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Introduction
01
Cannabis as medicine: therapeutic use for centuries
The use of cannabis as a medicine goes back many centuries. For example, Chinese doctors used it in early dynasties to treat concentration disorders and fever. At the end of the 19th century, cannabis-based medicines were used in Europe to treat pain and sleep disorders, but also asthma, depression and loss of appetite, as well as to relieve convulsions.1
Since it was not possible for a long time to decipher the chemical structure of the ingredients of the hemp plant (Cannabis sativa L.), cannabis lost its medical significance as a medicine. The chemical definition of tetrahydrocannabinol (THC, dronabinol) was first achieved in 1964.2
Thus, medical cannabis research is a relatively new discipline. It was not until 1993 that the Israeli scientist Prof. Raphael Mechoulam, together with colleagues at the National Institute of Mental Health, discovered the endocannabinoid system.3 Since this important signaling system of the organism was only discovered in connection with the study of the mechanisms of action of the ingredients in Cannabis sativa, this plant served as its namesake.
Endocannabinoid system
The endocannabinoid system: a highly complex component of the human organism
The endocannabinoid system (eCB system) is an endogenous neurohumoral regulatory system: in addition to its function in the central nervous system (CNS), it is also involved in the control of the immune system and other systems of the human organism.4,5
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Cannabinoids and terpenes
Cannabinoids and terpenes: ingredients of the cannabis plant with therapeutic potential
The cannabis plant owes its diverse active properties mainly to the cannabinoids, THC and CBD. In addition, cannabis contains a large number of active substances such as terpenes: More than 550 substances have now been isolated and at least 144 of these have been classified as cannabinoids.6,7
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Medical cannabis strains
Medical cannabis strains: distinguishing criterion cannabinoids and terpene profile
In most cases, cannabis strains are distinguished by the plant morphology, but this is not a distinguishing criterion for their therapeutic spectrum.8,9 Today, there are different cultivated varieties, i.e. breeding forms (cannabis strains) with stable genetics and constant ingredients, whereby the individual varieties also differ in the smell, which is based on the respective terpene profile and thus the content of essential oils.1,8
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Legal basis
Cannabis as a medicine: expansion of prescription and reimbursement capacity in 2017
Since the cannabis plant and all parts of the plant are classified as narcotics, they are subject to the Narcotics Act (BtMG) and the Narcotics Prescription Ordinance (BtMVV). Since 2017, the prescription of medical cannabis has been permitted in Germany, i.e. cannabis flowers and cannabis flower extracts in pharmaceutical quality can be prescribed and qualify for reimbursement as medicines.10,11
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Treatment options
Areas of application of medical cannabis: clinical efficacy in a wide range of indications and symptoms
Medical cannabis shows a variety of therapeutically beneficial effects. Potential therapeutic indications include painful muscle spasms, chronic or neuropathic pain, chemotherapy-induced nausea and vomiting, and a number of other indications.12,13
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Dosage forms
Dosage forms of medical cannabis: Flowers, extracts and finished dosage forms
In Germany, various dosage forms of medical cannabis can be prescribed: dried cannabis flowers, standardized full-spectrum extracts, dronabinol and cannabidiol formulas as well as finished dosage forms.5
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Forms of application
The two possible application methods of medical cannabis are: inhalation or oral administration
There are two options for the medical use of cannabis: either cannabis or cannabinoid-containing medications are inhaled or orally applied. A combination therapy consisting of inhalation and oral intake is also possible.14
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References
Status: 2021
Frankhauser M. Cannabis in der westlichen Medizin. In: Grotenhermen F (ed). Cannabis und Cannabinoide. Pharmakologie, Toxikologie und therapeutisches Potential. 2nd edition. Göttingen: Hans Huber 2004:57-71.
Gaoni Y, Mechlulam R. Isolation, structure, and partial synthesis of an active constituent of hashish. J Am Chem Soc 1964; 86:1646-7.
Ulrich, O. & Schneider-Stock, R. Endocannabinoide können mehr. 2005 Pharmazeutische-Zeitung.de https://www.pharmazeutischezeitung.de/inhalt-06-2005/titel-06-2005/ (last visited on 30 June 2021).
Hoch E, Friemel CM, Schneider M. Cannabis: Potenzial und Risiko. Cannabis, Cannabinoide und das Endocannabinoidsystem 2019. https://link.springer.com/chapter/10.1007%2F978-3-662-57291-7_1 (last visited on 30 June 2021).
Freeman TP et al. Medicinal use of cannabis based products andcannabinoids. BMJ 2019;365:l1141 doi: 10.1136/bmj.l1141 . https://www.bmj.com/content/bmj/365/bmj.l1141.full.pdf (last visited on 21 July 21).
Russo EB. Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. British Journal of Pharmacology 2011;163:1344–1364. https://bpspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1476-5381.2011.01238.x (last visited on 21 July 21)
Chouvy P-A. Cannabis cultivation in the world: heritages, trends and challenges. Echo Géo 2019. https://doi.org/10.4000/echogeo.17591 (last visited on 17 July 2021).
McPartland JM. Cannabis sativa and Cannabis indica versus “Sativa” and “Indica”. 101-121. In: Chandra S., Lata H, ElSohly M. (eds) Cannabis sativa L. - Botany and Biotechnology. Springer 2017. https://doi.org/10.1007/978-3-319-54564-6_4 (last visited on 17 July 2021).
BfArM: Änderungen in der Betäubungsmittelgesetzgebung: Änderungen 2017. https://www.bfarm.de/DE/Bundesopiumstelle/Betaeubungsmittel/_artikel.html (last visited on 05 July 2021).
BfArM: Bundesamt für Justiz. Verordnung über die Begleiterhebung nach § 31 Absatz 6 des Fünften Buches Sozialgesetzbuch. https://www.gesetze-im-internet.de/canbv/__3.html (last visited on 05 July 2021).
Grotenhermen F, Häußermann K. Cannabis. Verordnungshilfe für Ärzte. Wissenschaftliche Verlagsgesellschaft Stuttgart 2019.
Müller-Vahl K, Grotenhermen F. Cannabis und Cannabinoide in der Medizin. Medizinisch Wissenschaftliche Verlagsgesellschaft Berlin 2020.
Cannabis: Verordnungshilfe für Ärzte von Franjo Grotenhermen; Klaus Häußermann 2017; Verlag. Wissenschaftliche Verlagsgesellschaft Stuttgart – ISBN 10: 3804737595 – ISBN 13: 9783804737594