Final Test

Earliest evidence of cannabis cultivation was found in *

Europe

China

North America

Central America

In which religious scripture is the cannabis plant referred to as a sacred plant *

Hindu

Judaic

Islamic

None of the above

Cannabis was introduced to western medicine by *

Queen Victoria

William O’Shaughnessy

Sir William Osler

JFK

1924, Sajous’s Analytic Cyclopedia of Practical Medicine summarized that cannabis was useful in the treatment of *

Migraines

Tetanus

Rabies

All of the above

Published evidence of the benefits of medical cannabis for the treatment of symptoms of cancer *

Does not support its use

Is mostly opinion-based

Includes systematic review and meta-analysis

Is of low quality

The most effective way to treat chemotherapy induced nausea and vomiting (CINV) with medical cannabis is *

High dose oral CBD at the onset of the symptoms

Inhaled flower with appropriate entourage effects prn

Balanced CBD:THC, oral, 2 hours prior to worst nausea periods, titrated to effect

B and C

Terpenes and cannabinoids known to be beneficial for pain include *

THC, CBD, CBG

Beta-caryophyllene, Myrcene, Linalool

All of the above

None of the above

Published evidence of the benefits of medical cannabis to reduce tumour burden and increase survival rates in cancer *

Is non-existent

Is limited to murine studies

Is overwhelming

Includes positive data in humans

For patients with multiple sclerosis, there is systematic review and meta-analysis evidence for safety and efficacy relating to *

Spasticity

Pain

Bladder Dysfunction

All of the above

Medical cannabis’s benefits in patients with Multiple Sclerosis are possibly due to *

Immune modulation (at least in rodents)

A general decrease in CNS activity, analogous to benzodiazepines

Remyelination

All of the above

A reasonable starting dose for a cannabis naive patient with moderate pain would NOT include which one of the following *

100mg inhaled tds 20% THC Flower

0.25ml po bd Balanced (10mg/ml THC, 10mg/ml CBD) oil

0.25ml po bd 100mg/ml CBD oil

0.1ml po nocte 25% THC Indica dominant oil

Patients with a history of anxiety or psychosis should generally NOT be prescribed *

High doses of CBD

THC oils of any sort

Sativa-dominant THC products

Myrcene

Molecules with clinically relevant activity in cannabis include *

THC and CBD

Cannabinoids

Terpenes

All of the above

Which of the following statements is correct *

Prescriptions of greater than 30mg THC/day can be supported by AP

Doses of greater than 200mg per day of CBD are required to reduce osteoarthritic pain

THC-containing products consistently cause increased appetite

CBD can ameliorate the psycho-active effects of THC

Which of the following is a symptom of anxiety *

Feelings of uneasiness

Risk taking

Mania

Fever

Part of the pathophysiology of anxiety disorders is *

A dysfunctional processing in decision making situations

Overestimation of risk

Inappropriate associations between inappropriate associations between neutral stimuli and danger

All of the above

Which of the following statements regarding the ECS and anxiety is NOT true *

Endocannabinoid receptors are located throughout the limbic system

CB1 receptor agonists are reported to induce biphasic effects, with lower doses being anxiolytic and higher doses being anxiogenic

The presynaptic release of GABA and glutamate, is affected by CB1 receptor activation

The activation of GABA release by CB1 activation seems to be the cause of the anxiogenic- responses to a high dose of cannabinoids

Which of the following statements regarding phytocannabinoids and anxiety is true *

There is no association between cannabis use and anxiety

Cannabis has been used across most ancient civilizations for its medicinal, relaxing and mood-enhancing properties

CBD has antagonist properties at the serotonergic 5-HT1A receptor

THC is never effective in reducing anxiety

The four clusters of PTSD symptoms are *

Intrusions, Avoidance, Negative alterations in cognition and mood, Alterations in arousal and reactivity

Intrusions, Panic, Stress, Depression

Avoidance, Inclusions, Cognitive dysfunction, sleep disorders

Depression, Anxiety, Sleep disorders, Daytime arousal

Which of the following best describes the treatment options with cannabis for PTSD *

Medicinal cannabis can not play a significant role in the management of PTSD

The is no role for the modulation of the ECS in management of PTSD

ECB signalling enhancement by phytocannabionids from medicinal cannabis reduce reactivity of the amygdala

Only THC showed significant benefit in the treatment of PTSD

Regarding the ECS and PTSD, which of the following statements is incorrect *

The ECS plays an important role in the modulation of the physiologic and behavioural response to stress exposure

The ECS modulates the activation and termination of the HPA-axis function in response to stress

Acute and repeated stress exposure increases AEA levels in limbic regions including the amygdala, PFC, hippocampus, and hypothalamus

Stress exposure causes CRH release, which in turn increases FAAH activity to drive down AEA levels within cortico-limbic structures

Which of the following statements have not been shown to be an outcome of the use of phytocannabionoids in PTSD *

Anxiety reduction

Suppress of the recall and enhancement of extinction of emotionally aversive memories

Reduction of time spent sleeping

Dampening of inflammatory processes

Regarding the role of the ECS in insomnia, the following is true *

Inhibiting the catabolism of endocannabinoids by enzyme blockage has been shown to increase non-REM sleep and regulate sleep stability in animal models

There is no association between the ECS and circadian rhythm

ECS function does not show diurnal variation

It is largely cannabinoid receptor 2 (CB2) that contributes to modulating sleep and circadian cycles

Regarding conventional management of insomnia, the following statement is true *

Pharmacological intervention is first line treatment of insomnia

There is no specific psychological intervention available for the treatment of insomnia

Selecting the right medication is dependent on the type of insomnia symptoms

There is no role for non-pharmacological management

Regarding THC and sleep disorders, the following statement is incorrect *

THC and its sedative and muscle-relaxant properties have been extensively discussed by leading cannabinoid researchers

THC acts as an antagonist on CB1 receptors in the central nervous system and brain

It is hypothesised CB1 activation induces sedation via increasing acetylcholine release in areas of the brain associated with sleep

Human research has indicated acute THC administration improves sleep onset latency, decreases waking, increasing non-REM sleep and decreasing REM sleep

The most evidence from recent clinical trials for treatment options with medicinal cannabis for insomnia exist for *

Combinations of THC and CBD

THC only

CBD only

Topical CBD

Regarding toxicity of medicinal cannabis, the following statement is correct *

Medicinal cannabis has high level of toxicity

Toxicity of THC is very low compared to most other recreational and pharmaceutical drugs

High doses and concurrent use of other drugs will not mask the effect of cannabis and will not increase the likelihood of adverse events

It is quite realistic that a 70kg person could consume a lethal dose of cannabis

Which of the following is not a known side effect of cannabidiol *

Somnolence

Hallucinations

Diarrhea

Transaminase elevations

Regarding cannabidiol (CBD) drug interactions which of the following is incorrect *

CBD does not have any significant interactions with other medications

CBD is an inhibitor of several CYP450

CBD is an inhibitor of several UGT enzymes

CBD can be administered with other medications

The following statement is true *

There are no contraindications for the use of medicinal cannabis

Pure cannabis can be smoked with no detrimental health effects

Medicinal cannabis can never be used in patients with a history of CVD

Patients with history of schizophrenia can be prescribed with CBD

Cannabis medicines are NOT *

Effective at controlling acute pain

Effective at controlling chronic pain

Safe to use in inflammatory pain

All of the above

THC… (choose incorrect option) *

Should generally always be used in conjunction with CBD

Is the principle nociceptive compound in cannabis medicines

Has nociceptive activity primarily via anti-inflammatory effects

May induce somnolence

Cannabis interacts with opioids… (choose incorrect option) *

THC and opiates create a synergistic analgesic effect when used concurrently, known as the "opioid sparing effect"

Cannabis and opioid medications should not be used conjunctly, though can be given if separated in time by 2 hours or greater

THC stimulates release of endogenous opioids via stimulation of delta and kappa opioid receptors

THC, CBD and opioids when used together, often results in reduction of opiate dose and reduced chance of respiratory depression

A 65 year old woman presents with spinal degeneration and neuropathic pain, which of the following would NOT be a reasonable initial choice of medicines *

Oral preparation 10mg THC/mL and 10mg CBD/mL- starting dose 0.2mL TDS titrating to pain tolerance

Oral preparation 25mg THC/mL – starting dose 0.2mL BD titrating to pain tolerance

Oral CBD 10mg/mL- 20-30mg BD + Oral THC 25mg/mL- starting at 0.1mL BD and titrating to pain tolerance

Inhaled cannabis indica flower – 0.1-0.25g BD prn

Choose the incorrect statement below *

High prevalence of cannabinoid receptors in the respiratory centres of the brainstem mean respiratory suppression via overdose of THC is not possible

Onset of action of inhaled cannabis is less than 5 minutes, with an approximate duration of 2-4hrs, so it is useful for treatment of breakthrough pain

CBD should always be used in conjunction with THC

Onset of action of oral/ sublingual cannabis is approximately 1hour, with an approximate duration of 8hrs, so it is suitable as a regular long acting nociceptive medicine

Choose the incorrect statement *

THC is the principle cannabinoid and binds orthsterically to cannabis receptors

THC is responsible for the psychoactive effects of cannabis

Cannabis medicines are generally well tolerated, and can not cause mortality via overdose

CBD is the main pain relieving cannabinoid

Choose the incorrect statement *

The cannabis plant is composed of many bioactive molecules, with (potentially) over 144 cannabinoids, and over 400 terpenes combining in a synergistically in what is coined “the entourage effect”

Isolated or purified CBD and THC more efficacious than whole plant cannabis extracts, as the isolated molecules have uninterrupted binding to cannabis receptors

Terpenes such as myrcene, linalool and beta caryophyllene, are commonly found in “indica” varieties of cannabis

CBD is an excellent anxiolytic molecule, and reduces negative psychoactive effects of THC. CBD should always be used in conjunction with THC

Choose the incorrect option *

CBD inhibits FAAH, resulting in extended action of anandamide and activates 5HT1A receptors resulting in increased levels of dopamine and serotonin

CBD is neuroprotective and anti-inflammatory

CBD may antagonize CYP450 enzyme activity in the liver, usually at higher doses

Low doses of CBD are necessary due to potential neurotoxic effects associated with CBD use- doses of 30mg daily should not be exceeded

In regards to the ECS (endocannabinoid system) please choose the incorrect answer *

The ECS is a discreet closed system of vessels that regulates activation of all other bodily systems

The ECS is an homeostatic, regulatory system influencing multiple physiological systems. Its aim is the maintenance of a stable internal bodily environment

Retrograde inhibition is a term that indicates the inhibitory effect of cannabinoid receptor stimulation on presynaptic receptor neurotransmitter release

CB1R are located mainly in the CNS. CB2R are mainly located peripherally and are associated with immune and inflammatory physiological response

Regarding epilepsy please choose the incorrect answer *

All types of epilepsy may be amenable to treatment with cannabis medicines, and CBD is a mainstay of treatment

CBD may interact in an antagonist way with CYP450 at higher doses (consider this at doses greater than 80mg CBD daily)

CBD treatment may take some time to take effect, and higher doses of CBD may be required to get anti seizure effect

Isolated CBD is a good choice for epileptic patients as larger doses of CBD may be used

Drugs which are commonly effected by high doses of CBD and its interaction with CYP450 include… *

Clobazam

Phenytoin

Apixaban

All of the above

When dosing cannabis medicines for epilepsy… (choose incorrect option) *

CBD in a 20:1 ratio (CBD:THC) seems effective, titrating to effect with an approximate max dose of 15mg CBD/kg

Concurrent ailments/ symptoms should be treated symptomatically with THC where appropriate- eg sleep/ pain insomnia

Patients will respond individually to different chemovars. Minor cannabinoids and terpene variations between chemovars may, so changing between chemovars may be useful in treating epileptic patients

All conventional medications should be discontinued prior to commencement of cannabinoid medications

A 32 year old female presents with long standing, treatment resistant epilepsy, which of the following is not a reasonable way to commence treatment for the patient *

CBD full spectrum 100mg/mL – 0.5mL BD / TDS

CBD isolated 100mg/mL – 0.5mL BD / TDS

Inhaled “balanced” mid strength flower- 10mgcbd + 10mg THC/g- 0.2-0.5g BD vapourized

CBD full spectrum 100mg/mL – 0.5mL BD / TDS + THC full spectrum 25mg/mL- 0.1-0.8mL nocte

ANZCCP Authorised Prescriber Course