RN Karen Harris shows a group the new central monitoring system in the nurse's station at the Haliburton emergency department on Feb. 14. /JENN WATT Staff

Start low and go slow doctor cautions on cannabis

By Darren Lum

Published Oct. 23 2018

A few weeks before the Canadian government passed the Cannabis Act making the purchase and consumption of the drug legal CARP’s Haliburton branch held an information session at the fish hatchery.

There was a packed room of interested people for guest speaker Dr. Norm Bottum who has been a doctor in Haliburton County since 1987.

Bottum said he has been open to working with his patients in using cannabis products as long as his care abides by the Hippocratic oath to “do no harm.”

His talk on Sept. 30 included a PowerPoint presentation on cannabis treatment effectiveness current uses and recommendations outlined by the College of Family Physicians of Canada followed by a question and answer period.

Cannabis is comprised of two natural compounds the psychoactive compound THC or tetrahydrocannabinol and CBD or cannabidiol including more than 60 other inactive ingredients.

THC provides the euphoric feeling associated with cannabis while CBD provides consumers with pain relief.

There are varying levels of THC and CBD in every product. Cannabis can be consumed in myriad ways including through edibles oils or inhaled in smoke.

Bottum’s main message to the audience which was composed mostly of seniors was to start slowly with a low dosage and to monitor the effects closely because everyone is physiologically different.

“Starting low and going slow” he said.

This sentiment of low dosage is echoed by Health Canada which also recommends to choose products with a low amount of THC and an equal or higher amount of CBD; avoid combining cannabis with alcohol and/or other substances; avoid smoking cannabis avoid frequent use and don’t drive or go to work impaired.

According to Health Canada cannabis affects attention memory and learning. It is not recommended for anyone under 25 because the brain is still in a process of development.

Bottum recommended consulting your doctor and said he’s told patients to call the company producing the product to explain what they want to use it for. What could work for one person may not work or could harm another person he said.

He knows patients with anxiety issues who have been helped but also those whose anxiety was worsened.

A part of the problem is how there has been very little formal testing with credible sample sizes which needs to be in the thousands – something similar to what is done with pharmaceutical drug trials.

Much of the current information related to cannabis is related to personal experiences.

In his experience as a doctor working in emergency he has seen very little misuse.

“I’ve been very thankful I haven’t seen a lot” he said.

However he didn’t discount that misuse could happen without needing emergency care.

Bottum said some patients don’t realize how expensive it can be. In terms of safety it’s more important to know the source of the cannabis rather than focusing on saving money.

“There have been cases where marijuana [purchased on the street] has been laced with other drugs whether it was cocaine or fentanyl or something on those lines so certainly you want to know where it’s coming from. It may be worth the cost to get a quality product” he said.

Other areas of concern is who is predisposed to be adversely affected.

Bottum cited statistics outlined by the College of Family Physicians of Canada which state that cannabis intoxication increases the risk of fatal car collisions and that users should not drive for at least four hours after inhalation and for eight hours following use if euphoria is experienced. Impairment can last up to 24 hours for anyone who requires the ability to drive or perform activities requiring alertness.

Under the guidelines for authorizing dried cannabis for chronic pain or anxiety: dried cannabis is not appropriate for patients under the age of 25; those who have a personal history or strong family history of psychosis; those who have a current or past substance use disorder; have cardiovascular disease; have respiratory disease; or are pregnant planning to become pregnant or breastfeeding.

It “should be authorized with caution” in patients who have a concurrent active mood or anxiety disorder smoke tobacco have risk factors for cardiovascular disease and are heavy users of alcohol or taking high doses of opioids or benzodiazepines or other sedating medications prescribed or available over the counter.

During the presentation there was a question about whether cannabis consumption could become addictive.

“People can become dependent. There’s a physical addiction where [if] you don’t get it you have a withdrawal. People can become dependent on Tylenol or sleeping pills or cellphones for sure” Bottum said.

The legal age for cannabis consumption in Ontario is 19 years or older.

The limit for growing cannabis is four plants per residence (not per person). An individual can have a maximum of 30 grams (about one ounce) of dried cannabis in public. According to the government of Ontario website cannabis can be purchased online through the Ontario Cannabis Store (OCS.ca). Consumers will be required to verify their age to accept delivery and no packages will be left unattended at the door. You are permitted to purchase up to 30 grams (about one ounce) of dried recreational cannabis at one time for personal use. Currently edibles and concentrates are not available for purchase.

Despite anecdotal success stories the verdict is still out about the efficacy of medical marijuana Bottum said. He cautioned that cannabis edibles can have delayed effects which could lead to over consumption.

He said it’s not expected producers will provide data on marijuana but he hopes government and universities will fund research so the public can “use these products or start to use safely.”

Bottum said there is still a lot to learn which applies to everyone from patients to doctors looking to help.

“We’re learning. We’re learning from you. We’re learning from the College of Family Physicians. We’re going to learn from other research as time goes on so we’re all going to become more knowledgeable. Let’s do it together. Let’s do it safely and I don’t think anybody that I know from my group is going to try and stop you from trying something if you do it safely” he said.