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Cannabinoids, Terpenes, and Flavonoids as Reasonable Alternatives to Opioids

Ethically, Professionally and Legally, ALL practicing physicians should learn about cannabinoids, terpenes, and flavonoids as reasonable alternatives to opioids to use in treating chronic pain.  They should acquaint themselves with the articles (resources) and videos provided on the Seminar Website link: Home | Webinar2025

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1. Basic Pharmacology of Cannabinoids:

   • The endocannabinoid system (ECS): CB1 and CB2 receptors, endogenous ligands (anandamide, 2-AG), and metabolic enzymes.

   • Phyto cannabinoids: THC, CBD, and other relevant cannabinoids (CBG, CBN).

   • Pharmacokinetics: Absorption, distribution, metabolism, and excretion of cannabinoids.

   • Pharmacodynamics: Mechanisms of action, including receptor binding and non-receptor-mediated effects.

   • Pharmacogenetics (PharmacoGX).
      

2. Specific Cannabinoids:

   • THC: Psychoactive effects, analgesic properties, risks, and benefits.

   • CBD: Non-psychoactive effects, analgesic and anti-inflammatory properties, risks, and benefits.

   • Other cannabinoids: CBG, CBN, and their potential therapeutic roles.
      

3. Terpenes:

   • Common terpenes in cannabis: Myrcene, limonene, pinene, linalool, and their potential effects on pain, inflammation, and mood.

   • The "entourage effect": How terpenes may interact with cannabinoids to modulate effects.
      

4. Flavonoids:

   • Types of flavonoids and their known anti-inflammatory and antioxidant properties.

   • Potential role in pain management and the current evidence base.
      

5. Evidence-Based Use for Pain Management:

   • Review of clinical trials and systematic reviews on cannabinoids for different types of chronic pain (neuropathic, nociceptive, inflammatory).

   • Efficacy for specific conditions: Fibromyalgia, arthritis, multiple sclerosis, cancer pain.

   • Comparison with other pain management modalities (opioids, NSAIDs, etc.).
      

6. Risks and Side Effects:

   • Short-term and long-term adverse effects of cannabinoids.

   • Psychiatric effects: Anxiety, psychosis (especially with THC).

   • Cognitive effects: Memory impairment, attention deficits.

   • Cardiovascular effects: Heart rate and blood pressure changes.

   • Gastrointestinal effects.

   • Drug interactions: Cytochrome P450 enzyme interactions.
      

7. Cannabinoid Use Disorder (CUD):

   • Diagnostic criteria and prevalence.

   • Risk factors and prevention strategies.
      

8. Routes of Administration:

   • Inhalation (smoking, vaping): Risks and benefits.

   • Oral (oils, capsules, edibles): Pharmacokinetics and dosing.

   • Topical (creams, patches): Efficacy and safety.

   • Other routes: Sublingual, rectal, vaginal.
      

9. Dosing and Titration:

   • Starting low and going slow.

   • Individual variability in response.

   • Optimal THC:CBD ratios for different pain conditions.
      

10. Legal and Regulatory Issues:

    • Federal vs. state laws regarding cannabis and CBD.

    • The legal status of hemp-derived CBD.

    • Medical cannabis programs in specific states.

    • FDA regulation (or lack thereof) of cannabis products.
       

11. Product Quality and Safety:

    • The unregulated nature of many cannabis products.

    • Risks of contamination, mislabeling, and inconsistent THC/CBD content.

    • Importance of third-party testing and certificates of analysis.
       

12. Patient Communication and Informed Consent:

    • Discussing the risks and benefits of cannabinoids with patients.

    • Shared decision-making.

    • The importance of setting realistic expectations.

    • Monitoring for efficacy and side effects.
       

13. Special Populations:

    • Use of cannabinoids in elderly patients.

    • Use during pregnancy and breastfeeding.

    • Use in patients with psychiatric conditions.
       

14. The Endocannabinoid Deficiency Syndrome (CECD):

    • Understanding the theory and its implications for treating chronic pain.

    • Conditions associated with CECD (migraine, fibromyalgia, IBS).
       

15. Integration with Other Pain Management Modalities:

    • How cannabinoids can be used in conjunction with other treatments (physical therapy, medications, etc.).

    • Opioid-sparing strategies.
       

16. Resources for Further Education:

    • Reputable sources of information on cannabis and pain management.

    • CME opportunities and professional organizations.