CU Skaggs School of Pharmacy and Pharmaceutical Sciences

Associate Dean Gina Moore, PharmD

and associated symptoms, as the diagnosis of cancer,
ALS, or any chronic disease is accompanied by comorbidities like anxiety, depression, and insomnia.
Medical cannabis can affect multiple symptoms
across various systems, which affects quality of life,"
said Bersten.
Connecticut dispensary pharmacists gained authority to treat pediatric patients with certain conditions in October 2016. "We are currently treating six
pediatric patients. We're using high-CBD cannabis
oils or tablets to treat their seizure disorders with
some of these medical cannabis preparations that
aren't intoxicating-they don't have THC, which
causes the euphoric effect associated with cannabis
use, but they provide the therapeutic effect of CBD,"
Slomski said.

HOW SHOULD PATIENTS USE CANNABIS?
"A lot of people's perception about medical marijuana
is what they see on the news. You see file footage from
Colorado, California, where there's jars of marijuana on
display, and that's just not the case," Slomski said.

said Matt Makelky, PharmD, clinical neurology research
fellow at University of Colorado (UC) Skaggs School of
Pharmacy and Pharmaceutical Sciences. Makelky also
works at UC Hospital's epilepsy clinic. "And the reality is
that CBD does interact with some medications, and if
you're doing this unguided, bad things could happen."
Makelky participates in research on CBD's effect
on Parkinson disease, using certain products with
reliable properties to "figure out the holy grail
of doses"-not an easy feat, since DEA places

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