No gatekeeping here, we share our skills and knowledge acquired from 10 years of experience in medical cannabis care.

Santé Cannabis has been at the forefront of medical cannabis consultation and research in Québec since 2014. With over 7500 physicians and nurse practitioners having referred more than 20,000 patients, our multidisciplinary team comprises family physicians, specialists in chronic pain, oncology, palliative care, gastroenterology, endocrinology, psychiatry, pediatrics, and nurses with expertise in cannabis medicine. Beyond patient care, we are dedicated to educating healthcare professionals, researchers, and policymakers through both online and onsite training programs.

Over the last 10 years, we saw growing interest from the Quebec patient community for medical cannabis treatments and very few doctors were open to prescribing it. Often due to a lack of knowledge about this treatment, poor scientific evidence being available, and ongoing stigma.

A 2018-2019 survey of medical students in Quebec revealed that cannabis-related topics were minimally covered in their curricula, leading to low comfort levels among them. The majority felt unprepared to address cannabis-related issues in their future practices, highlighting a need for enhanced medical education on cannabis in Quebec’s medical schools.

Addressing the Gap in Medical Cannabis Education

As strong advocates for patient rights and medical cannabis access, we needed to address the gap in medical cannabis education. In 2019, we launched the Prescriber Training Program for healthcare professionals. Initially created for Quebec physicians, interested in learning more about clinical guidelines for medical cannabis and developing individualized treatment plans, it sparked interest from Canadian and international physicians.

With the legalization of recreational cannabis in 2018 came changes and challenges for Quebec’s medical cannabis landscape. Santé Cannabis is always adapting to the evolving industry and staying on the frontline to provide the best care to the community. Some negative points of this legalization were medical cannabis patients turning to self-medicating and accessing their medicine through recreational outlets like the SQDC. While some of the positives are less stigmatization around cannabis and more interest in training from healthcare professionals, guidance from trained healthcare practitioners remains essential to safe access.

Importance of Specialized Training

As Dr. Michael Dworkind, Medical Director of Santé Cannabis and Associate Professor of Family Medicine at McGill University, emphasizes, “It is our duty as physicians to understand the available treatment options for our patients, and medical cannabis treatments have emerged as an important clinical tool.” This sentiment underscores the necessity for healthcare professionals to engage in specialized training to effectively meet patient needs.

With the launch of our online boutique in 2024, a platform created to provide healthcare professionals direct access to a wealth of educational and training resources, we bridge the educational gap and facilitate medical cannabis education.

Through our practical education materials, we aim to empower general practitioners, specialists and, nurse practitioners and enable them to deliver the best care possible. These learning tools are accessible from anywhere at any time and adaptive to your needs and your calendar.

Additionally, we offer in-person training opportunities to help professionals enhance their skills and knowledge.

Together, let’s explore all the possibilities!

Virtual and In-Person Training

Prescriber Training Program

Recognizing the growing demand for medical cannabis education, Santé Cannabis offers a transformative training initiative for Québec healthcare professionals. The Prescriber Training Program, meticulously designed by clinicians, provides a practical approach to medical cannabis education. Developed from our years of clinical care and research we have based on real-world data and the latest research on medical cannabis treatments.

The complete Prescriber program package comprises 10 self-learning modules. In these modules, you will learn about Cannabis as a medical treatment, Patient assessment, and Prescribing. You will find treatment evidence for specific conditions and symptoms, allowing physicians to customize learning based on their professional needs. The virtual program can be followed at your own pace, however, if someone wants to focus on one subject, selected modules can be purchased separately.

For reference module 3 The Prescription Guide covers initial and follow-up treatment protocols for each indication and treatment objective, as well as product format details and drug interaction information.

The Prescriber Package also includes: a Clinical toolkit, and a starter kit of clinic forms, available for customization to your practice, including our referral form, patient evaluation, follow-up form, treatment plan form, and authorization form (Medical Document).

Viewing access to an educational video and presentation, about determining the appropriate medical cannabis treatment, also available for purchase separately.

Personal Mentorship Sessions: Group or 1 on 1 sessions to address all of yours and your teams’ training questions.

Shared Care

This service allows your medical team to request support from our nursing team on a patient-by-patient basis. Available Monday to Friday and includes direct (our nurse to your patient) or indirect (our nurse to your clinical team member) support to develop treatment plans and dosing schedules, source product recommendations, insurance coverage questions or any other needs.

The program was designed for Quebec clinics and practitioners as it includes regulatory information and guidance specific to the Quebec healthcare system. However, the medical cannabis content can be adapted and integrated into your local practice.

“I turned to Santé Cannabis in order to train myself and be able to respond correctly to demand. It gives me the opportunity to prescribe cannabis and also to follow up with my patients properly.  I’ve noticed that a deeper relationship of mutual trust has developed because they don’t feel judged.” – Dr.Jerome Lopez

The course will teach you all the essentials of medical cannabis-based treatments and care, and you’ll leave with the knowledge you need to prescribe with confidence.

“They clearly put a ton of effort into setting up this training program, which demonstrates their commitment to advancing the field of medical cannabis for the health care profession. As well, Dr. Dworkind specially tailored certain aspects of my rotation to me based on my interest in palliative care and chronic pain management, as he has expertise in this area after his long clinical career. ” -Dr.Lorne Wiseblatt

Ask the Expert Sessions

One might wonder what is an “Ask the Expert” session? These 1-1 sessions are the perfect opportunity to get answers to all your questions about medical cannabis as well as to review and discuss complex patient files. They can be done virtually or by phone with one of our physicians or nurses.

In-person Training

We offer onsite preceptorships for doctors, nurse practitioners, pharmacists, nurses or clinic directors that want to learn in a clinical setting. During their preceptorship, they will observe initial and follow-up patient consultations and see our model of care in action.

They can participate in patient file reviews and attend patient education sessions led by a nurse.

The trainees may debate cases and collaborate on patient care decisions and personalized treatment plans. Our team will adapt to the trainees’ needs and their schedule, whether they can commit to a full day or a half day, we will make the most of their time spent in our practice.

“Thanks to their expertise, I feel fully equipped to support my patients in the safe and effective use of medical cannabis. Thank you to Santé Cannabis for their commitment to the training of healthcare professionals and the accessibility of this therapy in Quebec.”  – Dr. G. Lemire, Global MD – Saguenay, completed our prescriber training program and onsite preceptorship and will be integrating a medical cannabis consultation service into her practice.

Educational Tools and Videos

To make our training program more accessible, we have broken down the program into 10 self-learning modules. You can choose the modules you want specific to your field of practice. The self-learning modules Sleep Disturbances and Post Traumatic Stress Disorder are gaining in popularity and meet a growing demand to support these patient populations suffering from uncontrolled symptoms. Other modules like Neurologic Indications or Gastrointestinal Indications can provide valuable insight and evidence-based data about these disorders.

Our educational videos are a fun way to learn, presented by a Santé Cannabis physician or nurse, they are a simple and effective way to understand the fundamentals of providing medical cannabis care in a clinical setting.

Introduction to medical cannabis covers the following concepts: medical cannabis status, the endocannabinoid system, main Phyto cannabinoids and chemovars, indications and relative contra-indications, treatment options and titration, adverse effects and drug interactions, main regulations as well as patient education.

The Santé Cannabis Model of Care; through our peer-reviewed model of care, we’ve achieved standardized patient care. Get to know the secret of our inner workings and our success as a free clinic.

The 5 Common Myths about medical cannabis and the supporting evidence to debunk them:

• The only way to take medical cannabis is to smoke it
• Medical cannabis is harmless and impossible to overdose
• There are no drug interactions with medical cannabis
• Medical cannabis causes addiction and makes you high
• CBD can be converted to THC

Clinical Tools

Our clinical materials will get you to a place where you are ready to prescribe to your community of patients. With our customizable clinic forms, you get to integrate this treatment seamlessly into your practice.

• The Patient Evaluation Form can provide targeted data collection for healthcare professionals and allow you to organize their symptoms more effectively.
• The Patient Treatment Plan Form is a clear and simple formulated document explaining the patient’s medical cannabis treatment containing valuable information like the name of the licensed seller, the name of products, dosage instructions and titration protocol and relevant precautions.
• The Patient Follow-up Form allows you to monitor a patient’s health and make adjustments to their treatment as required.

With the right tools, you can achieve your prescriber goals.

International Offering

International practitioners too can benefit from our trainings, by adapting the Prescriber Training Program, signing up for a preceptorship or a session with a mentor and using the International Prescriber Guidebook. We will help you build your confidence in patient screening and assessment for medical cannabis treatment.

“Santé Cannabis provided me with the most comprehensive training that I have ever received.  The doctors and nurses welcomed me and made me feel part of the team.  I am excited to take my knowledge home and to start prescribing confidently in my practice.” -Dr. Paula Martinez, MD (Neurology), Bogota, Colombia

The International Prescriber Guidebook is a complete and practical training resource for medical cannabis prescription and education, applicable across Canada and international jurisdictions.

It features:

• Active Therapeutic Compounds
• Methods of Administration
• Patient Evaluation and Prescribing Instructions
• Detailed Treatment Protocols and Product Selection by Indication
• Dosing Instructions
• Titration tables
• Follow-up and Monitoring
• Frequently Asked Questions
• Options for Prescriber Support

The guidebook is a valuable asset for international prescribers to navigate medical cannabis care with clarity and certainty.

Our Commitment

Why does medical cannabis education remain so important?

Under the Cannabis Act, the current recreational market has threatened the viability of the medical cannabis access program. This treatment option needs to stay available and be considered as a complementary and adjuvant treatment when conventional medications fail. It can support medication substitution including opioids, benzos, etc, and even improve the quality of life of countless patients.

Santé Cannabis remains steadfast in its commitment to empowering healthcare professionals with the knowledge and tools needed to integrate medical cannabis into patient care safely and effectively.

Through clinical research and real-world data, together we can bring progress to medical cannabis care.

The landscape of medical cannabis is rapidly evolving, and staying informed is crucial for healthcare providers aiming to offer comprehensive patient care. Santé Cannabis’s training materials serve as a valuable resource, equipping professionals with the knowledge and skills required to navigate this field confidently.

We know you can find your medical cannabis community of practice with us.

Ready? Train with us!

Visit our boutique

For more continuing education opportunities

Author:
Alexia Bellemare

Leading Patient Service, Clinical Care Standards and Clinical Research Data Collection in Cannabinoid-Based Medicines

By Erin Prosk, President and Co-Founder of Santé Cannabis

As the President and Co-founder of Santé Cannabis, an organization at the forefront of medical cannabis clinical practice and research since 2014, I could not be more proud of what we have accomplished and the advancements that we have made to establish evidence-based practices in medical cannabis care.

The last decade has been both challenging and deeply rewarding and as Canadian leaders, we have a responsibility to share our experience, to support medical cannabis programs worldwide to build on our strong foundation to accelerate safe, supported access to cannabinoid-based medicines worldwide.

To that goal, I am excited to share that a detailed description of the Santé Cannabis clinical practice model has been published in the journal Complementary Therapies in Medicine. Our entire Santé Cannabis team has contributed to this achievement, the article is the first peer-reviewed publication describing a dedicated medical cannabis clinic.

This publication shares our clinic development experience and evolution of our clinic model and practice since 2014. It serves as a reference for physicians and allied healthcare professionals who are developing their own dedicated medical cannabis practice with details such as clinical organization, healthcare team, annual clinic data as well a discussion of the strengths, weaknesses and future directions of the clinic model.

Prosk E, Arboleda M, Rapin L, El Hage C, Dworkind M. The model of care at a leading medical cannabis clinic in Canada. Complementary Therapies in Medicine. 2021; 60.

Dedicated medical cannabis clinics have become an essential service delivery model in global jurisdictions such as Canada, Australia, the United Kingdom, Colombia and other Latin American countries and across several state jurisdictions in the US. The emergence of dedicated clinics is due to still-remaining critical gaps between patient needs and the traditional healthcare system. Medical cannabis assessment, prescription and follow-up remains service provided by a limited number of physicians, with the majority citing lack of training, limited amount of high-quality research, complex regulatory frameworks and lack of clinical guidelines for medical cannabis products.

As the primary point of access for the majority of the 300 000 registered medical cannabis patients in Canada, dedicated clinics have provided a critical source of evidence-based information, personalized medical support and treatment recommendations and ongoing follow-up. Several initiatives are underway in Canada to increase knowledge, including several that are described in the article.

Santé Cannabis assesses almost all of its patients on referral from their primary care physician or specialist, supporting patients to discuss the referral with their treating physician in order to integrate their care. Following a patient’s initial visit at Santé Cannabis, our team provides a consultation report to the referring physician. By this initiative, the clinic has introduced medical cannabis treatments to more than 5000 physicians since we opened our doors in 2014. Such commitments provide required integration between medical cannabis clinics and the “traditional” healthcare services and improve patient outcomes by sharing information between the healthcare team. The consultation reports support knowledge transfer between healthcare professionals and continued learning for the referring physicians as they continue to follow the patients in their care.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Similarly, this article breaks down practices at a medical cannabis clinic that are often viewed as a black box. Concerns have been raised about why these clinics exist and questions of the care provided; dedicated service is often required to meet patient and medical community needs within a complex regulatory system and lack of professional training for healthcare professionals.

As there have been to date no peer-reviewed publications describing a medical cannabis clinic model, the development of an article was critical to share practices. With limited resources, it is not always possible to maintain such advocacy. At minimum, practice standards must adhere to regulatory guidelines and clinics must operate in transparently, encouraging communication with regulators while raising any challenges to providing safe, effective patient care. Patients and partners of the medical cannabis clinic must be aware of its practices and of any funding relationships that may present a conflict of interest. Such relationships can be difficult to navigate, especially in emergent medical cannabis industries and collaboration with experience medical cannabis clinics is recommended.

Despite 20 years of legal access to medical cannabis in Canada, the majority of patients still rely on dedicated medical cannabis clinics as the availability of training opportunities on cannabinoid-based medicines remain limited and outside the standard medical curriculum at Canadian institutions.

Santé Cannabis is a unique medical cannabis clinic as its purpose and leadership extends beyond direct patient care. Operating as a clinical research site since 2015, Santé Cannabis emerged as Canada’s first Contract Research Organization dedicated to medical cannabis in 2018 and has since continued to expand its services to support the development of high-quality research. Santé Cannabis is also dedicated to training healthcare professionals and supporting the development of leading medical cannabis clinics worldwide.

As a still unapproved medical treatment, consideration of medical cannabis often emerges at the end of a long patient journey. Patient needs are high and long-standing stigma demands a responsive support service and dedicated patient education. This delivery is resource-intensive, especially when few details are available to clinic operators. This article introduces several available resources developed to support efficient, high-quality care and tested by our Santé Cannabis team.

Getting started with a medical cannabis practice introduces several challenges and little guidance is available from experienced clinicians and operators. Physicians and allied healthcare professionals who are developing a dedicated medical cannabis practice will benefit from the sharing of years of experience outlined in this article from our Santé Cannabis team, including the development of an operational plan that integrates objectives and community needs with available resources.

When well-developed, medical cannabis clinics provide an unparalleled opportunity for the collection of Real-World-Data and even the recruitment and operation of clinical trials. Whether clinical research is a priority initiative on clinic launch or in later years, considered planning is critical to ensure efficient collection of high-quality data.

The significant global evolution of regulatory frameworks in recent years indicates the validation of an essential treatment option for patients, one that patient advocates, physicians and supporting healthcare professionals for access to cannabinoid-based medicines have been pushing for decades.

It is clear that medical cannabis access will continue to expand worldwide, and with that the need to establish clinical practice standards to support patients and medical communities. Effective service delivery will only be possible with increased international collaboration between healthcare professionals to exchange knowledge, share experience and optimize resource development in the coming years.

Look to Santé Cannabis for this collaboration and to find innovative, practical training opportunities for international physicians and healthcare professionals and access personalized consultation from our expert team.

To discuss your project and find out if Santé Cannabis might accelerate your development, please contact us. From one innovative team to another, we’re looking forward to hearing from you.

Author

Erin Prosk

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

In Quebec, whether one is for or against its therapeutic use, medical cannabis is now one more tool in the modern pharmacopoeia. We believe that it is now essential to recognize the multidisciplinarity of the stakeholders involved in medical cannabis treatments, whether it is in relation to authorization, services and care provided to patients or in relation to research. More importantly, we want to bring these stakeholders together to discuss the integration of this additional tool into clinical practice in Quebec. 

This conference aimed to provide a better understanding of some of the challenges surrounding medical cannabis and to offer resources, including our training program, to overcome these challenges and increase general medical cannabis knowledge. 

We hold this event every year because we believe that medical cannabis is an essential service that must be free of stigma and integrated into medical practice. By hosting we hope to bring together the diverse perspectives of our presenters and audience to encourage innovative medical cannabis patient care, and do so by expanding on the learning beyond each participant’s specialization.

Highlights from the talks:

If you weren’t able to attend we’re excited to share some of the highlights that our staff shared from each of the talks. 

Lack of knowledge of the endocannabinoid system: An important obstacle to overcome

Vi Dam, RN, MSc

Ms. Dam’s presentation was highlighted by a patient testimony that was very powerful and touched other presenters as well as attendees. It showed how complex and difficult it is for patients to find the right treatment and highlighted the lack of healthcare professional training and support for patients for whom conventional treatments do not work. It reminded us why we do what we do and how essential our services are. 

Testimony of a specialized nurse practitioner

Isabelle Têtu, IPS, MSc

Ms. Têtu has noted the number of patients asking about medical cannabis in her clinical practice is increasing, but inadequate training for healthcare professionals have left many professionals unable to support their patients with the answers to the questions they have. 

PANEL: Integrating medical cannabis into your clinical practice: From novice to experienced physicians

Dr. Naïla Debache, MD, Dr. Jérôme Lopez, MD and Dr. Viviane Hoduc MD

All three of these inspiring doctors took different paths leading them to integrate medical cannabis to their routine practice. At first, it was a frustrating trial-and-error, learn-as-you-go method to learn about medical cannabis, and we are proud that Santé Cannabis was the resource that helped them overcome this challenge through our clinical experience. 

“Cannabis is illegal in France, and I arrived here with apprehensions […] I started learning about it, thinking that I would maybe have patients using cannabis for recreational purposes. I wanted to be ready to meet problems related to this. So I collected information, in the end mostly about medical cannabis.” (our translation) – Dr Lopez

He expanded about how his training and investigation changed his mind, and he now considers medical cannabis as part of his routine practice.

Cannabinoid Titration and Opioid Tapering in Patients with Chronic Pain – a consensus-based algorithm

Dr. Jordi Perez-Martinez

Dr. Perez’s presentation was very interesting and pertinent for clinical practice, especially considering the current opioid crisis. He presented an algorithm for cannabinoid titration and opioid tapering in patients with chronic pain that has been built as many chronic pain specialists reached a consensus.This algorithm brings hope that more algorithms and clinical guidelines can be developed, even without a conclusive medical cannabis consensus in the general medical community. 

About the important question, “are there age limits with this algorithm?”:

“We always start with the notion that the use of THC in young patients with a developing brain is probably not a good candidate. But we can’t forget that these are patients who are already taking opiates and we know that opiates have a negative effect on cognitive development.” Dr. Perez-Martinez

There remains a need for rigorous research, and a broader consensus must be reached before medical cannabis for pain management will be implemented everywhere. 

Workshop: Should cannabinoid-based treatments be maintained in the medical field?

Dr. Charles Sun

Cannabis is a unique medicine, as there are currently two access points to this substance: for medical purposes through the medical cannabis program, and for non-medical use through the retail points of the SQDC. Dr. Sun asked the audience about their opinions on maintaining two separate programs, and what might be reasons for or against.

 We were pleasantly surprised to see that almost every person who responded said they believe that a seperate medical cannabis program should exist outside of the non-medical program. Dr. Sun asked them to expand on their reasoning and the answers collected from the different questions provided food for thought:

• A large number of responders agreed that some of the disadvantages of the medical cannabis program are related to the complexity of the system and prescription process. Indeed, the medical cannabis program is far from perfect, but hopefully these disadvantages can be minimized in the future as the regulations evolve.
• There was a great consensus on the importance of patient medical assessment by healthcare professionals prior to medical cannabis treatment, in order to limit potential harms: 96% of responders chose this reason concerning the need for a seperate medical cannabis program.

Panel: medical cannabis use and management issues in different healthcare facilities in Quebec: the pharmacist’s perspective

Sarah Girard, pharmD M.Sc., Philippe Arbour, BPharm MSc and Andrée Néron, BPharm DPH FOP

The panel composed of three pharmacists was extremely interesting as they shared their challenges with medical cannabis in their practices. They are trying to work within a system where they are traditionally seen as experts on the medicine, but find themselves at a loss when asked by their patients and colleagues about cannabis treatments. 

A particular friction point they brought forward was how difficult and tedious it is to obtain complete patient drug information, as medical cannabis is not included in the usual drug list that patients bring. Furthermore, patients do not always think of informing their pharmacist that they take cannabis, be it for medical or non-medical purposes – highlighting the need for pharmacists to update their questionnaires to include cannabis as well as recreational substances like alcohol.

Legal Issues and Patient Education

Max Silverman, LL. B and Naomie Parrot, RN, BSc

For medical cannabis patients, not only do they have to concern themselves with the understanding of their medication, but also with understanding complex laws surrounding cannabis. Our nurse Naomie Parrot covered some of the medical side of education, while Mr. Silverman, a lawyer engaged in litigation for human rights, covered some of the current legal consequences for medical cannabis patients, highlighting some of the regulations that are incomplete or missing. 

For example, there are contradicting and unclear laws between federal and provincial levels as to workplace accommodations. An employee cannot be terminated for using medical cannabis, yet the same employee could be terminated because of medical cannabis side-effects impacting their ability to accomplish their work. It is an issue that is especially worrying if the workplace is resistant against medical cannabis use, and patients’ rights are on the line. Mr. Silverman ended the day with a call to action for all of us – some things need to change, and it’s up to each of us to make a difference.

Conclusion

We were thrilled by the attendance of so many Quebec healthcare providers, patient advocates and organizations, and industry representatives who came to learn about the current state and future of medical cannabis in Quebec. Our speakers brought their expertise, passion and new ideas and for that we are very grateful.

We look forward to hosting our next event in May – this one focusing on international research innovations to improve patient care; and to many more years of our Conferences on Cannabinoid Medicines. Will we see you there?

Authors: Charlotte Bastin, Andrée Charbonneau

Join us at our next event

Quebec Cannabis Forum: Moving Towards a Comprehensive Approach to Public Health

8:00-5:00 pm EDT May 18th, 2022
Scena, Montreal
(EVENT IN FRENCH)

Register here

Substance Use Disorder is defined as problematic patterns of substance consumption that lead to impairment and distress. According to a 2012 study, more than 21% of Canadians meet the criteria for a substance use disorder at one point in their lifetime.

Alcohol (18%) and tobacco (16%) are the two most common substance use disorders among Canadians, while nearly 7% of Canadians are thought to abuse or have developed a dependence to cannabis. Opioids meanwhile were responsible for more than 25% of all drug overdose deaths worldwide in 2017. Over 9,000 people have died from opioid overdoses in Canada since 2016. 

While it is important to remain cautious about the risks of cannabis use disorder in this patient population, carefully developed and closely monitored medical cannabis treatment plans can be an option for those who are struggling to manage cravings and other symptoms of withdrawal. 

SUBSTANCE USE DISORDER AND THE ENDOCANNABINOID SYSTEM: CBD & THC

The role of cannabinoid receptor CB1R in the modulation of dopamine activity is the basis for using medical cannabis as a possible treatment option for SUD. 

“The ECS, by direct CB1R activity, modulates and is modulated by mesolimbic[dopamine] activity […] It is thus thought that the disruption of endocannabinoid signaling may prove effective in treating SUDs”. (Chye et al. 2019)

Both preclinical and clinical studies indicate that CBD has the potential to help relieve withdrawal symptoms like convulsions, as well as reduce cravings and drug intake. Trials have found that CBD may also attenuate the impulsive discounting of delayed rewards, which may help diminish the risks of relapse in substance users who are already in remission. 

In a short article for Neuropsychopharmacology, Friedbert Weiss and Gustavo Gonzalez-Cuevas suggest that CBD may also be an advantageous treatment for SUD due to its efficacy with multiple substances, including cocaine, opiates, cannabis and alcohol. 

According to Weiss and Gonzalez: “Since co-abuse of opiates and cocaine with alcohol is common, the reported anti-reinstatement actions of CBD across three major classes of abused drugs further add to the putative treatment drug promise of this phytocannabinoid” 

Since CBD has a low potential for abuse, it may be aninteresting option for patients who might bet at moderate risks of developing a Cannabis Use Disorder. 

THC also shows some promise in the treatment for SUD, particularly for the treatment of opioid use disorder.  

Preclinical evidence suggests the use of THC-based pharmacological products like nabiximols and dronabinol could help mitigate the severity of precipitated opioid withdrawal. Researchers posit the mechanism for this process could be a result of cannabinoid agonists like THC modulating opioid signaling in noradrenergic cells of coeruleo-cortical pathways. 

OUR CLINICAL EXPERIENCE

The two most common administration methods in clinical trials for SUD were oral administration of ingestible CBD oil, dronabinol or nabilone capsules and oromucosal sprays like nabiximols. 

Conversely, Santé Cannabis’ clinical experience prefers the use of ingestible oils and nabilone over nabiximols or dronabinol (as it is not available in Canada). 

As for CBD, patients at Santé Cannabis tend to be prescribed doses that are significantly lower than the typical dose found in existing clinical trials. For instance, most clinical trials used doses of more than 100mg of CBD, but most patients take daily doses lower than 100 mg CBD at Santé Cannabis. CBD-rich products are expensive, therefore CBD daily dose is not increased further than 100 mg if there is no benefit and if the patient cannot afford it.

Nabilone doses in clinical research studies also ranged from 6 to 8mg/day, whereas the maximum dose of nabilone prescribed at Santé Cannabis was 6mg per day. 

Approaches to treating substance use disorders have sought shed taboos about addiction and dependence, and prioritize interventions like behavioral therapy and pharmacological treatments. 

CBD, SUBSTANCE USE DISORDER & YOUR PRACTICE

At Santé Cannabis we work alongside patients to help them achieve their desired health outcomes, including assessing if medical cannabis is an appropriate medication and ensure that they are receiving the correct dosing. We have developed dosing instructions and titration charts, and we modify these for our individual patients using our years of experience while considering findings coming from recent research. 

Interested to learn more about CBD and the correct dosing for your patients, but not sure how especially during COVID-19? We offer a training program for Quebec doctors, available online, free of charge, including learning modules, webinars, and virtual preceptorships. Registered doctors also have access to our support line with direct calls to our knowledgeable nursing team.

You can sign up here

In August 2010, nabiximols -trade name Sativex- became the first natural cannabis-based medication to be fully approved by Health Canada for a specific indication. An adjunctive treatment for spasticity in multiple sclerosis, the drug has over the years gained approval from regulatory bodies in France, Germany, the U.K. and several other countries.

Recent studies suggest a wide acceptance of medical cannabis within the MS patient community. Yet still today, the large majority of M.S. patients who use medical cannabis continue to favor oils, sprays and other medical cannabis products over nabiximols. 

Why do so many multiple sclerosis patients and their healthcare providers still rely on unapproved medical cannabis treatments when a natural pharmaceutical cannabinoid is available?

The answer lies in a combination of factors, particularly economic barriers to access and the importance of personalized, adaptable treatments. 

Multiple Sclerosis and Spasticity

Multiple Sclerosis is characterized by demyelination, a process that sees cells involved in neuro-inflammation mistake the myelin sheath covering the nerves for a foreign antigen and attack it. While the myelin sheath can be repaired, the attacks nonetheless leave scars, the accumulation of which cause a wide range of symptoms. 

Approximately 50% of MS patients experience some pain associated with the disease.

Most frequent MS symptoms include neuropathic pain, spasticity, bladder dysfunction, and fatigue. Spasticity is thought to affect about 80% of M.S. patients, with symptoms ranging from light muscle tightness to painful involuntary spasms and contractions. 

Baclofen, a muscle relaxant and anti-spastic medication, is often prescribed to treat spasticity but research suggest as many as 25-30% of M.S. patients do not respond to the drug. 

For these patients, nabiximols could be a potential option. 

Nabiximols and Treatment Resistant Spasticity

Nabiximols is an oromucosal spray that consists primarily of a controlled dosage of THC and CBD extract from the cannabis plant. It is usually the first cannabis treatment option Santé Cannabis physicians consider for M.S. patients with treatment resistant spasticity.

But nabiximols isn’t covered by provincial health insurance plans in Canada, and is only covered by a handful of private health insurers. With the monthly cost of treatments ranging anywhere from 226$ to 903$, the drug is rarely an affordable option for patients. To counter this barrier to access, Santé Cannabis has developed effective alternatives using medical cannabis sprays and oils to treat spasticity in M.S.

TO FIND OUT MORE ABOUT TREATMENT RECOMMENDATIONS FOR SPASTICITY IN MULTIPLE SCLEROSIS, SIGN UP TO OUR PRESCRIBER TRAINING PORTAL

Testing Different Ratios: The Importance of A Personalized Approach

Nabiximols is a product with a balanced ratio of THC to CBD (2.7mg to 2.5 mg). At Santé Cannabis, the majority of treatments are initiated with products that have balanced THC:CBD ratios, particularly if patients are inexperienced with cannabis as CBD is thought to lessen some of the psychoactive effects of THC. 

But medical cannabis requires a highly-personalized approach to be effective. While balanced THC:CBD products may be effective for many, they aren’t necessarily the optimal ratio for every patient. 

Indeed, some patients may benefit from an increase in CBD or THC levels. The use of medical cannabis oils allows patients to test different ratios to find the right combination that meets their therapeutic goals, something that isn’t possible with pharmaceutical cannabinoids.

The Need for More Research

A 2019 review of 27 different studies on spasticity in adult patients with a range of conditions, including 21 studies on multiple sclerosis patients, demonstrated support for the trial of cannabinoids as a treatment for spasticity or pain in patients with M.S, 

This review “found evidence that THC and THC:CBD products may reduce spasticity or concluded that it generally favoured cannabinoids to treat spasticity based on the results of individual studies or trends towards significant effects.” (Nielsen et al. 2019)

Discrepancies in the scales used to assess the effectiveness of treatments have at times made comparing findings from different studies difficult. Although the Ashworth scale has been used to measure the efficacy of treatments on spasticity, researchers have over recent years suggested the 88-item Multiple Sclerosis Spasticity Scale (MSSS-88) as a more accurate approach. (Nielsen et al 2019) (Fu et al. 2018)

Carefully conducted, high-quality studies that focus specifically on the activity of different cannabis compounds are still required to further expand understanding of the benefits of cannabinoids for M.S. patients.

For more information about the potential of medical cannabis treatments for MS symptoms and improved quality of life, reach out to us. 

Patients who commit themselves to a comprehensive approach that combines a carefully monitored medical cannabis treatment with physical activity, improved sleep hygiene and mental health treatment can often significantly improve their quality of life.

“Fibromyalgia is a disease that we see a lot at Santé Cannabis and we have a good deal of success with its treatment. We can work to improve it over time, but it requires full participation by the patient and, if possible, their families or support system.”

– Santé Cannabis Medical Director Dr. Michael Dworkind

UNDERSTANDING FIBROMYALGIA

Fibromyalgia is characterized by chronic musculoskeletal pain and diagnoses usually include other symptoms, such as chronic fatigue, poor sleep, mood and cognitive issues. The condition is thought to affect slightly less than two percent of Canadians, and is most common among women over 40 years of age.  

While the pathophysiology of the disorder remains poorly understood, several possible mechanisms have been advanced, including central sensitization, suppression of descending inhibitory pathways, excessive activity of glial cells, and abnormalities in neurotransmitter release. A clinical endocannabinoid deficiency has also been hypothesized as an underlying pathophysiology but there remains insufficient evidence to support the theory. [i] 

FINDING THE RIGHT CANNABIS STRAIN AND DOSE

Patients react to cannabinoids differently so it’s important to find the specific dose and strain that meets their personal needs. Through trial and with the continuous assessment of a supportive healthcare team, patients can attain that goal.

Although treatments at Sante Cannabis are initiated with products that have balanced levels of THC and CBD (THC:CBD), patients with fibromyalgia seen by our physicians generally report greater relief from THC-rich products. Patients who are inexperienced with cannabis should introduce THC slowly to avoid possible adverse effects. Inhaled THC-rich products are usually recommended to treat breakthrough pain. 

Quebec physicians who want to learn more about the different strains of medical cannabis and administration methods can sign up to the Sante Cannabis Prescriber Training Program for convenient online access to clinical guidelines, education material and support.

SLEEP AND CHRONIC PAIN

Finding the right type of cannabis is not the only requirement for success in the treatment of fibromyalgia. Research and clinical experience show that an overwhelming number of fibromyalgia patients suffer from poor non-restorative sleep, often because they are frequently awoken by pain throughout the night.

Optimal sleep is critical in the treatment of fibromyalgia, with no more and no less than eight hours of nourishing deep sleep needed most nights. This may require an inhaled sedating strain of medical cannabis to induce the sleep, combined with the use of either a longer acting medical cannabis oil, a pharmaceutical cannabinoid or an edible medical cannabis product to maintain sleep. 

The ability to induce and maintain a good quality of sleep is a solid indication that a medical cannabis treatment is effective. 

PHYSICAL ACTIVITY AND MENTAL HEALTH

Another important component of treating fibromyalgia is physical activity. When fibromyalgia pain is adequately controlled, and patients are sleeping well, they can gradually become more active on a daily basis. Simple aerobics or brisk walking, preferably in a natural surrounding, can make a marked difference, as vigorous daily activity often leads to an improved mood and outlook, something that can be difficult for those with living chronic pain.

Chronic fibromyalgia patients may suffer from depression or adjustment disorders from years of poor treatments. The support of mental health professionals can be an important aspect of some fibromyalgia patients’ treatment plan. 

Physicians and nurses should also emphasize lifestyle components in the ongoing treatment of all fibromyalgia patients. In our experience, mindfulness is another way to create positive lifestyle changes. By incorporating mindfulness approaches into their daily lives, patients can learn strategies and techniques to calm their minds and reduce anxiety, a symptom that frequently accompanies chronic pain conditions.

SYNERGY BETWEEN OPIOIDS AND CANNABINOIDS

Activity not only improves physical conditioning but it also stimulates the endorphins system, our body’s opioid system. Clinical experience indicates a synergy between cannabinoids and opioids that sees a mutual increase in therapeutic effects without increasing plasma levels. Working together, both cannabinoid receptors and opioid receptors can combine to better control the pain symptoms. Synergism between opioids and cannabinoids has been postulated and subsequently demonstrated in a number of animal models, and there is some evidence that cannabinoids might increase the synthesis or release of endogenous opioids. [ii]

“There is no cure for fibromyalgia,” says Dr. Michael Dworkind. “But we’ve seen this approach help patients find a life that is much more active and not centered on pain, a life in which the patient can better control the intensity and impact of a previously debilitating condition.” 

Physicians with patients who might benefit from this Santé Cannabis approach can find a referral form to our clinic here. Patients who have questions about medical cannabis as a possible treatment option can access more information on our FAQ page.

[i] Russo, E. B. (2008). Clinical endocannabinoid deficiency (CECD): can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome and other treatment-resistant conditions? Neuro Endocrinology Letters, 29(2), 192–200.

[ii] Abrams, D. I., Couey, P., Shade, S. B., Kelly, M. E., & Benowitz, N. L. (2011). Cannabinoid-opioid interaction in chronic pain. Clinical Pharmacology and Therapeutics, 90(6), 844–851. https://doi.org/10.1038/clpt.2011.188 ; Cichewicz, D. L. (2004). Synergistic interactions between cannabinoid and opioid analgesics. Life Sciences, 74(11), 1317–1324. https://doi.org/10.1136/bmj.f7339

During this unprecedented crisis, Mental Health Week offers an important opportunity to discuss misconceptions and taboos surrounding medical cannabis and mental health, particularly in the context of the growing popularity, evolving access and new regulatory frameworks. 

Indeed, healthcare professionals and their patients are increasingly turning to medical cannabis as a possible option when conventional approaches to treating anxiety have proven ineffective. 

Yet the use of medical cannabis as a mental health treatment is particularly complex, and high-quality clinical evidence is still limited and sometimes conflicting. Treatments  are also often poorly understood by patients, some of whom have unrealistic expectations about possible therapeutic benefits. 

THE IMPORTANCE OF SUPPORT AND SUPERVISION

In Santé Cannabis’ own experience, the effects of cannabinoids are highly individualized. Clinical approaches to different mental health conditions also each rely on very specific cannabis compounds, dosages and administration methods. 

The integration of individualized education and supervised access to cannabinoid treatments is crucial to ensure that patients struggling to find effective treatments receive the support they need to make safe and informed decisions. 

In regulatory environments like Canada and some U.S. states, where cannabis is legal and readily available, integration into healthcare models can help mitigate the risks of unsupervised use. 

Any decision to use medical cannabis to treat a mental health condition should be taken in conjunction with the close support of a healthcare professional and a mental health expert. 

SUFFERING ANXIETY? YOU’RE NOT ALONE

According to a 2016 Canadian Public Health Agency study, more than three and a half million Canadians are believed to live with anxiety or a mood disorder. Anxiety disorders encompass a range of conditions, including generalized anxiety disorder, social anxiety disorder, specific phobias and other conditions characterized by significant feelings of anxiety and fear. 

While cognitive behavioural therapy or psychotherapy are often recommended as non-pharmaceutical treatment options, only about 20% of Canadians with anxiety or mood disorders report having undergone psychological counselling to help manage their condition. In contrast, more than 90% report using or having used prescription medication to treat their disorder. 

Serotonin inhibitors, conventional anxiolytic medication like benzodiazepine and antidepressants are the most commonly prescribed pharmaceutical treatment for anxiety. Although these treatments have proven efficient, undesired and adverse side effects are often reported from their use.

When patients do not respond well to these pharmaceutical treatments, the medical use of cannabidiol (CBD) products can be a safe alternative worth exploring. 

CBD AS A COMPLEMENTARY TREATMENT: DESIGNING TREATMENT PLANS WITH SANTÉ CANNABIS

The tolerability and generally good safety profile of CBD, as well as its demonstrated effectiveness as an anxiolytic have made it the cannabinoid of choice to treat anxiety.[i] After assessment of medical history, pharmacological and non-pharmacological interventions and screening for potential risk factors, patient treatments for anxiety at Sante Cannabis are usually initiated with ingestible CBD oils, administered with a drop counter, in capsules or a spray. 

In case of acute anxiety symptoms or panic attacks, the use of sublingual sprays or the inhalation of dried flowers or extract with a vapourizer are recommended for their rapid onset of action, which occurs in seconds or minutes. The onset of effects from ingestion, on the other hand, can take anywhere between one to two hours.

Medical cannabis treatments start with low doses but slowly increase during a titration period. Quebec physicians who want to learn more about dosages, titration recommendations and methods of administration can sign up to the Sante Cannabis Prescriber Training Program for convenient online access to clinical guidelines, education material and support.

WHAT ABOUT THC?

For some patients, small doses of THC have proven effective to counter anxiety attacks. The biphasic nature of cannabinoids is important to consider here: THC in small doses has shown anxiolytic properties, but larger doses of THC may induce or worsen anxiety. [ii]  Patients who are inexperienced with cannabis should introduce THC slowly to avoid possible adverse effects.

WHEN IS MEDICAL CANNABIS THE RIGHT TREATMENT FOR ANXIETY?

Most of our patients with anxiety are referred by their psychiatrists directly or their family doctor. When assessing a patient’s file, our staff ensures that first line medications have been tried and that the patient has consulted a mental health professional.  

It’s important to differentiate generalized anxiety from regular anxiety. Regular anxiety is a normal adaptation reaction to stress and is transitory, with a source that can often be identified. In the case of generalized anxiety, on the other hand, the source of the patient’s fear is diffuse.

In cases where medical cannabis may be an option for treating anxiety, patients should view their treatment as just one tool among many, including psychotherapy and lifestyle changes, that can help manage their mental health. Combined with this holistic approach, medical cannabis can be an empowering option for patients with difficult to treat anxiety and help them take action on the entire lifestyle spectrum, from sleep hygiene and exercise to diet and meditation. 

[i] Turna J, Simpson W, Patterson B, Lucas P, Van Ameringen M. Cannabis use behaviors and prevalence of anxiety and depressive symptoms in a cohort of Canadian medicinal cannabis users. J Psychiatr Res [Internet]. 2019 Apr 1 [cited 2019 Mar 4];111:134–9. Available from: http://www.sciencedirect.com/science/article/pii/S0022395618304783

Zuardi AW, Rodrigues NP, Silva AL, Bernardo SA, Hallak JE, Guimar.es FS, et al. Inverted Ushaped dose-response curve of the anxiolytic effect of cannabidiol during public speaking in real life. Front Pharmacol. 2017;8:259.

Crippa, JA, Derenusson, GN, Ferrari TB, Wichert-Ana L, Duran FL, Martin-Santos R, et al. Neural basis of anxiolytic effects of cannabidiol (CBD) in generalized social anxiety disorder- a preliminary report. J Psychopharmacol [Internet]. 2011 [cited 2019 Aug 19]; Available from: https://www.theroc.us/researchlibrary/Neural%20basis%20of%20anxiolytic%20effects%20of%20cannabidiol%20(CBD)%20in%20generalized%20social%20anxiety%20disorder-%20a%20preliminary%20report.pdf

Bergamaschi MM, Queiroz RHC, Chagas MHN, de Oliveira DCG, De Martinis BS, Kapczinski F, et al. Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-na.ve social phobia patients. Neuropsychopharmacol Off Publ Am Coll Neuropsychopharmacol. 2011 May;36(6):1219–26.

[ii] Fusar-Poli P, Crippa JA, Bhattacharyya S, Borgwardt SJ, Allen P, Martin-Santos R, et al. Distinct effects of {delta}9-tetrahydrocannabinol and cannabidiol on neural activation during emotional processing. Arch Gen Psychiatry. 2009 Jan;66(1):95–105.

Sante Cannabis has assessed over 8,000 patients over the last six years and served as an important recruitment site for the Quebec Cannabis Registry. Patients and their healthcare teams seek our support for the consideration of medical cannabis treatment when conventional medications have failed to provide sufficient relief. In our clinical experience, the effectiveness of medical cannabis treatment for IBS varies significantly from one patient to another, a reality that speaks to the importance of developing personalized treatment plans under the supervision of experienced healthcare professionals.

For the moment, Santé Cannabis clinicians treat patients who have IBS in conjunction with other diagnoses when conventional treatments have failed, using individually tailored plans and product selections to address associated symptoms such stress, anxiety, sleep disturbances and pain. 

UNDERSTANDING IBS

IBS is characterized by recurrent abdominal pain associated with changes in bowel habits, which are divided into three main subtypes: IBS with predominant diarrhea (IBS-D), IBS with predominant constipation (IBS-C) and IBS with mixed bowel habits. (IBS-M).

IBS is also a non-specific disorder, meaning that it likely encompasses different pathologies that range from undefined gut dysfunctions to mental health and stress related issues. While Santé Cannabis does not typically see patients who have a primary diagnosis of IBS, our physicians and nurses have developed treatment plans for patients who suffer from it as a comorbidity. IBS is a common comorbidity in fibromyalgia and several other chronic pain disorders, including chronic fatigue syndrome, temporomandibular joint disorder, chronic pelvic pain and non-ulcer dyspepsia. 

THE SANTÉ CANNABIS APPROACH

 Our clinicians favour a holistic approach that aims to reduce anxiety, stress and pain, while incorporating elements such as dietary changes, meditation and psychotherapy.The rationale that underpins the treatment of IBS with medical cannabis is based on the understanding of the Endocannabinoid System (ECS) as a modulator of gastrointestinal propulsion, secretion and inflammation, as well as on the presence of receptors associated with the ECS in the gastrointestinal system. 

 Patients treated for IBS at Santé Cannabis are primarily prescribed CBD-rich oils. If patients experience difficulties falling asleep after the ingestion of CBD-rich oil, they may be prescribed THC:CBD balanced oil for use at night. Oils with higher ratios of THC can also be introduced during flare-ups or periods of increased discomfort but always in combination with CBD.

Evidence suggests CBD inhibits gastro-intestinal inflammation and may have a possible effect in controlling visceral hypersensitivity and pain, although studies remain in preclinical stages. Results from the limited studies on the use of THC have produced mixed results. 

THE IMPORTANCE OF CLOSE OBSERVATION AND FOLLOW-UP

Santé Cannabis’ clinical experience also highlights the importance of avoiding oils with MCT, as some patients with IBS have reported digestive troubles or increased diarrhea from their use. Making sure to choose the most natural oil available or switching to capsules can help reduce the quantity of ingested oil and mitigate associated side effects. 

The effects of medical cannabis on IBS symptoms vary greatly. Patients in retrospective and prospective studies have reported symptomatic relief from medical cannabis for gastrointestinal problems, but the body of evidence supporting its efficacy in IBS is still limited. In certain cases, patients are able to achieve total control of their symptoms or even resolve them. Others, however, experience side effects or observe no effects at all. When IBS therapies have been ineffective, the guidance of experienced healthcare professionals is crucial to helping patients determine if medical cannabis treatment could be beneficial.

While it is important to keep in mind the need for more and better research amid the diverse outcomes observed, the use of medical cannabis under the Santé Cannabis approach does hold out hope for IBS patients when other therapies have brought no relief. 

TTRAINING OPPORTUNITIES FOR HEALTHCARE PROFESSIONALS

Quebec physicians interested in finding out more about the use of medical cannabis to treat gastrointestinal problems or other health concerns can register to our Prescriber Training Program for access to free support services and educational material, including the clinical guidelines we’ve developed for treating specific conditions.

Sign up here

Dr. Vigano was one of the first international experts to be invited to a conference on medical cannabis in Thailand since the country officially legalized the production and use of cannabis for medical purposes in late 2018. Dr. Vigano’s presentations sought to help healthcare professionals at the Karunruk Palliative Care Center at Khon Kaen University integrate cannabis treatments into their supportive and palliative care network.

Although medical cannabis has been legalized for over a year, limited formal education and training on its therapeutic properties continue to restrict patient access. The Santé Cannabis model of care presented by Dr. Vigano was a useful reference for conference attendees, many of whom are working to establish an institute specializing in medical cannabis within Khon Kaen University’s medical school.

For the moment, medical cannabis patients in Thailand can only access cannabis oil extracts for ingestion. The country’s production of cannabis oil extracts still falls short of demand and there remains a lack of product variety, particularly CBD-rich products.