Introduction
The global position
Continent | Country | Year approved | Notes |
---|---|---|---|
North America | 1996-2017 | Cannabis illegal under federal law, individual states have legalised to varying degrees Medical use: -Legalised by 33 states -FDA has approved dronabinol (Marinol ®, Syndros® ), nabilone (Cesamet ®,) and cannabidiol (Epidiolex ®) (CBMs) for specific indications, but cannabis plant not FDA approved Recreational use: -Legalised by 10 states (Alaska, California, Colorado, Maine, Massachusetts, Michigan, Nevada, Oregon, Vermont, Washington) and District of Colombia for recreational use -Illinois to be legalised January 1 2020 -Multiple states have bills in session to legalise recreational and medicinal cannabis and its products -“Decriminalised” in numerous states (ie avoid jail term) | |
1999/2018 | Medical use: -Regulated by federal government -Healthcare practitioner authorisation required -Patients can access cannabis through federally licensed seller, designate someone to produce, or grow their own. Recreational use: -Cannabis for recreation legalised October 2018 under Cannabis Act -Cannabis act permits sale of cannabis oil, fresh cannabis, dried cannabis, cannabis plants and seeds -Retailers must be authorised to sell cannabis | ||
2017 | Medical use: Cannabis use allowed for medical and scientific purposes Application required for import and use of cannabis and CBMs for medical purposes Products with < 1% THC recently marketed under Government authorisation with no prescription required | ||
South America | 2013 | Medical use: -Prescription required for CBM for medicinal use -Medicinal cannabis not authorised to be sold -CMs accessible via specialist prescription Recreational Use: -Cannabis legalised and market regulated from December 2013 with strict controls | |
Chile (Aguilar et al. 2018) | 2015 | Medical use: -Medical prescription required for medicinal cannabis -CBM can be imported under special license | |
2014 | Medical use: -Imports of medications based on CBD oil for medical and therapeutic use for patients with prescription allowed -Nabiximols (Sativex ®) licensed for MS -Cannabis plant prescription prohibited | ||
2017 | Medical use: -Prescription and government authorisation required through ministry of health -State produced pharmaceuticals for domestic market -Cannabis oils legal for import | ||
Oceania | 2016 | Medical use: -cultivation, manufacture, prescribing and dispensing of medicinal cannabis products for patients now legal -Access via authorised prescriber program, or special access scheme on individual patient basis. Must be prescribed -Cannabis, THC, nabiximols (Sativex ®), dronabinol (Marinol ®), nabilone (Cesamet ®, Canemes ®) listed under schedule 8, require prescription -Cannabidiol listed under schedule 4, requires prescription | |
1977 | Medical use: -Prescription required for most cannabis-based products, some require ministerial approval -Nabiximols (Sativex ®)and CBD based products available without ministerial approval -Bill currently passing through NZ parliament to improve access | ||
Europe | 2000 | Medical use: -Medicinal use legalised in 2000 -Office of Medicinal Cannabis government agency responsible for supplying medicinal cannabis to pharmacies, prescription required -5 compositions produced, with varying strengths of THC and CBD Recreational use: -Illegal, but smoking cannabis under strict conditions allowed | |
2017 | Medical use: -Medicinal cannabis products able to be prescribed by physician -CBMs included in range of medications covered by public and private health insurance | ||
Poland (Aguilar et al. 2018) | 2017 | Medical use: -Medicinal cannabis sold in registered pharmacies. -Patients need permission from pharmaceutical inspector and physician | |
2013 | Medical use: -Law changed to allow marketing authorisation of products containing cannabis or its derivatives -Dronabinol (Marinol ®) approved and marketed -Nabiximols (Sativex ®) approved but not marketed due to price disagreements | ||
Medical use: -Cannabis for medical use access programme enables prescribing of Cannabis for medical use by Medical Consultant -Authorised CBMs (nabiximols (Sativex ®) , dronabinol (Marinol ®), nabilone (Cesamet ®, Canemes ®) should be used in first instance with prescription -Cannabis (plant or extracts not authorised as medicine) considered as treatment option -Cannabidiol (Epidiolex ®) not currently authorised | |||
2018 | Medical use: -CBMs recently rescheduled, only available via prescription from doctor on the specialist register -Nabilone and Nabiximols (Sativex ®) currently licensed but the latter is not approved by NICE -Dronabinol not available as a licensed medicine -Cannabidiol not classed as CBM, and not controlled. Epidiolex® currently in licensing process. -NICE draft guidance for prescription of CBMs currently open for public consultation | ||
Middle East | Israel (Aguilar et al. 2018) | 1992 | Medical use: -Medical Cannabis Unit established for the regulation of Cannabis -Specialist physicians apply for Medical Cannabis permit on behalf of patient - > 40,000 patients receiving medicinal cannabis |
Asia | Japan (Aguilar et al. 2018) | Prohibited | |
Pakistan (Aguilar et al. 2018) | Prohibited | ||
2016 | Medical use: -Cannabis allowed with prior authorisation from a doctor and treatment delivered in dedicated centres -Covers all forms of Cannabis, no specific mention CBMs | ||
Medical use: -Legal provisions for medicinal use yet to be implemented -Council of Scientific and industrial research currently undertaking research into medical benefits | |||
Africa | 2018 | Medical use: -Special authorisation from Medical Control Council by physician can be requested for prescription of medicinal cannabis products -Cannabidiol preparations excluded from Medicines and related substances act |
Definitions of cannabis and cannabinoids
Cannabis
Cannabinoids
Group | Where found | Major known Compounds | Substance found in | Trade name | Route of administration | Current uses |
---|---|---|---|---|---|---|
Endo -cannibinoid | Endogenous within body | -Arachidonoyl ethanolamide (Anandamide) -2-arachidonylglycerol (2-AG) -Docosatetraenoyl-ethanolamide (DEA), -N-arachidonyldopamine (NADA), -Virodhamine, -2-arachidonylglyceryl, -noladin ether -dihomo- gamma-linolenoylethanolamide (HEA). | ||||
Synthetic cannabinoids | Chemically synthesised | Synthetic THC -(-) trans isomer of delta 9 THC | Dronabinol | Marinol® | Oral capsule (formulated in sesame oil) | US; FDA approved; -anorexia associated weight loss in AIDS patients -chemo induced nausea and vomiting * UK; not available |
Syndros® | Liquid formulation | US; FDA approved - anorexia associated weight loss in AIDS patients -chemo induced nausea and vomiting * | ||||
Synthetic THC analogue (single molecule) | Nabilone | Cesamet® | Oral capsule | US; FDA approved chemo induced nausea and vomiting UK; -chemo induced nausea and vomiting * | ||
Variety; mainly aminoalkylindole derivatives ie JWH-018, UR-144, PB-22 | Legal highs | Spice, K2, eclipse | Oral Smoked | |||
Phyto -cannibinoid (plant derived) | Cannabis genus; -cannabis sativa, -cannbis indica -cannabis ruderalis | THC content varies 1-22% CBD content varies 0.05-9% | Cannabis; Marijuana | Inhalation (commonly smoked) | UK; Illegal US; legalised for medical use in 29 states, recreational use in 9 states | |
THC content varies 1-22% CBD content varies 0.05-9% | Cananbis; Hashish | Oral | UK; Illegal US; legalised for medical use in 29 states, recreational use in 9 states | |||
Pure CBD (no psychoactive properties) | Cannabidiol | Oral capsule Oromucosal spray | ||||
Epidiolex | Oil | US;FDA approved for treatment resistant epilepsy | ||||
2.7mg THC and 2.5mg CBD per spray | Nabiximols | Sativex® | Oromucosal spray | US; not approved. Approved in 30 other coutnrie UK; MHRA but not NICE approved. MS induced spasticity | ||
2.5mg THC, 1.25mg CBD | Cannador | Oral capsule | German based research only |
Pharmacology of cannabinoids
Mode of action
Opioid system interaction
NMDA system interaction
Gamma amino butyric acid
Pharmacokinetics
Absorption
Distribution
Metabolism
Elimination/excretion
Pharmacodynamics (of relevance to the perioperative physician)
Cardiovascular system
Central nervous system
Respiratory system
Interactions of note for the perioperative physician
Induction agents/volatiles
Opioids
Ketamine
Gabapentinoids
Dexmedetomidine
Medical conditions where cannabinoids are recommended
Chronic pain
Nausea and vomiting secondary to chemotherapy
Multiple sclerosis
Epilepsy
Other
Evidence of benefit | Condition |
---|---|
Moderate | -Improving short-term sleep in sleep disturbance associated with OSA, Chronic pain, MS |
Limited | -Improving symptoms of post-traumatic stress disorder, anxiety -Improving appetite and decreasing weight loss associated with HIV/AIDS -Tourette syndrome |
None | -Treatment of cancer -Irritable bowel syndrome symptoms -Neurodegenerative conditions -Addiction |