Using cannabis flos originating from controlled producers means patients are assured there is no biological or toxicological contamination.
In the Netherlands cannabis flos is produced under strict quality conditions by the government licenced company Bedrocan.
Administration by vaporization
Aside from eliminating the harms from smoking, what are the benefits of administration by vaporization?
With vaporization cannabis flos is heated to a specific temperature without burning it. Cannabinoids and terpenes are released in a vapour which is directly inhaled.
There are three main advantages of administration by vaporization is that it:
- allows for exact dosing,
- leads to a rapid effect, and
- avoids the disadvantages of smoking (i.e., no tar, ammonia, carbon monoxide).
What do patients say about the administration of cannabis flos by vaporization?
Using vaporized cannabis flos is the preferred means of use by most patients, especially when compared with an oral application. This is due to the more rapid effect by inhalation.
For some years the vaporizers where reimbursed by Dutch health insurance, thereby eliminating the threshold of a financial burden for the patient.
Thinking about a first consultation with a patient, how do you start a conversation about cannabinoid therapeutics?
There are two types of discussion around the use of cannabinoids:
The elderly, cannabis naive patient:
An elderly cancer patient may be hesitant to use cannabis as a medication. This likely is related to prejudices about cannabis being a product for ‘recreational’ use. With these patients, I rarely discuss the use of these medicines during a first consult. If the patient is eligible and several other therapies did not provide sufficient pain relief, I then mention cannabinoid therapeutics as a possible option. This allows the patient and his/her family to contemplate that treatment option until the next appointment.
The experienced patient:
There may be patients who have extensive experience using cannabis recreationally. They may be actively looking into cannabinoid therapeutics as a potential adjunct to their pain therapy. These patients emphasise the ineffectiveness or side effects of other therapies, and may push clinicians towards prescribing a cannabis product. With these patients the topic must be discussed fully during a first consult. The main question during this consult is are they at all eligible to receive cannabinoid products.
Are you aware of patients experiencing interactions with cannabinoid therapeutics and other medicines?
Indeed, we do see patients who experience drug interactions using cannabinoids alongside other CNS depressant medications (e.g. opioids).
Sedative effects can be enhanced especially in the geriatric population. Severe drowsiness and hallucinations can also be provoked.
Aside from drug interactions, the smoking of cannabis is related to an increased risk of myocardial infarction and stroke. Cannabis as a trigger of myocardial infarction is plausible, given its cardio-stimulatory effects, which may cause ischemia in susceptible hearts. Carboxy-hemoglobinemia from the smoking of cannabis may also contribute to ischemia. Smoking is never recommended.
Do you encounter diversion for misuse or the abuse of cannabinoids? How do you identify this issue in your practice?
During the period when Dutch health insurers widely reimbursed medicinal cannabis, we had frequent discussions with patients, best described as ‘recreational users’, about their eligibility.
Patients of this group, who were already using large amounts of cannabis, were requesting access for rather dubious indications. Some patients were seeing it as a cheap way to get a ‘recreational drug’ which they were already abusing.
How do you deal with diversion for misuse or abuse in your practice?
This patient group can be quite challenging. They may put pressure on clinicians to prescribe cannabinoids as the only means to relieve their pain. Mentioning misuse and abuse can provoke abrupt reactions.
Clinicians should be coherent in prescribing cannabinoids only for indications with enough evidence for beneficial effects (e.g. analgesic for neuropathic pain, appetite stimulation etc). Misuse and abuse should be discussed openly if they become apparent.