We recently completed the first commercial harvest from our hybrid, controlled environment cultivation facility. This was a major milestone for us and marked the end of the first full growing cycle at our rural Waikato site.
Over the course of the harvest, we hosted several guests and journalists eager to share our story, we also produced our own video to mark the occasion. These videos are compiled below:
Lucas De Jong from Seven Sharp (TVNZ1) produced this video of the harvest.
We also hosted journalist Rachel Moore from Stuff, who wrote this article.
Finally, here’s a video we produced in-house of CEO Mark Lucas, updating our followers about the significance of this event.
Year-round cultivation activities are now in progress at our custom-built facility, with the next batch of medicinal cannabis plants ready to be transplanted, once a deep clean and routine maintenance has been completed.
The harvest was a team effort, with internal staff helping. This was an important aspect of the harvest, not only giving all staff the opportunity to gain a good understanding of the product, but also for validating our processes before completing GACP (Good Agricultural and Collection Practices) audits.
Harvesting approximately 500 mature cannabis plants is no small feat, a special thanks to all our helpers (both internal and external), our team at Cannasouth Cultivation Limited for being wonderful hosts and accommodating our guests, and for caring for this crop right through to harvest.
The harvested flower will now dry in purpose-built drying rooms, until it is at optimum moisture levels, before being trimmed, packaged, and stored ready for sale.
Successful assessment by the Medicinal Cannabis Agency of Cannasouth’s first medicinal cannabis products will deliver wider treatment options to New Zealand patients and prescribers.
Cannasouth has had three products successfully verified by the Government’s Medicinal Cannabis Agency (Agency).
Cannasouth CEO Mark Lucas says our products differ from other medicinal cannabis products on the New Zealand market because they contain different ratios of cannabinoids.
“The differentiated formulations of our products will provide New Zealand patients and prescribers with new treatment options compared to existing products on the New Zealand market. At the moment products available offer very few differences in formulation. We are confident these products offer patients and prescribers a point of difference to meet the treatment needs of a wider range of conditions.
“Full-spectrum extracts contain complex mixtures of cannabinoids. While the technical challenges from this did result in us navigating a lengthy regulatory pathway, the wait is worthwhile because of the benefit patients will receive from these enhanced product options.”
In making the announcement, Mr Lucas reinforced the complex nature of the medicinal cannabis industry and acknowledged the hard work of Cannasouth’s skilled and experienced team.
“These product approvals are another sign that the industry is maturing, which will ultimately benefit those who need these medicines most.
“Patients have been desperately waiting for high-quality and competitively priced new cannabis-based medicines to become available under the Medicinal Cannabis scheme. Now we are one step closer towards making more medicinal cannabis options available and giving prescribers and patients more choice for treating a variety of medical conditions.”
Suzanne Burge and Jack Lee are founders of PillDrop, a leading NZ online pharmacy and medicinal cannabis dispensary. Pharmacist Mr Lee says “These products have a unique combination of cannabinoids. It is great to see new products verified with a point of difference to meet the treatment needs of a wider range of patient conditions. We are seeing strong growth in demand for medicinal cannabis products”
Agency approval of these products is also a major step forward for Cannasouth in terms of generating medicinal cannabis revenue. Revenue generation from the sale of medicines in New Zealand, in addition to high-quality dried flower biomass, is one of the company’s key goals for 2022.
This will complement Cannasouth’s existing non-cannabinoid revenues generated through its subsidiary Midwest Pharmaceutics NZ Ltd, which sells products and services to the pharmaceutical, health, and wellness supplement sectors.
Cannasouth is also close to harvesting its first commercial crop of medicinal cannabis flower at its controlled environment agriculture (CEA) cultivation facility in the Waikato, while progressing GACP and GMP certification.
A list of all medicinal cannabis products that meet the New Zealand minimum quality standard can be found here: Medicinal cannabis products that meet the minimum quality standard
Our most recent newsletter features our 2021 annual report and also has an exciting update from inside our sealed, controlled environment greenhouse and cultivation facility.
If you’ve yet to be asked about prescribing medicinal cannabis, there’s a good chance your patients will be requesting information in the coming months.
Data released by the Ministry of Health under the Official Information Act shows that the number of packs of medicinal cannabis prescribed and supplied in New Zealand has grown at an average rate of 250% annually. In the year to 30 June 2021, 31,000 packs of medicinal cannabis were supplied in New Zealand compared with just 2,000 in 2018.
Studies have shown that many healthcare practitioners considered themselves to be lacking knowledge surrounding the pharmacology, pharmacokinetics and pharmacodynamics of medical cannabis. But with more product registrations from Medsafe in recent months, healthcare practitioners need to ensure they are adequately equipped to provide clinical advice and oversight in the safe management and dispensing of medical cannabis.
The legalities of medicinal cannabis in New Zealand.
Many NZ pharmacists believe that patients need to be referred to a specialist to receive a prescription for medicinal cannabis in New Zealand but this is incorrect.
Since the Medicinal Cannabis Scheme came into effect on 1 April 2020, GPs have legally been able to prescribe CBD, THC or a combination of these products on the proviso they have been manufactured according to current Good Manufacturing Practices (cGMP) and conform to strict quality standards.
However, as these medicinal cannabis products are currently unapproved by MedSafe, they will not be funded by Pharmac, and will be needed to be prescribed under Section 29 of the Medicines Act.
The workings of the endocannabinoid system
Since research tells us that deficiencies in the endocannabinoid system may be the cause of many medical conditions, it’s important that healthcare practitioners pharmacists have a good understanding of how best to support a healthy endocannabinoid system (ECS).
Like other transmission pathways, the endocannabinoid system (ECS) is comprised of receptors, ligands, and transport/degradation proteins. Endocannabinoids are the endogenous ligands that interact with cannabinoid receptors CB1 and CB2. The interaction between endocannabinoids and the CB1 and CB2 receptors help regulate important physiological processes involving the central nervous system, immune system, and metabolism. In fact, CB1 is among the most abundant receptor present in the central nervous system.
Our endocannabinoids e.g., anandamide (AEA) share structural similarities with cannabinoids found in the cannabis plant e.g., tetrahydrocannabinol (THC). By targeting the ECS system, medicinal cannabis extracts can help ameliorate ECS dysfunction and improve symptoms of multiple disorders such as obesity, vomiting, anorexia, multiple sclerosis, pain, inflammation, epilepsy, Parkinson’s disease, Huntington’s disease, Tourette’s syndrome, Alzheimer’s disease, Bipolar disorder, Schizophrenia, Post-Traumatic Stress Disorder (PTSD), depression, anxiety, insomnia, asthma, cardiovascular disorders, glaucoma, and cancer.
There are several online resources available on the ECS including a video Cannasouth has produced that walks you through this.
Where to find more information
Cannasouth has partnered with the Goodfellow Unit to develop a course on Medicinal Cannabis and Chronic Pain which covers the potential value of medicinal cannabis in chronic pain, how to start prescribing, who is likely to benefit, potential side effects and contraindications for prescribing. Upon completion of this short course, you can print your certificate for one (1) Continuing Professional Development (CPD) hour. There are also several more online and on-campus courses throughout New Zealand that can expand your knowledge further.
In addition to professional courses, we encourage you to explore our Clinical Fact Finder, an online suite of resources designed to support healthcare practitioners to quickly and easily find clinical evidence on the use of medicinal cannabis. All research has been fact-checked by Cannasouth’s team of scientists. The Clinical Fact Finder also contains reviews undertaken by Heath Agencies around the world on medicinal cannabis and its use in clinical practice. Here is a short video demonstrating how to use the Clinical Fact Finder.
Finally, at last year’s Medsafe event, Cannasouth received feedback from healthcare practitioners requesting a short guide that details common conditions and which products may be suitable treatment options. If you would like a copy of the guide, please email us at email@example.com and a member of our team will have this sent to you.
Cannasouth enjoys interacting with our social media audience and engaging in thoughtful discussion.
At Cannasouth we encourage an inclusive, informed and engaged online community. We feel fortunate to be involved in the medicinal cannabis industry in New Zealand and know that we have a passionate audience who come from a wide variety of backgrounds, with a vast range of different views and life experiences. We also understand that due to the history of prohibition surrounding medicinal cannabis, many patients and caregivers are frustrated with the history of or continued lack of access to medicinal cannabis products.
Cannasouth operates in a highly regulated sector and is a publicly listed company. We also produce products that are in most jurisdictions, including New Zealand, controlled drugs, or prescription medicines. As such we cannot discuss products specifically or certain company-specific information that may be deemed commercially sensitive. There may be questions that we will not answer in a public forum for these reasons.
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Last updated 17/11/2021
Cannasouth has appointed Tony Clark as Operations Manager of its Cannasouth Cultivation Limited joint venture business.
Mr Clark brings to Cannasouth more than 20 years of engineering, manufacturing, and pharmaceutical industry experience, having worked with Pentair Valves & Controls Pacific Pty Ltd and Douglas Manufacturing Ltd. He is currently the General Manager of Douglas and will join Cannasouth on 20 September 2021.
Clark will manage the company’s state-of-the-art controlled environment agriculture (CEA) sealed greenhouse and headhouse facility in the Waikato, which was recently completed and is now in the final phase of equipment installation and validation.
Cannasouth CEO Mark Lucas says his team is excited to attract talent of Mr Clark’s caliber to the business.
“We are fortunate to have attracted some exceptionally skilled and knowledgeable people to our business. We have assembled a world class team. With our senior executive team now in place, Tony’s appointment represents one of the final pieces of the puzzle.
“Cannasouth Cultivation has an existing team of cultivation and production specialists who have been working closely with our Colorado based partner, Vera Cultivation, on the design and implementation of our commercial cultivation operations. Tony’s appointment as Operations Manager will be key to providing leadership and expertise across all aspects of our cultivation business.
“The design of our innovative facility represents the next generation of cannabis cultivation operations. It has been set up to produce premium pharmaceutical quality biomass at a highly competitive production cost, whilst being more energy efficient and environmentally sustainable than indoor cultivation operations.
“Tony understands the importance of a culture that prioritises the health and safety of its people. He will also provide leadership to environmental sustainability and responsibility, which are key values of Cannasouth.”
Mr Clark’s first priority will be preparing for a successful first commercial scale harvest scheduled for the end of this year. He will also be focused on leading the team towards achieving Good Agricultural and Collection Practices (GACP) and Good Manufacturing Practice (GMP) Certification. There is strong global demand for premium pharmaceutical quality cannabis flower, which will provide lucrative export opportunities for Cannasouth.
Mr Clark says Cannasouth is at the forefront of an emerging industry and he is excited to be joining the team.
“Cannasouth’s priority is to improve patient access to medicinal grade cannabis products that contribute to better health outcomes for New Zealanders. I am looking forward to being part of the team that will make that happen.”
Last week, Cannasouth released its plans to purchase the remaining 50% stake in Cannasouth Cultivation Limited it does not already own from Aaron Craig and his family interests.
Leading medicinal cannabis company, Cannasouth Limited has today entered into two conditional agreements to acquire the balance of the stakes that it does not already own in its cultivation and manufacturing joint venture businesses.
Acquisition of outstanding interest in Cannasouth Cultivation Limited
Cannasouth has entered into a conditional agreement with Aaron Craig and his family interests (Craig Family Interests) to acquire the remaining 50% stake in Joint Venture business Cannasouth Cultivation Limited that Cannasouth does not already own.
Cannasouth Cultivation has built a state-of-the-art growing and processing facility that will produce medicinal cannabis flower biomass at highly competitive production cost. It is energy efficient and more environmentally sustainable than indoor cultivation operations.
The facility, designed to produce premium Good Agricultural and Collection Practices (GACP) and Good Manufacturing Practice (GMP) pharmaceutical compliant biomass, is now in the equipment installation and validation phase. It is anticipated that the new facility will have sufficient capacity to generate circa $8 million of revenues per annum (based on conservative current global pricing), subject to Cannasouth Cultivation securing commercial offtake agreements and completing quality certification. The facility has been designed to be scalable.
Cannasouth Chief Executive Mark Lucas says, “There is strong global demand for premium pharmaceutical quality cannabis flower. The timing of the acquisition will bring all future revenues generated from the cultivation facility into the Cannasouth Group’s P&L. It also enables the Company to control all aspects of the cultivation operation.
“Cannasouth would like to take this opportunity to thank the Craig Family interests for their support and expertise as a valued joint venture partner in developing the innovative cultivation facility to such a high standard and in a cost-effective manner.”
The acquisition of the outstanding interest in Cannasouth Cultivation is conditional on the Company raising new capital by 30 September 2021through a capital raising initiative. Settlement for the acquisition of Cannasouth Cultivation is expected to happen shortly after this capital raise condition has been met.
Acquisition of outstanding interest in Midwest Pharmaceutics NZ Limited
Cannasouth has also entered into a conditional agreement with Mark Balchin and Greenmeadows Health Limited to acquire the remaining 40 per cent shareholding in Hawkes Bay-based Midwest Pharmaceutics NZ Limited that it does not already own.
Currently Cannasouth owns 60% of Midwest. The business generates circa $2 million per annum in revenues, which after the completion of the transaction will be consolidated into Cannasouth’s P&L from the date of acquisition.
Mark Lucas says, “The Midwest acquisition provides Cannasouth with the opportunity to streamline operations and generate additional revenues from existing operations, while positioning the business for GMP certified medicinal cannabis manufacturing.”
CEO of Midwest, Mark Balchin, will continue as Chief Manufacturing Officer for the Group.
The Midwest transaction is conditional on the parties obtaining the approvals of several landlords and regulators to the change in control of Midwest on or before 31 August 2021.
Commercial Benefits of the Acquisitions
- Take 100 per cent control of both joint venture cultivation and manufacturing businesses.
- Accelerate pathway to significant revenue generation.
- Improve operational efficiencies across the Group.
- Post-acquisition revenues and 100 per cent of future profits will be consolidated into the Cannasouth Group P&L.
- Opportunity to generate additional revenues from existing operations at Midwest while positioning the business for GMP certified medicinal cannabis manufacturing.
Cannasouth is proposing a capital raising to fund the acquisitions. The Company is currently finalising its capital raising strategy and will release details to the market in due course.
Cannasouth Limited has released a Medicinal Cannabis Industry Update.
The update is designed to share information about the emerging medicinal cannabis industry both in New Zealand and globally; the opportunities and challenges facing industry players, the New Zealand regulatory environment, and the barriers to entry.
CEO Mark Lucas says: “There is a lot of confusion and a lack of understanding about what is a highly complex and regulated industry. Releasing this update is an opportunity for Cannasouth to share its knowledge and expertise and provide our investors, stakeholders and the wider public with some clarity around the myths and misconceptions of the industry.”
The update is presented in 8 sections:
2. Products and Services
3. Product Quality: Pharma Vs non-Pharma
4. Patients: Challenges and Opportunities
5. Geographic Markets
6. Cultivation and Pharmaceutical Manufacturing
7. Regulatory Environment in New Zealand
8. Closing Remarks
Cannasouth is preparing a follow-up to this update. This information will focus on how it is working to create genuine advances in the medicinal cannabis industry, insight into Cannasouth’s growth strategy, timelines for implementation, and exploring the competitive advantage that makes it a leader in the New Zealand market.
The comprehensive document is available to view and download here:
Download 2021 Industry Update
Cannasouth has recently been approved for a new Fellowship Grant from Callaghan Innovation to support a Masters research study in conjunction with the University of Waikato to create a library of cannabis-derived biomolecules.
The cannabis plant contains several hundred known molecules and likely many more unique and as yet unidentified compounds of interest. This library of biomolecules can be used in computational molecular docking studies allowing Cannasouth to investigate potential pharmacological activity of selected molecules prior to undertaking complex chemical extraction and isolation processes of these minor compounds. This approach aids fast-track assessment of new compounds in terms of safety and efficacy leading to the potential for new medicines and Intellectual Property.
Chief Science Officer David Gill says, “it is important to build strong, focussed, scientific collaborations with our leading academic institutes and these grants enable Cannasouth to undertake cutting edge research into next generation cannabis related therapeutics in parallel with our goal of delivering products to the patients who need them now.”
Cannasouth is also conducting a neuropathic pain / drug delivery PhD project with support from Callaghan Innovation. In addition, Cannasouth recently completed a Masters research study focusing on Tissue Culture research providing Cannasouth with new knowledge related to micropropagation techniques to support commercial growing activities. The Masters student has since been employed in a new R&D role supported by a Callaghan Innovation Careers Grant.
CEO Mark Lucas says, “Cannasouth actively works with government agencies such as Callaghan Innovation to support research and development opportunities both in-house and with our research partners. We are pleased to be part of developing future generation scientists of New Zealand and offer them a career pathway in the emerging medicinal cannabis industry.
“It is rewarding to know that Callaghan is funding these research activities to create opportunities to discover unique IP and help advance this emerging industry sector in New Zealand.”
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The range of conditions that can be managed with medical cannabis is increasing exponentially, this article aims to give a brief overview of what the basics of medical cannabis are, which illnesses it may help, and how it is prescribed.
Are you a doctor considering prescribing cannabis? or a patient suffering from a medical issue that cannabis can help manage? Would you like more information on medical cannabis? If you answered “yes” to any of these questions, read on.
What is medical cannabis?
In very simple terms, medical cannabis is prescribed specifically to alleviate the symptoms of an illness. In New Zealand, medical cannabis needs to be prescribed by a doctor for a particular condition.
The therapeutic properties of the cannabis plant come mainly from the cannabinoids naturally occurring in the plant. There are between 80 and 144 cannabinoids present in the cannabis plant- the two main cannabinoids that have been found to have therapeutic effects are tetrahydrocannabinol (THC) and cannabidiol (CBD). Many of the therapeutic effects of THC and CBD are thought to be the result of their interactions with the endocannabinoid system.
The endocannabinoid system (ECS) is a complex cell-signaling system discovered in the 1990s. As a result of this discovery, it was found that the ECS regulates multiple physiological processes involving the immune system, the nervous system, and metabolism. It also discovered cannabinoid receptors (CB1 and CB2) are scattered throughout your central and peripheral nervous system. Additionally, it found that naturally occurring cannabinoids (endocannabinoids) bind to the CB1 and CB2 receptors to exert an influence on various physiological processes. Furthermore, it was established that exogenous cannabinoids such as THC and CBD were able to bind to cannabinoid receptors in a similar way to endogenous cannabinoids.
THC is responsible for the ‘high’ often associated with cannabis due to its psychoactive properties. CBD does not create a ‘high’ and, when taken in conjunction with THC, can mitigate some of THC’s negative effects such as anxiety.
Medical cannabis can be specifically formulated to contain different ratios of THC:CBD allowing prescribers to tailor each patient’s treatment depending on their condition. This is in contrast to recreational cannabis, which is unregulated, and often contains very high levels of THC in order to maximise the ‘high’.
What conditions can medical cannabis treat?
The list of conditions that have shown benefits from medical cannabis is growing rapidly as more and more research is being published. Therefore, the following list will grow considerably as the plant is more widely studied and prescribed.
There is currently evidence for the use of medical cannabis for the following conditions:
|There is ample clinical evidence for the use of medical cannabis in the management of refractory epilepsy, especially in childhood.|
Multiple sclerosis (MS)
|There is clinical evidence for the use of medical cannabis in the management of the pain and spasticity of MS as well as the urinary dysfunction associated with MS.|
|There is pre-clinical and clinical evidence to show that medical cannabis alleviates the pain associated with osteoarthritis.|
|There is clinical evidence supporting the use of medical cannabis in the management of chronic pain (cancer and non-cancer chronic pain) as well as painful spasticity. Medical cannabis may also have opioid-sparing properties in the management of chronic pain.|
|There is clinical evidence to support the use of medical cannabis in the following psychiatric disorders: anxiety, social anxiety, insomnia, post-traumatic stress disorder, and schizophrenia (as adjunctive therapy).|
Chemotherapy-induced refractory nausea and vomiting
|There is clinical evidence that shows medical cannabis can decrease the symptoms of nausea and vomiting associated with chemotherapy.|
|Medical cannabis has been shown to assist with improving sleep quality, decreasing sleep disturbances, and decreasing sleep onset latency.|
Weight gain in patients with cancer, HIV, or undergoing palliative care
|Some benefit has been shown in using medical cannabis to assist with increasing appetite in patients with cancer or HIV.|
|In vitro and preclinical trials have shown inhibition of the growth of certain tumour cells in response to cannabinoids.|
Rheumatoid arthritis (RA)
|Preclinical trials have indicated a place for cannabinoids in the management of RA as a result of their anti-inflammatory properties.|
Chronic pruritus (associated with contact dermatitis, atopic dermatitis, eczema, psoriasis)
|Multiple pre-clinical and some preliminary clinical trials have shown medical cannabis to be effective in reducing intractable pruritus.|
The range of medical conditions that respond to medicinal cannabis is likely to increase as further research takes place.
Prescribing medical cannabis
Currently, medicinal cannabis is available in New Zealand only on a doctor’s prescription. According to the BPACNZ better medicine website, as of 1 April 2020, any practitioner can now prescribe any medicinal cannabis product. These products must meet the minimum quality standards set by the Medicinal Cannabis Agency and can be prescribed for any indication within their scope of practice and where there is a clinical need.
It is important to remember the maxim ‘start low, go slow’ when initiating treatment with medical cannabis.
What to look for when prescribing medical cannabis products
The specifications surrounding the production and manufacture of medical cannabis in New Zealand stipulate that the products must comply with Good Manufacturing Practices (GMP). Therefore, these products are amongst the highest quality medicinal cannabis products available globally. This means that all registered products are extremely well-regulated. Therefore, registration of a product by Medsafe ensures that there is adequate safety and efficacy data available for the product.
There is more than just safety and efficacy to consider when prescribing medical cannabis, however.
The following also need to be considered:
- Start low and go slow: It is important to remember the maxim ‘start low, go slow’ when initiating treatment with medical cannabis. Tolerance to THC is patient-dependent depending on a range of factors including age, metabolism, pre-existing illnesses/medications, and prior THC use. Therefore, starting at a low dose and titrating up as necessary to achieve the desired result ensures that any potential side effects are avoided or minimised.
- Delivery method: Medical cannabis products come in various delivery methods, such as oils, sublingual sprays, capsules, creams, etc. Therefore consider what is available, which delivery methods are acceptable and which delivery methods are most efficacious for the medical condition being treated.
- Formulation: Medical cannabis can potentially come in different ratios of THC:CBD. Ideally, one would want to be able to choose from the following: a high THC: low CBD ratio, a balanced THC:CBD ratio, and a high CBD: low THC ratio, depending on what medical condition is being treated. It is also useful to have CBD-only formulations for those patients who are wary of THC or when THC is contraindicated. The following table can give an indication of various uses of different ratios of THC:CBD:
- Cost: Certain medical cannabis products on the market are prohibitively expensive, so check the cost before making a decision on a product.
Ratio of THC:CBD
Moderate pain, e.g. arthritis type pain
|Choosing a high CBD:low THC ratio allows for pain relief without impacting functioning or mental acuity.|
Severe pain, e.g. neuropathic pain and cancer pain
|Severe pain responds better to either balanced THC:CBD formulations or formulations with a higher THC:lower CBD ratio. When using a higher THC component, remember the ‘start low, go slow’ principle as patients will all have a different tolerance to THC depending on age, metabolism, prior THC use etc.|
|Anxiety responds better to a balanced THC:CBD ratio or a higher CBD:lower THC ratio. In addition, CBD alone is also effective for the management of anxiety.|
|THC has well-recognized sedating effects but can possibly increase anxiety. Adding CBD can mitigate increased anxiety. Therefore you could choose either a balanced THC:CBD formulation or a higher CBD: lower THC formulation.|
Chemotherapy induced nausea and vomiting
|Choose a balanced THC:CBD or higher THC:lower CBD formulation.|
Spasticity (especially related to MS)
|Studies were done using a balanced THC:CBD formulation (1:1 ratio).|
How safe is medical cannabis?
It is reassuring to know that medical cannabis is well-tolerated and generally considered safe. Furthermore, a 2020 review of the scientific evidence for the use of THC:CBD oromucosal spray for the management of chronic pain showed no new safety concerns with long-term THC:CBD use. The review also showed no evidence of dependence. This finding supported the findings of a 2019 study that found medical cannabis, especially CBD-only formulations, to have minimal side effects.
Although medical cannabis is a very safe option for most people, there are some contra-indications to be aware of. THC and CBD are metabolised via the cytochrome P450 (CYP450) pathway. As a result, medical cannabis is contraindicated in people with disorders of CYP450 enzymes.
Medical cannabis can interact with certain medications so care should be taken when medical cannabis is prescribed with any of the following medications: warfarin, ketoconazole, clobazam, theophylline, olanzapine, and clozapine, opioids, anticholinergics, and certain antihistamines.
Patients can use medicinal cannabis for the treatment of a growing list of medical conditions. Due to that growth, this list will likely expand as more research is published. Furthermore, medical cannabis is considered safe and is generally well-tolerated with little risk of dependence.
The strict regulations in place around the registration of medical cannabis products in New Zealand should ensure that doctors feel confident when prescribing medical cannabis that they are prescribing a safe and efficacious product. You should take care when prescribing to choose the optimum delivery method and formulation specific to your patient.
Pain is the number one indication treated by medical cannabis, with over 70% of prescriptions made for pain-related symptoms.
Now that patients can legally access medical cannabis in New Zealand, it’s more important than ever for doctors to understand how cannabis works for pain.
Here’s everything you need to know.
What is medical cannabis?
The term “medical cannabis” refers to cannabis products containing the cannabinoids tetrahydrocannabinol (THC), cannabidiol (CBD), or a combination of both, specifically used for the management of medical conditions. Medical cannabis can also refer to synthetic cannabinoids and “minor cannabinoids” such as cannabigerol (CBG) and cannabinol (CBN).
Cannabis sativa contains around 113 chemical compounds known as cannabinoids. The most commonly known and studied of these are THC and CBD. THC is responsible for, among other effects, the intoxicating and psychoactive effects of cannabis. CBD does not have the same intoxicating “high” like THC. When taken together at suitable ratios, CBD may mitigate some of the intoxicating effects of THC.
Although this article primarily looks at medical cannabis to alleviate pain, it has been widely studied and has shown to be effective in helping with a wide range of other medical conditions as well.
How medical cannabis works to alleviate pain
Extensive preclinical and a few clinical studies suggest promising pain-relieving properties of THC and CBD. Until recently, studies assessing the use of medical cannabis were limited due to legal and accessibility issues surrounding medical cannabis. As the use of medicinal cannabis is legalised and becomes more widespread, more extensive clinical trials will likely be performed. These will help to determine the efficacy and safety of medical cannabis.
Animal models show medical cannabis has significant analgesic (pain-relieving) effects on inflammatory, neuropathic and arthritis-related pain. Many of these studies have investigated the mechanism of action of THC and CBD in pain relief.
Researchers believe it is primarily through the interaction with the endocannabinoid system (ECS) that medical cannabis works to reduce pain.
The ECS is a complex biological system comprised of cannabinoid receptors (CB1 and CB2) that regulates many physiological processes, including immunity, appetite, metabolism, and more.
How THC can alleviate pain
THC acts in a similar way to endogenous endocannabinoids to activate the CB1 and CB2 receptors, which is how it’s thought to affect pain.
Activation of the endocannabinoid system by THC causes the inhibition of ascending nociceptive transmission (pain perception). It also causes the activation of the inhibitory descending pain pathways and the modulation of the emotional component of pain. This happens through the activation of CB1 receptors in the limbic and cortical areas of the brain. The overall effect is to decrease the patient’s sensation of pain.
In chronic pain conditions, there is often increased sensitisation to pain. The increased sensitisation means that the more pain individuals experience, the more sensitised they become to feeling pain. This becomes a pain cycle that is hard to break.
Activation of peripheral and central CB2 receptors modulate immune and inflammatory responses, leading to neuronal sensitisation inhibition in chronic pain. THC can intercept the cycle of increased pain sensitisation.
How CBD can alleviate pain
The interaction of CBD on the endocannabinoid system is not as straightforward.
CBD is an allosteric inhibitor of THC binding to CB1. That means CBD modifies how THC binds to CB1 receptors to lessen THC’s stimulatory effect on the receptors. Through this mechanism of action, CBD, when combined with THC in medical cannabis, alleviates the psychoactive effects of THC; lessening the “high” patients might feel.
CBD is an inverse agonist of CB1 and CB2. This means that when CBD binds to CB1 and CB2 receptors, it inhibits rather than activates them.
Typically, activation of CB2 leads to cytokine release, which causes the migration of immune cells to target sites. This is part of the normal inflammatory pathway and is necessary for normal immune function, wound healing, and more.
However, it becomes problematic when the inflammatory response is exaggerated, as it is in certain pain conditions such as arthritis. CBD binding to the CB2 receptor inhibits the inflammatory response, decreasing inflammation.
There are secondary pathways by which CBD can decrease pain. Some of the analgesic effects of CBD are mediated by the activation of the serotonergic 5HT1a receptors, key mediators in anxiety and depression. This pathway is important when considering the link between pain and depression.
CBD has also been shown to have sleep-promoting effects, which also plays a role in pain reduction and increases the quality of life of people suffering from painful conditions.
Conditions medical cannabis may treat
Multiple Sclerosis (MS) is a degenerative disease that affects the central nervous system, especially the brain, the spinal cord, and the optic nerves. Symptoms can range from mild visual loss and weakness to severe, debilitating muscle spasms, loss of mobility, and paralysis.
Many clinical trials support medicinal cannabis in the treatment of the pain and spasticity associated with MS. A 2020 review of over 33 studies and 7500 patients found adequate data to support the safe and effective use of medical cannabis at a THC to CBD ratio of 1:1 for alleviating pain and spasticity in MS patients.
Neuropathic pain is pain resulting from nerve damage. Often described as a severe burning sensation, it can result from trauma, diseases (e.g. diabetes, thyroid disease), or medication. It is also largely intractable pain and is notoriously unresponsive to standard pain medication.
A 2020 review of the use of medicinal cannabis in the management of pain found the most evidence to support its use in chronic neuropathic pain. Medical cannabis could be a welcome option for many who are unable to treat chronic neuropathic pain.
The pain from arthritis is a combination of inflammatory, nociceptive, and neuropathic pain. The articular cartilage of joints breaks down in patients with rheumatoid arthritis and osteoarthritis (primarily mediated by proinflammatory cytokines). Animal models have shown cannabinoids are effective in reducing joint damage from the breakdown of cartilage.
A 2019 review found a potential for the use of cannabinoids in managing rheumatoid arthritis by using a targeted receptor approach. Further clinical trials are required in this area to understand its full potential.
A 2020 review of cannabinoid use in cancer patients showed promise for medical cannabis in the management of cancer pain. The results showed improved pain scores in patients with advanced-stage cancer when medical cannabis with a THC:CBD ratio of 1:1 was added to opioid treatment. An observational study also showed an improvement in pain and the quality of life. However, it was also mentioned that there is a need for further high-quality randomised controlled trials to adequately define the role of medical cannabis in managing pain in cancer patients.
Medical cannabis has not only been used directly for cancer pain but has also been used successfully in alleviating the side effects of chemotherapy. There is good evidence to show that medical cannabis can reduce nausea and vomiting associated with certain chemotherapy treatments. It can also help counteract the loss of appetite and wasting (cachexia) that many cancer patients suffer from.
Importantly, across all reviewed studies in patients with cancer-related and non-malignant pain who were using daily THC:CBD for an extended period, there were no new safety concerns identified. There was also no evidence of the development of tolerance to the medication i.e. the dose did not have to be increased with extended periods of use in order to have the same effect.
Opioid-sparing effect of medical cannabis
Opioids are usually the drug of choice for chronic, severe pain when first-line pain options (paracetamol and non-steroidal anti-inflammatories) have proved ineffective. Although opioids are effective, they come with a host of risks and side-effects. Most concerning, is their addictive potential, with up to 1 in 4 patients in primary care who have been prescribed opiates developing dependence.
Even without addiction, opiates have many unwanted and intolerable side-effects such as constipation, nausea, drowsiness, itching, depression and tolerance (meaning that with time, you need a continually higher dose to achieve the same level of pain control).
Medical cannabis has been shown to be opioid-sparing. This means that if a patient is already on opioid medication, by adding medical cannabis the patient is able to decrease their dose of opioids. This decreases both side-effects and the risk of dependence.
The bottom line
There is a growing body of evidence to support the use of medical cannabis in the management of pain. This is only likely to increase going forward as further legal restrictions on the use of medicinal cannabis are lifted.
Traditional methods of pain management come with many unwanted risks and side-effects and can often be lacking in efficacy. Medical cannabis could well fill the gap in pain management left by existing pain medications.