A few years ago, we published part 1 of this blog series All About Cannabis Administration – Part 1 , introducing two of the most common ways of using medical cannabis: inhalation and ingestion. Since then, cannabinoid medicine has continued to evolve rapidly. New formulations have become available, and our understanding of cannabinoid pharmacology has grown considerably. As a result, patients, researchers, and clinicians have increasingly explored alternative routes of administration.

Today, patients have access to a much wider range of options, including oromucosal sprays, topical products, transdermal patches, and suppositories. Each route has unique advantages and limitations, and understanding these differences can help patients and healthcare providers make more evidence-informed treatment decisions.

WHY DOES ADMINISTRATION ROUTE MATTER?

Choosing how cannabinoids enter the body is just as important as choosing which cannabinoid to use. The route of administration influences how quickly the medication works, how long the effects last, how much reaches the bloodstream (bioavailability), and the likelihood of specific side effects.

Cannabinoids like delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are highly lipophilic, dissolving easily in fat but poorly in water. This is why medical cannabis products are often oil-based and better absorbed when taken with fatty foods. While this property allows cannabinoids to cross fatty cell membranes efficiently, it hinders their passage through water-rich environments such as saliva, mucus, or deeper skin layers. Formulations may include absorption enhancers, such as ethanol, medium-chain triglycerides (MCTs), or surfactants, to improve transfer across biological barriers and raise bioavailability.

Orally ingested cannabis undergoes hepatic first-pass metabolism: after absorption in the gut, blood carrying the drug passes through the liver before reaching the rest of the body. During this initial pass, part of the drug is metabolized, reducing the remaining amount of drug reaching the rest of the body. This contributes to the delayed and more variable effects of oral cannabis products. In the liver, delta-9-THC is also converted into 11-hydroxy-THC (11-OH-THC), an active metabolite that produces stronger and longer-lasting psychoactive effects than THC itself (1). This is why edibles can feel more intoxicating (“feeling high”) and last longer than inhaled cannabis, even at similar doses.

Alternative routes of administration—including oromucosal, transdermal, and rectal/vaginal—partially or completely bypass the first-pass metabolism. Because less THC is converted into 11-OH-THC, these routes can offer a faster onset of action, more predictable absorption, and a lower relative risk of unwanted intoxication compared to orally ingested THC. However, the degree to which these benefits appear depends considerably on the formulation used and individual factors such as genetics, body composition, and a person’s sensitivity or tolerance to THC (2).

OROMUCOSAL ADMINISTRATION

Although both oral and oromucosal products begin in the mouth, they follow very different paths. Oromucosal formulations – sprays, strips, or lozenges – are mostly absorbed directly through the mucous membranes (under the tongue or inside the cheeks), allowing cannabinoids to partially bypass first-pass metabolism and reach the bloodstream more directly. In theory, this translates into a more predictable effect and a faster onset of action.

The oromucosal route has gained particular importance in medical cannabis care because it is the route used by nabiximols (Sativex®), a standardized pharmaceutical product that has generated one of the strongest bodies of evidence in cannabinoid medicine (3). Because it is a licensed pharmaceutical product with a standardized THC:CBD formulation and dosing regimen, it has been evaluated in numerous randomized controlled trials, particularly for multiple sclerosis-related spasticity and neuropathic pain (4).

Controlled pharmacokinetic studies comparing oral THC to oromucosal Sativex found a trend toward greater THC bioavailability and a lower 11-OH-THC-to-THC ratio with the oromucosal spray, consistent with partial avoidance of first-pass metabolism (5). Its ethanol-based formulation allows rapid absorption through the oral mucosa, although some patients may experience local irritation or mouth discomfort. Sativex® is not covered by government-based prescription plan (RAMQ in Quebec), but some private insurers may offer coverage under specific criteria.

TOPICAL AND TRANSDERMAL ADMINISTRATION

These two terms are often used interchangeably, but they describe different therapeutic approaches.

Topical products are designed to act locally within the skin and underlying tissues. Creams, gels, lotions, and oils are commonly used to target localized symptoms such as pain and a variety of dermatological conditions. Without significant absorption into the bloodstream, they carry little to no risk of intoxication. A placebo-controlled clinical trial reported that topical CBD oil significantly reduced pain and other symptoms in patients with peripheral neuropathy, with minimal side effects (6). These findings are consistent with our clinical experience; our clinical staff and patients have observed positive effects with the use of topical products for localized pain.

Transdermal patches, adhesive strips applied to the skin, are specifically formulated to deliver cannabinoids across the skin barrier and into the bloodstream, providing longer-lasting effects throughout the body. This distinction matters because the skin is naturally designed to keep substances out, so transdermal formulations require specialized technologies — such as chemical permeation enhancers or microneedle systems — to help cannabinoids cross this barrier (7) Although preclinical studies demonstrate the anti-inflammatory properties of cannabinoids that may benefit certain skin conditions, clinical evidence for the use of cannabinoids in dermatology remains limited, underscoring the need for further research (8).

RECTAL AND VAGINAL ADMINISTRATION

Suppositories are solid preparations designed to melt at body temperature and deliver medication via the rectal or vaginal route. They are typically made from fatty bases — such as cocoa butter, shea butter, or coconut oil — which suit the lipophilic nature of cannabinoids.

Cannabis suppositories have attracted growing interest from both patients and clinicians in recent years. Although clinical data remain scarce, patients living with conditions such as chronic pelvic pain, endometriosis, and dyspareunia are increasingly seeking out this route, and it is being prescribed more often in clinical practice.

Suppositories are thought to offer higher local bioavailability within the pelvis while reducing how much of the cannabinoids circulate throughout the body compared with the same dose administered orally or by inhalation. Because this route partially avoids first-pass metabolism, it produces less 11-OH-THC and may result in lower concentrations of this metabolite reaching the brain. In theory, this may reduce the likelihood of THC-associated psychoactive effects while maintaining local therapeutic benefits. Real-world evidence suggests they may improve pelvic pain and menstrual discomfort while being generally well tolerated (9).

While some studies exist for the rectal route (10), none have yet been published for the vaginal route, despite considerable patient interest. In a survey of persons taking cannabis for perimenopause and post menopause, 78% expressed interest in cannabis-based vaginal products, most commonly to address vaginal atrophy, dryness, and localized pain — needs that current products on the market do not adequately serve (11).

COULD EYE DROPS BECOME A FUTURE OPTION?

Researchers have been exploring ocular administration of cannabinoids for decades, particularly for glaucoma, but also for other ophthalmologic conditions such as dry eye disease and diabetic retinopathy. Cannabinoids—particularly THC—may reduce intraocular pressure (IOP) while also exerting anti-inflammatory and neuroprotective effects (12). The main challenge has been developing formulations capable of delivering cannabinoids effectively to ocular tissues while avoiding the systemic exposure and psychoactive effects associated with conventional routes of administration. To address these limitations, researchers are investigating advanced drug-delivery technologies to improve ocular bioavailability (13). Though this method sounds promising, cannabinoid-based ocular products are not available on the market.

LOOKING AHEAD

The legalization of recreational cannabis in Canada has accelerated innovation in cannabis formulations, expanding the range of therapeutic options available to patients. As this article has shown, each formulation and route of administration offers unique advantages that may better suit different symptoms, lifestyles, and treatment goals. While patients and clinicians have readily embraced these new products, further research is needed to improve their cost-effectiveness and to support policy changes that expand access and reduce the persistent stigma surrounding medical cannabis.

At Santé Cannabis, research and patient care go hand in hand. For more than a decade, our clinical research program has generated real-world evidence and clinical trials and helped advance cannabinoid-based care. Every patient who participates in research contributes to closing important knowledge gaps and moving the field toward safer, more effective, and more personalized treatments. Whether you’re just beginning your medical cannabis journey or exploring new treatment options, our multidisciplinary team is here to help you find the approach that best fits your needs.

Author: Luiza Marouelli, Clinical Educator at Santé Cannabis.

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

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Don’t miss the first part of this series

Discover the main routes of administration for medical cannabis.

Discover the first part

REFERENCES

1. Lemberger L, Martz R, Rodda B, Forney R, Rowe H. Comparative pharmacology of Δ9-tetrahydrocannabinol and its metabolite, 11-hydroxy-Δ9-tetrahydrocannabinol. J Clin Invest. 1973;52(10):2411–2417. 

2. Olivero MM, Colom J, Gual A. Psychoactive constituents of cannabis and their clinical implications: a systematic review. Constituyentes psicoactivos del cannabis y sus implicaciones clínicas: una revisión sistemática. Adicciones. 2018;30(2):140-151. Published 2018 Apr 15. doi:10.20882/adicciones.858 

3. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA. 2015. 

4. Novotna A, Mares J, Ratcliffe S, et al. A randomized, double-blind, placebo-controlled, parallel-group, enriched-design study of nabiximols (Sativex®), as add-on therapy, in subjects with refractory spasticity caused by multiple sclerosis. European Journal of Neurology. 2011. 

5. Karschner EL, Darwin WD, Goodwin RS, Wright S, Huestis MA. Plasma cannabinoid pharmacokinetics following controlled oral Δ9-tetrahydrocannabinol and oromucosal cannabis extract administration. Clin Chem. 2011;57(1):66–75. 

6. Xu DH, Cullen BD, Tang M, Fang Y. The effectiveness of topical cannabidiol oil in symptomatic relief of peripheral neuropathy of the lower extremities. Curr Pharm Biotechnol. 2020;21(5):390–402. 

7. Torabi A, Madsen FB, Skov AL. Permeation-enhancing strategies for transdermal delivery of cannabinoids. Cannabis Cannabinoid Res. 2024. 

8. Hashim PW, Cohen JL, Pompei DT, Goldenberg G. Topical cannabinoids in dermatology. Cutis. 2017;100(1):50-52. 

9. Dahlgren, M.K., Smith, R.T., Kosereisoglu, D. et al. A survey-based, quasi-experimental study assessing a high-cannabidiol suppository for menstrual-related pain and discomfort. npj Womens Health 2, 29 (2024). 

10. ElSohly MA, Gul W, Walker LA. Pharmacokinetics and tolerability of Δ9-THC-hemisuccinate in a suppository formulation as an alternative to capsules for the systemic delivery of Δ9-THC. Med Cannabis Cannabinoids. 2018;1(1):44–53.

11. Dahlgren MK, El-Abboud C, Lambros AM, Sagar KA, Smith RT, Gruber SA. A survey of medical cannabis use during perimenopause and postmenopause. Menopause. 2022;29(9):1028–1036. 

12. Tomida I, Azuara-Blanco A, House H, Flint M, Pertwee RG, Robson PJ. Effect of sublingual application of cannabinoids on intraocular pressure: a pilot study. J Glaucoma. 2006;15(5):349–353. 

13. Saraiva SM, Martín-Banderas L, Durán-Lobato M. Cannabinoid-based ocular therapies and formulations. Pharmaceutics. 2023;15(4):1077. 

If you imagine someone smoking a joint, you’re not wrong, but that’s not the only method of administration, nor the most recommended.

In the early years of medical cannabis legalization, patients mostly smoked their medical cannabis, as it was the only legal option at the time. Since then, other methods of administration (and associated medical formulations) gained recognition and wider acceptance both from patients and prescribers.

Administration of cannabinoid-based medicines can go through several routes: inhaled (in the lungs), oral (swallowed), oromucosal (through the mouth’s mucosa), transdermal (through the skin), ocular, rectal, etc.

If you want to learn how that works and debunk some myths, tag along in this dive into medical cannabis administration.

CLEARING THE SMOKE ON INHALED ADMINISTRATION

Cannabinoid inhalation produces a fast onset of effects, which can begin within seconds after inhalation; effects peak within 3 to 15 min (depending on authors) and last approximately 2 to 4 hours. [1-3]

With this method of administration, the body absorbs a high proportion of active cannabinoids that can then exert their effects on their site of action. This high bioavailability ranges from 10 to 35%, and sometimes up to 56%. The inhalation method (smoked vs. vapourized) and technique influence bioavailability, where technique may vary on depth of inhalation, puff duration, and breath hold. [1, 2, 4, 5]

Prescribers often consider smoking cannabis as an inadequate method to administer a medication due to the harmful combustion by-products. [6-8] Vapourization appears as a safer, smokeless administration method producing much less harmful by-products than smoking; [3, 9, 10] the latter is possibly less efficient since it could destroy from 30% to 50% of its cannabinoid content. [6] Vapourization also minimizes throat and lung irritation and can lead to higher cannabinoid blood concentrations as compared to smoking. [3, 6, 11]

BUT WHAT’S VAPOURIZATION?

Cannabis vapourization consists in creating a vapour with cannabinoids (and other desirable elements like terpenes) without burning the plant material.

The current terms used to describe vapourization overlap and makes it somewhat complicated. Two types of vapourization exist:

• Dried Cannabis Vapourization;
• Cannabis Extracts / Concentrate Vapourization (also called “vaping”, or “dabbing” in the case of concentrates).

ARE ALL VAPOURIZERS THE SAME?

Each vapourization method requires a specific type of vapourizer device, which is not necessarily compatible with the other vapourization type. However, those devices fit under the generic name “vapourizer”.

• Dried cannabis vapourizers, also called “dry-herb vapourizer”, use a lower heat (170 to 230˚C) than the one created by burning and smoking cannabis (500-600˚C), and thus creates less harmful by-products [3, 6].
• Cannabis Extract Vapourizers, also called vape pens or e-cigarettes, are portable electronic devices that require cartridges (or vape cartridge, vape carts, refill pods, etc.).
• Cannabis Concentrate Vapourizers can be 2 things: either a “dabbing rig”, a specialized water filtration device with a heating element [12], or a compact electronic device (also called dab pen, wax pen) with a small oven to heat concentrates. Depending on the device, cannabis extracts or concentrate vapourizers can operate at higher temperatures (up to around 500˚C). Since concentrates contain very little to no vegetal matter apart from cannabinoids and terpenes, it’s hypothesized that their vapourization at higher temperatures cause less harmful by-products than dried cannabis combustion.

Cannabis concentrates come in a wide selection, such as rosin, live resin, shatter, full-melt hashish, etc. 

Some prescribers prefer recommending dried cannabis vapourization over vaping, as Health Canada approved some dried cannabis vapourizers as Class II medical devices (like the Volcano Medic and other devices from the brand Storz & Bickel) [13]. Veterans Affairs and some private insurances may reimburse such medical devices.

Vaping of unregulated cannabis products also caused worry in 2019, when Health Canada issued a warning concerning potential pulmonary illness associated with vapourization products (with cartridges) [14]. Vitamin E acetate, an additive present in illegal THC vaping products, is strongly associated with e-cigarette (or vaping) associated lung injury [15]. Health Canada strictly regulates the manufacturing of medical cannabis vaping products and prohibits potentially harmful solvents.

Note that in Quebec, it is illegal to smoke or vapourize cannabis in a public place without a prescription, whether indoor or outdoor [16].

For several patients, smoking or vapourizing cannabis is not the best option. The second most common administration is through the oral route (ingested).

ORAL ADMINISTRATION

Compared to inhaled administration, which acts fast and for a relatively short period, oral administration takes a while to produce effects and they last longer. Ingested (swallowed) cannabinoid products take effect after a delay of 1 to 3 hours, and the effects last for about 6 to 8 hours, or longer depending on dose, fasted state, and other individual factors [3].

The different times of action between inhaled and oral administration are explained by the distinct absorption speeds. Where inhaled cannabinoids go into the lungs and quickly reach blood circulation, ingested cannabinoids get absorbed in the intestine and metabolized (transformed) by the liver, only then reaching blood circulation. This absorption is slow and variable; the bioavailability ranges from as low as 6% and up to 30% [5, 17].

*A note that the liver converts THC (specifically, delta-9-THC) into an active and potent metabolite (11-Hydroxy-THC) [18, 19], which can contribute to heightened side effects.

Some absorption factors we can’t control, like individual rates of metabolism (some being much faster than others) and sex-related absorption differences; a factor we can control is food intake [5, 20]. Cannabinoids have a high affinity with lipids (fats), and studies found that the absorption of THC and CBD increases (up to 5-fold for CBD) when taken with a high-fat meal [20, 21].

Oral administration includes several medical cannabis products: 

• Oils, made of cannabis extracts and diluted with a carrier oil;
• Capsules, containing a precise dose of cannabis extract diluted with a carrier oil;
• Oral sprays, that deliver tiny drops of cannabis oil;
• Lozenges, sublingual strips, and edibles.

“Edibles” refers to food and beverages that contain cannabis and/or cannabis extracts. While edibles make an appealing administration method for recreational purposes, not all prescribers agree that edibles are an adequate dosing method for medical purposes. Advocates argue that a wider selection of ingested product ameliorate patient access and can better meet their individual needs.

COMPLEMENTARY METHODS

As discussed in our Chronic Pain post series (Chronic Pain – Part 1, Chronic Pain – Part 2), both oral and inhaled administration can serve in some treatment plans:

• Oral administration can serve when a treatment requires day-long pain relief, for example, because of its long-lasting effects [3] and the accurate dosing of ingested products [22]. Administration frequency then varies according to pain frequency, from once daily to two or three times a day [22].
• Inhalation administration can be helpful to quickly relieve breakthrough pain [9, 10], with its onset of effects within minutes of inhalation [1-3]. Administration frequency is usually as needed.

However, in some cases a fast onset of effect is needed, but administration through the lungs won’t do because of a medical condition (like chronic obstructive pulmonary disease); in other cases, spot application could be a more direct method of administration, compared to the oral administration that produces effects on the whole body. In such cases, other methods of administration can prove useful.

Stay tuned for Part 2 of this blog post, where we’ll go over oromucosal sprays, topicals, suppositories, and more!

Author: Charlotte Bastin

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

Ready to discover the other methods of administration?

Read part 2 of this blog!

 
All About Cannabis Administration – Part 2

You would like an assessment for a medical cannabis treatment?

Meet with a Santé Cannabis doctor or nurse practitioner today!

 
Book an appointment

Want to learn more? Train with us!

Our boutique equips healthcare professionals with the tools and knowledge to confidently recommend and prescribe cannabinoid-based treatments.

 
Visit our boutique

REFERENCES:

1. Sharma, P., P. Murthy, and M.M.S. Bharath, Chemistry, Metabolism, and Toxicology of Cannabis: Clinical Implications. Iranian Journal of Psychiatry, 2012. 7(4): p. 149-156.
2. Grotenhermen, F., Pharmacokinetics and pharmacodynamics of cannabinoids. Clinical pharmacokinetics, 2003. 42(4): p. 327–360.
3. MacCallum, C.A. and E.B. Russo, Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine, 2018. 49: p. 12-19.
4. Vučković, S., et al., Cannabinoids and Pain: New Insights From Old Molecules. Frontiers in Pharmacology, 2018. 9: p. 1259.
5. Bruni, N., et al., Cannabinoid Delivery Systems for Pain and Inflammation Treatment. Molecules : A Journal of Synthetic Chemistry and Natural Product Chemistry, 2018. 23(10).
6. Pomahacova, B., F. Van der Kooy, and R. Verpoorte, Cannabis smoke condensate III: the cannabinoid content of vaporised Cannabis sativa. Inhal Toxicol, 2009. 21(13): p. 1108-12.
7. Notcutt, W.G., Clinical Use of Cannabinoids for Symptom Control in Multiple Sclerosis. Neurotherapeutics, 2015. 12(4): p. 769-777.
8. Zajicek, J., et al., Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): multicentre randomised placebo-controlled trial. The Lancet, 2003. 362(9395): p. 1517-1526.
9. Bhaskar, A., et al., Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process. Journal of Cannabis Research, 2021. 3(1): p. 22.
10. MacCallum, C.A., L.A. Lo, and M. Boivin, “Is medical cannabis safe for my patients?” A practical review of cannabis safety considerations. European Journal of Internal Medicine, 2021.
11. Spindle, T.R., et al., Acute Effects of Smoked and Vaporized Cannabis in Healthy Adults Who Infrequently Use Cannabis: A Crossover Trial. JAMA Network Open, 2018. 1(7): p. e184841-e184841.
12. Hädener, M., et al., A preliminary investigation of lung availability of cannabinoids by smoking marijuana or dabbing BHO and decarboxylation rate of THC- and CBD-acids. Forensic Sci Int, 2019. 295: p. 207-212.
13. Health Canada and Government of Canada, Medical Devices Active Licence Listing. 2019.
14. Health Canada and Government of Canada, Information Update – Health Canada warns of potential risk of pulmonary illness associated with vaping products. 2019.
15. Public Health Agency of Canada, Vaping-associated lung illness. aem, 2020.
16. Gouvernement du Québec, The legislation on cannabis. Regulation of cannabis in Québec, 2020.
17. Lucas, C.J., P. Galettis, and J. Schneider, The pharmacokinetics and the pharmacodynamics of cannabinoids. British Journal of Clinical Pharmacology, 2018. 84(11): p. 2477-2482.
18. Lemberger, L., et al., Comparative pharmacology of Delta9-tetrahydrocannabinol and its metabolite, 11-OH-Delta9-tetrahydrocannabinol. J Clin Invest, 1973. 52(10): p. 2411-7.
19. Goullé, J.P., E. Saussereau, and C. Lacroix, Pharmacocinétique du delta-9-tétrahydrocannabinol (THC). Annales Pharmaceutiques Françaises, 2008. 66(4): p. 232-244.
20. Lunn, S., et al., Human Pharmacokinetic Parameters of Orally Administered Δ9-Tetrahydrocannabinol Capsules Are Altered by Fed Versus Fasted Conditions and Sex Differences. Cannabis and Cannabinoid Research, 2019. 4(4): p. 255-264.
21. Taylor, L., et al., A Phase I, Randomized, Double-Blind, Placebo-Controlled, Single Ascending Dose, Multiple Dose, and Food Effect Trial of the Safety, Tolerability and Pharmacokinetics of Highly Purified Cannabidiol in Healthy Subjects. CNS Drugs, 2018. 32(11): p. 1053-1067.
22. MacCallum, C.A., et al., Practical Strategies Using Medical Cannabis to Reduce Harms Associated With Long Term Opioid Use in Chronic Pain. Front Pharmacol, 2021. 12: p. 633168.

I often get patients wondering in the same manner. There is still much reprehension about cannabis. Our society is unceasingly finding fault with it, no matter how its status has evolved. The public has yet to fully and intuitively confirm its moral direction. Cannabis perception is changing at a very slow pace. 

Even the method of administration is very much compatible to its malignant opinion. ‘’ I don’t want to smoke cannabis. I’m not a druggy.’’ one of our patients did say. The current terminology, slangs precisely, is still and probably throwing people off. Many of our patients do not want to be taking weed or puffing on a spliff. Our treatment plans are based on scientific data, and accordingly we make sure to use the appropriate terms to the purpose. 

Our esteemed doctors do not prescribe marijuana. They recommend inhaling dried cannabis for breakthrough pain. I would gently remind a patient when he or she uses such words as “pot” or “ganja”. The old proverbial ‘’to-may-to/to-mah-to’’ would ring out. So, what is the difference? Really? 

I believe words and how we understand them are very consequential moving forward. I remember back in the 1990’s, the semantics affecting the scope of the term ‘’death tax’’ eventually became the ‘’estate or inheritance tax’’ in the US? Basically, politicians and advocates tried to kill the bill by putting stress on how it harmed family farms and small businesses. They knowingly coined the term ‘’death tax’’ to get the public to consider their cause. Dying has more impact and meaning in the collective conscience. 

I think the transition toward a proper nomenclature in medical cannabis practice must be imposed, applied and supported by all parties involved. Indica dried cannabis, THC-rich, 3-4 inhalations at bedtime or as needed does serves as better example of a positive and trustworthy interpretation than 3-4 puffs of weed before going to bed. 

– Pheng Lim, LPN 

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

It’s very rewarding to know that as a research clinic we are collecting data for the advancement and development of medical cannabis. Much of the data we collect shows differences in effectiveness and side effects of cannabinoid treatments allowing us to better understand and therefore create valuable treatment plans. I’ve also noticed our research helps shift the mindset of some professionals who might know very little about this subject and tend to be apprehensive because of the limited evidence available. Similarly, we see a pattern that many physicians continue referring their patients to us, probably because they are encouraged by the results achieved.

Medical cannabis is a field where we treat our patients in a fairly multifaceted way. Most of our patients come to us for chronic pain relief, depending on the etiology. We also work in the mental health domain which, let’s face it, became more important due to the current pandemic. Each patient has a personalized treatment plan with the goal of reducing their symptoms.

Recently, I even observed a rather interesting pediatric case. We don’t see many minors, but we have a few isolated cases where we work closely with the patients’ doctors, and consider contraindications and proceed with caution. Liam, my pediatric patient, presented with a severe case of Gilles de la Tourette’s syndrome, which caused him to have a long series of associated symptoms including vocal tics, hyperactivity, generalized spasms, aggressiveness and self-injury.

Liam was very lucky to have incredibly involved parents who continued to look for solutions for their son. During his last follow-up, his mother was moved to tell me how he had been doing. It’s not easy to live with this type of syndrome and the current pharmacological treatments are quite limited. During the meeting, she explained to me that Liam has been able to considerably reduce his list of medications, many of which were not very effective. The CBD based treatment we had advised him on taking (a cannabis molecule called cannabidiol) provided a significant improvement in his overall condition, and according to his teachers, his behavioral problems had significantly decreased and his class periods were more enjoyable. There was a decline in his aggressive and impulsive behaviors, the elimination of dark thoughts, a proper and peaceful sleep and a decrease in his spasms. These changes were greatly appreciated by Liam, and those who surround and love him.

Certainly cannabis did not cure him and we don’t expect it to. However, I am proud to say, we were able to provide him with new and additional tools and support required to improve his quality of life. Our physicians work hand-in-hand with Liam’s specialists to ensure quality follow-up, and they have been pleased with the effectiveness of the treatment established.

*names have been changed to protect identity of our patients

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

Author: Laura Libralesso

It would be difficult to deny the impact of the COVID-19 pandemic on anxiety and anxiety disorders in the population. Whether there are new anxiety symptoms or an exacerbation of existing ones, most of us know people who have been affected, if not ourselves. 

Reasons for increased anxiety in 2020/2021? 

Social isolation, monetary stress, sudden major changes, uncertainty about the future, sensation of losing control, fear of illness, etc. Some people have been in extremely close contact with COVID-19: people who have been infected, people who have lost loved ones or who have feared losing them, essential workers and, of course, healthcare professionals in many areas.

According to a  survey by Statistics Canada and the Public Health Agency of Canada conducted between September and December 2020 and published in March 2021, 7 out of 10 Canadians have been negatively affected by the pandemic and 2 out of 5 have experienced distress related to it. 

A survey was also conducted by the University of Sherbrooke on the psychosocial impacts of the pandemic: 

“What we see today is that levels of depression and anxiety in Quebec are currently considerably higher than what was observed pre-pandemic. These numbers are similar to the levels observed in the community of Fort McMurray, 6 months after the 2016 forest fires” (Dr Mélissa Généreux, septembre 2020 – Link available in french)

WHAT IS ANXIETY?

Anxiety is an emotion characterized by feelings of tension, worry and physical changes such as increased blood pressure.

Although this emotion can be useful to us, it sometimes takes on magnitudes that have a negative impact on our ability to function, our quality of life and on our interpersonal relationships. It can even have a significant impact on our long-term health. The effects that anxiety and anxiety disorders can have on a person are real, undeniable and deserve our attention.

According to Anxiety Canada, there are 11 categories of anxiety disorders in adults: Agoraphobia, Separation Anxiety, Health Anxiety, Body-Centred Repetitive Behaviours, Specific Phobia, Generalized Anxiety Disorder, Compulsive Hoarding Disorder, Social Anxiety Disorder, Post-Traumatic Stress Disorder, Obsessive Compulsive Disorder and Panic Disorder.

In addition to considering the impact of anxiety on a person, specialists also evaluate 4 broad categories of symptoms and their frequency: 

• Physical responses
• Thoughts
• Emotions
• Behaviors

If you think you may be suffering from anxiety, an anxiety disorder or any other psychological condition, it is important to talk to your doctor. You can also refer to several resources such as those offered by the Government of Canada on their website.

TREATMENTS AVAILABLE AT THIS TIME

• Pharmaceutical Treatments: The main pharmaceutical treatments for anxiety are usually antidepressants. Benzodiazepines may also be prescribed for acute symptoms and/or until the therapeutic effects of the antidepressant are achieved, as antidepressants can take several weeks to have an impact on mood-related symptoms.
• Psychotherapy: Several approaches in psychology are recommended for the management of anxiety, such as cognitive-behavioral therapy and psychodynamic therapy, and can be of great help. 
• Exercise: Experts agree that exercise has great benefits on anxiety. This is because physical activity activates the production of neurotransmitters in the brain. These neurotransmitters include those targeted by many antidepressants such as serotonin, which helps combat anxiety.
• Mindfulness techniques: Often associated with meditation, mindfulness is an approach, an attitude as well as a set of techniques including meditation. Many of these techniques can also be practiced in everyday life, for example, while eating, walking or exercising. These techniques allow you to better understand and identify what triggers anxiety. They allow you to take a step back from these stressors and make it easier to manage them. Moreover, as this approach can be very beneficial both mentally and physically, we have recently partnered with MindSpace to offer opportunities for our patients to practice mindfulness techniques. If you are interested, you can join the mindfulness-based stress reduction program this coming fall. Our patients are eligible to 20% off. You can ask our clinic staff for the promo code!
• Cannabinoids: The endocannabinoid system present in our body also plays a role in the mechanisms related to anxiety. This is why they are also used as an adjunctive therapy for anxiety symptoms.

A treatment that combines several options (e.g., pharmaceutical treatment and psychological therapy) is far more effective than each treatment option alone.

CANNABINOID-BASED TREATMENTS FOR ANXIETY

The human body has an endocannabinoid system that manages many functions, including emotional behavior. This system includes cannabinoids and enzymes produced by this system that bind to various receptors. Cannabis is a plant that includes more than 100 cannabinoids, the main ones being cannabidiol (CBD) and delta-9 tetrahydrocannabinol (THC). We also know that CBD interacts with many receptors/anxiety targets. Indeed, strong preclinical evidence supports the use of CBD as a short-term treatment for generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and post-traumatic disorder (Blessing et al., 2015). The promising effects demonstrated by CBD in the preclinical phase – certainly influencing the “CBD craze” – highlight the critical need for more clinical studies. We recently published an article on this craze, and you can read it here. 

However, it is important to note that, for now, only limited evidence supports the use of medical cannabis for anxiety disorders (Walsh et al., 2015). 

Nevertheless, Santé Cannabis has observed some success with medical cannabis for the treatment of anxiety. In addition, in reviewing our patient data, we have also seen positive results with medical cannabis in patients with unrelieved secondary symptoms of anxiety or depression (chronic pain being the most common primary condition) (Rapin et al., 2021).  

The place of medical cannabis in the treatment of anxiety

On May 5th 2021, Santé Cannabis held a large-scale Conference on Cannabinoid-Based medicine focused on International Research and Innovation. As part of this event, Dr. Howard Mitnick presented a workshop exploring the question regarding the place of medical cannabis in the treatment of anxiety and managed to make this interactive workshop both amusing and incredibly insightful. He delivered powerful arguments starting with stating that cannabis isn’t the only field where evidence-based medicine and it’s usual hierarchy is a challenge. Obstetric and breast-feeding medicine are examples among others and for various reasons. In his clinical practice, particularly in 2016, when many veterans were coming back from Afghanistan, Dr. Mitnick said he was impressed by the very significant impact cannabis had on patients that were struggling with PTSD-related anxiety, grasping at anything to just stop their brain. He humorously pointed out that “if this talk was about what evidence there is supporting the use of medical cannabis on anxiety, it would be a very short talk.” The question then becomes,  how can we, as clinicians and as a community, negotiate with this limited evidence, while clinicians see that medical cannabis helps many patients effectively manage their anxiety?

ANXIETY AT SANTÉ CANNABIS

As clinicians, we have seen first hand the improvement many patients are able to experience with medical cannabis treatment. However, we know that individual success stories are not enough to provide insight into how to prescribe this medicine on a large scale. Through the use of our real-world data, our clinic strives to provide better patient care by advancing science including data regarding the place of cannabis in the treatment of anxiety.

We also offer our patients support groups, presentations and tools including stress management and mindfulness.

The combination of formal training of healthcare professionals and high quality research is essential to increase the selection of anxiety treatments and provide the best care for patients. 

Join us in working to develop the highest quality treatments for people with anxiety.  

Santé Cannabis is committed to advancing knowledge about anxiety and cannabinoid-based treatments, and as such, we offer research services to companies and institutions interested in developing clinical studies. 

For clinicians currently treating people with anxiety who wish to include medical cannabis in their practice, our preceptorships are available to all local and international physicians. For prescribers in Quebec, we also offer a free training program on cannabinoid-based treatments and how to prescribe them.

Author

Andrée Charbonneau, Nurse Coordinator

With thanks to the Research Department

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

There will be many articles published highlighting the highs and lows of the last two years. We have a healthcare and research  perspective as a dedicated medical cannabis clinic and research leader since 2014, and similarly have seen highs and lows for our patients and practitioners.

Importantly, before legalization, it was common thought that medical cannabis clinics were not long for the world, that  legalization would remove the need for dedicated medical support for patients. Having worked alongside patients for years, we knew that this would not be the case, and in fact, we have seen an increase in referrals from doctors and self-referrals from patients, stimulated by legalization. With better access to cannabis information, people are seeking support from trained healthcare professionals to make informed choices that can improve their health and wellbeing.

Our increased demand for service, and increasing number of appointments year over year indicate that the need for medical support and patient education from a dedicated healthcare team is not going away any time soon.

WHAT HAS GONE WELL

Less stigma Patients report feeling more comfortable speaking with the healthcare teams, their families and friends about medical cannabis. We’ve observed an increase in interest in educational patient events and our training programs from doctors, nurses and pharmacists.

Reduced ethical burden. Cannabis legalization has helped to provide a clearer role for healthcare professionals and reduce the ethical burden we faced in previous years where doctors were the gatekeepers to legal access. Now, within a legal cannabis framework, we can focus specifically on the patient’s eligibility for medical cannabis treatments and can discontinue treatment if the goals or the conditions of our medical program aren’t met without the concern for legal issues if patients continue to consume on their own.

Diversity of product formulations and methods of administration have provided more options for patients and doctors. In the last two years, cannabis extracts, oromucosal sprays, vapourizer pens and topical products, have become available, meaning patients are more likely to find a treatment regime that works for them.

Updated guidelines for prescription of medical cannabis from the Collège des médecins du Québec. The important emphasis on quality of care and documentation remains, however research is no longer mandatory and decisions such as follow-up frequency of stable patients are left to physician discretion. Santé Cannabis is still very committed to medical cannabis research and all patients assessed and followed at the clinic are enrolled in our Real-World Data study upon their consent. However as this is no longer a mandatory requirement, it reduces barriers for patients and physicians.

WHAT CAN BE IMPROVED

More public education required. Publically-funded and developed training for healthcare professionals is essential. There is still a lot of confusion between medical and nonmedical rules, especially in Quebec.

Commitment to healthcare professional training. Our public healthcare system is a pride of Canada, but the government responsibility for training of our doctors, nurses, pharmacists and healthcare support staff seems to be completely overlooked during the first two years of legalization. The fact that pharmacists still don’t have a defined role in Canada’s medical cannabis program is Canada’s most shameful deficiency.

Improved access points for patients Access has not really changed for patients in the last two years, they still cannot fill medical cannabis prescriptions at pharmacies or retail locations. While SQDC locations continue to expand across the province, and same-day home delivery is available in Montreal for non-medical consumers, patients must still order online or by phone directly from the licensed seller and wait 2-3 business days for delivery.

The cost of medical cannabis remains prohibitive to the majority of patients who could benefit. Legalization introduced an additional excise tax, in addition to the sales taxes already applied. Some improvement has been made with private insurance, however it remains limited and universal cost coverage is still far away.

The introduction of the Cannabis Research License, a license that must be obtained from Health Canada for all research that handles onsite cannabis or cannabis products, has delayed research projects and increased burden on clinical researchers. This barrier causes challenges with project planning and funding. Without improvements, Canada is at risk to lose its global leadership position for research and innovation of cannabis products and cannabinoid-based medicines.

Changes to product packaging with the implementation of the Cannabis Act have created unnecessary burden on patients, healthcare professionals and the licensed producers and manufacturers. After twenty years of medical cannabis in Canada, it is frustrating that policy decisions are still being made without putting patients’ needs first.

On the 2nd Anniversary of Legalization

We are proud to be practicing medicine and completing research in a province and country that has made such impressive gains in cannabis, medical and otherwise, over the past two years. Legalization was something we advocated for since we opened our doors in 2014, and we celebrate this anniversary each year, knowing how many strong people worked tirelessly to make it happen. There is still a lot of work to do, and we excitedly look towards the next two years and beyond. 

For more perspectives on the 2nd year anniversary of legalization, read here.