Medicinal cannabis

The term medicinal cannabis is commonly used by patients who consume cannabis to treat one or more of their symptoms. In that case, medicinal refers to the intended use as a medical treatment, as contrasted to the recreational use, where cannabis (marijuana) is consumed as an intoxicant. However, there is another way to use this term, which is more related to the world of medicine and pharmaceuticals. Under that definition, medicinal means that the product is of pharmaceutical quality, and that its exact contents are known.

What is quality control

By knowing the quality or composition of a medicinal product, its effects on specific groups of patients may become more predictable. Also it reduces the risk of harmful substances being present in the medicine. Quality control is the process of performing a series of tests to guarantee that a medicine has been checked before you buy it.

In some cases, the only thing needed to test the quality of medicinal cannabis is your own senses: your eyes, smell, and taste can give a lot of information for a first screening. Many patients can identify the potency of different cannabis strains simply by consuming it. Hair, insects and other solid particles can easily be spotted with the naked eye. And a major mold contamination can be identified by using a microscope and your nose.

Unfortunately, some of the bigger threats to your health can only be seen with specialized testing. For example, pesticides, heavy metals and certain fungal contaminations can only be visualized by proper lab testing. Also the exact chemical composition of the active ingredients can only be determined by laboratory tests.

Potency testing for THC, CBD and CBN

Clearly, one of the most important aspects of your medicinal cannabis is the potency. Each patient is looking for a cannabis variety that works best for his or her symptoms, and the potency is an important guide to help make the decision of what to buy. Once you know the most suitable potency-range for you, it is easier to find the right type of cannabis the next time you visit the dispensary.

The cannabinoid profiles provided by MBA are accurately determined by a specialized laboratory. Scientific and clinical research has shown that these two components of cannabis are responsible for many of its medicinal effects. A third important cannabinoid is CBN, which is a degradation product of THC. A higher concentration of it indicates that the cannabis is old or has been stored improperly. The concentration of CBN should therefore always be as low as possible.

Cannabinoid concentrations are expressed in percentage on a weight-to-weight basis. For example, a THC content of 10% means that 10% (or 1/10^th) of the weight of the sample is pure THC. In other words, one gram of that type of cannabis contains 100 milligrams (0.1 gram) of THC. In a similar way, the content of CBD and CBN can be calculated.

Impurities, the unwanted components of cannabis

When the cannabis plant is cultivated, contaminants may be intentionally or unintentionally added. Contamination can surface in any cultivation technique in any of three stages; in cultivation, storage and/or in retail. When such contaminants are present in a medicinal product, they are referred to as impurities.

During cultivation, intentionally added impurities include chemicals intended to enhance plant growth or for pest and disease control (pesticides, fungicides). Clearly, many of these chemicals may be harmful to people when ingested. Unintentional contamination may occur when plants are grown in soils high in heavy metals such as copper or cadmium, which are absorbed through the roots of the plant.

During cultivation or storage, certain types of molds and fungi may unintentionally grow on the plant. These molds are often of the species Aspergillus, Streptococcus or Penicillium, all of which may be harmful to human health. This type of contamination has been positively identified in cannabis from Dutch coffee shops. Bacteria may be transferred by human or animal contact, even when strict hygienic measures are in effect.

Finally, some substances can be added by retailers to increase the weight of the plant and mimic the appearance of greater potency, such as glass beads or lead particles. These occurrences although rare, have resulted in hospitalizations in several countries.

Quality is a choice

Although medicinal cannabis is not an FDA approved drug, it is obviously important to constantly improve the quality of it. The MCSC is working on this by setting up a system of self-regulation for greater quality control of medicinal cannabis products. Fortunately, proper laboratory testing can detect almost all of the impurities mentioned here, preventing them from ending up in the dispensary. However, most of these tests are relatively costly and they may take up to a week to perform. For that reason BPG has started with the most important test for patients: the potency testing. Other types of testing will hopefully be phased in at a later time.

Some impurities should be completely absent in medicinal cannabis, because they can be completely prevented from being added. This mainly applies to chemical products added by growers such as pesticides or fungicides. When cannabis cannot be grown without the help of such products, it should not be offered as a medicine. Be aware that the processing of contaminated cannabis into extracts, tinctures or baked products does not remove impurities. In some cases, the contamination may even become more concentrated, causing more harm when consumed.

It is good to remember that medicinal cannabis is a product intended to be used by patients, and many of them have a weakened resistance to impurities. What is relatively harmless to a healthy person may be a serious risk-factor to a patient. It is therefore important that the quality of your medicine is guaranteed as much as possible. Support the quality control of medicinal cannabis and help to bring your medicine to the next level.

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Cannabis strains

Cannabis plants come in lots of shapes and sizes. They clearly differ in many respects: smell, color, growth rate, bud size, and for many medicinal users they differ in therapeutic or medicinal effect. These various types of cannabis are commonly called varieties, strains, or cultivars (cultivated varieties). It is however incorrect to say there are many species of cannabis, because according to the latest scientific consensus, all cannabis plants belong to the same species. That means that in principle, all cannabis types can be crossed in breeding. The same is true for example for dogs or tulips: only one single species, but lots of variation. A further distinction can be made by identifying a number of sub-species, as explained below.

In general, strains are developed to highlight specific properties of the plant, or to establish marketing differentiation. Strains names are chosen by their creators, and often reflect properties of the plant, such as taste (e.g. Blueberry Haze) or the origin of the strain (e.g. G13 x Haze). Some strains, such as Haze and Thai refer to cannabis plants found growing wild in certain regions. Typically, these plants are used as bases for the production of more specialized strains (e.g. G13-Haze).

Although some strains are becoming well known for their specific therapeutic effect, it is hard to say that some strains are medicinal strains. In theory, all cannabis strains have the potential to be medicinal, if only they are used by the right patient.

Sativa, Indica, and the rest

So how many different strains of cannabis are known today? The exact number is impossible to determine, because there are no clear criteria to distinguish one variety from another. But roughly, at least several hundred varieties are known, as a result of the continuous breeding effort of breeders around the world.

The most commonly used (and least disputed) way to categorize cannabis strains is to distinguish between the subspecies “indica” and “sativa” types. Pure sativa strains are relatively tall (reaching as high as 4.5 meters), with long internodes and branches, and large, narrow-bladed leaves. On the other hand, indica strains are shorter and bushier, have wider leaflets, and are often favored by indoor growers. “Sativas” bloom later than “indicas,” often taking a month or two longer to mature. The subjective effects of “sativas” and “indicas” are said to differ, but contrary to popular belief, the ratio of tetrahydrocannabinol (THC) to cannabidiol (CBD) in most strains of both types is similar. In addition to “pure indica” and “pure sativa” strains, hybrid strains with varying ratios of these two types are common. Hybrid strains often have combinations of traits derived from both parental types.

Sometimes, the subspecies “ruderalis” is also recognized; a variety of cannabis that grows wild in parts of Eastern Europe and Russia. It is characterized by its early flowering, with some plants starting irrespective of the photo-period. Cannabis ruderalis is ideal for cultivation in cooler climates and areas where conditions are harsh.

The term ‘hemp’ is generally used to describe low-THC varieties of cannabis which are grown for industrial uses.

Do strains differ in their therapeutic effects?

Certain compounds found in the cannabis plant have well-documented medicinal effects on certain diseases. The most intensively studied are the cannabinoids THC and CBD. Pure THC is available as a medicine in the form of a capsule (Marinol), and the combination of THC and CBD is present in the sublingual cannabis-spray Sativex. Several other cannabinoids are present in the cannabis plant, and they probably play a role as well. Other important compounds are the terpenoids; volatile components that give cannabis much of its distinct smell and flavor. But beside that, many terpenoids have potent antibacterial, anti-inflammatory or other effects.

It is not yet fully understood what components of the cannabis plant are responsible for the many different medicinal effects. And because of the complex composition of any cannabis plant, it is too early to say what exactly makes some strains more effective as a medicine than others. Nevertheless, it is clear that differences in the chemical composition of cannabis strains may produce different effects in humans.

The trouble with strains

Just like any other medicine, identifying your cannabis of preference should be easy and reliable. This guarantees that you get an optimal medicinal effect each time you buy your medicine. But up to now, there has been no independent way of positively identifying a cannabis strain. In practice, people have to rely on their own experience, or on the expertise of others. And intentionally or not, mistakes can be made.

After all, strains are named by the breeder or grower to differentiate one from another. In competitive markets, there is significant pressure to create unique strains that dominate the market. When a strain becomes popular, breeders and growers may produce variations of the same strain using the same or similar name. This results in a number of distinct strain names that may refer to very similar cannabis. Also, because of financial reasons, cannabis dealers may distribute cannabis that is misleadingly called by a strain name, while a lower grade may actually be sold.

As a result, the commonly used cultivar names may not be the best tool to find your preferred medicine. What we need instead is a more reliable and effective way to label different medicinal types of cannabis.

From cultivar to chemovar

Each time you buy food or a drug, you want to know the ingredients; what is in it, and how does it affect me. Why should this be different for your medicinal cannabis? Because if the therapeutic effect of cannabis depends on its chemical composition, it makes lots of sense to identify a strain by analyzing its contents. In order to do that, we need the help of a properly equipped laboratory.

Specific analytical testing methods have been developed to determine the exact composition of a cannabis plant. (See factsheet on analytical testing). And an increasing number of dispensaries have begun to offer such testing services to their suppliers. This will enable dispensaries to provide you with the list of ingredients present in your preferred strain. Strains that have a known composition may soon be identified as a chemical variety, or chemovar.

When analytical testing is available, you will always know exactly what you buy. No more confusing names, but a reliable label of ingredients instead. Because the more we understand about the chemistry of medicinal cannabis, the better we understand the medicine itself.

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Medical Cannabis Contra-indications

There are a number of medical conditions which act as relative contra-indications for medical cannabis use by patients.

Pregnancy: Under no circumstances should women casually medicate with cannabis during pregnancy. Numerous studies suggest that excessive cannabinoid stimulation may make children susceptible to numerous behavioral problems like drug addiction, anxiety, schizophrenia and depression.

Anti-coagulation: If you are taking the blood thinning medication warfarin (Coumadin), you should tell your doctor. Cannabis use can affect the effectiveness and toxicity of this medication. Have your blood levels (INR) checked for the first several weeks after using medical cannabis. Please report any unusual bruising or bleeding to your doctor immediately.

Liver disease: Patients with liver disease need to tell their doctor(s) that they are using medical cannabis. Patients with Hepatitis C and other liver ailments need to monitor their liver enzymes for elevations and stool for excessive fat content (steatorrhea).