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For centuries, the cannabis plant has been used for food, fiber, and medicinal purposes.1 Marijuana and hemp are broad classifications of cannabis and do not qualify as 'species' or 'strains' of the same. The term hemp is used for cannabis plants that contain no more than 0.3% THC by dry weight of the leaves and buds.2
Traditionally, hemp has been grown for either seed or fiber and is viewed as an eco-friendly and highly sustainable crop. Hemp has high fiber content, and the seeds contain approximately 30% protein, 25% starch, and 30% oil. Hemp is harvested to produce a variety of products including, but not limited to:
<ul>
<li>Food products: hemp seed oil, hemp seed-based products, and hemp flour</li>
<li>Industrial products: clothing, carbon nanosheets, paper, plastic, and building materials</li>
<li>Medicinal products: </li>
<li>CBD-infused topicals and oil tinctures2,3</li>
</ul>
The cannabis variety containing &gt;0.3% THC is termed marijuana; its use can induce psychotropic or euphoric effects on the user. Differences in cultural practices of marijuana and hemp result in morphological variations, allowing the distinction between these two crops. In summary, the quantity of THC in the plant or whether this will get the user 'high' defines a significant characteristic difference between hemp and marijuana.
References
<ol>
<li>Pain S. A potted history. Nature. 2015;525:S10–11.</li>
<li>Schluttenhofer C and Yuan L. Challenges towards revitalizing Hemp: A multifaceted crop. Trends Plant Sci. 2017;22(11):917–29.</li>
<li>National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research, National Academies Press (2017). </li>
</ol>

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Cannabis versus Hemp

Medical cannabis and me

Due to lack of any established dosing guidelines for cannabis, individualization of dosing is the preferred option and depends mostly on titration (i.e. finding the right dose where potential therapeutic effects are maximized while adverse effects are minimized).1 Before you start using cannabis, it is critical to understand and identify the correct dosage of the cannabinoid(s) in consultation with your healthcare practitioner. Your healthcare practitioner will help you determine the most appropriate cannabinoid, type of cannabis product (capsule, oil, dried) and dosage most suitable for your condition.1</sup1>
Patients with no prior experience with cannabis and initiating therapy with cannabis-based therapeutics for the first time are advised to commence at a very low dose and gradually increase the dose to achieve the optimal therapeutic outcome and reduce possible adverse effects. Patients should immediately discontinue the treatment upon undesirable side effects. Patients are advised – start low and go slow – and wait for a minimum of 30 minutes between puffs or inhalation and 30–90 minutes between the ingestion of cannabis-based oral products to gauge for strength of effects or for possible overdosing.1,2 Results from various studies suggests that most individuals use less than 3 grams daily of dried cannabis, whether that amount is taken orally, inhaled, or a combination of both.1,2
We strongly suggest that you consult your healthcare practitioner for any queries related to dosing or identifying the most appropriate cannabinoid for your condition
References
<ol>
<li>Health Canada, “Consumer Information - Cannabis (Marihuana, marijuana)”, 2018. Available at <a href="https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/info/cons-eng.pdf">https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/info/cons-eng.pdf</a></li>
<li>Health Canada, &quot;Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids, 2018&quot;. Available at: <a href="https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html">https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html</a>.</li>
</ol>

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Dosing and Titration

Terpenes are organic compounds that are responsible to provide flavour and aroma to the plant. The yield of terpenes may represent 10% of the trichome content in the cannabis plant. Various factors may influence the concentration of terpenes in the plant including weather, climate, age and maturation, soil type, fertilizers, etc. Terpenes can also develop due to plant stress (such as excess heat).
Terpenes influence the differentiating effects of various cannabis strains e.g. citrus, berry, pine, etc. Research suggests that they may have a broad spectrum of action (e.g. anti-oxidant, anti-anxiety, anti-inflammatory, anti-bacterial, anti-neoplastic, anti-malarial). However, this information comes from few pre-clinical studies and there are no clinical trials to support these claims. 
The list of common terpenes found in cannabis plant are summarized below1,2
<table>
<thead>
<tr>
<th style="text-align: left;">Terpenes</th>
<th style="text-align: left;">Potential pharmacological activity</th>
<th style="text-align: left;">Also found in</th>
</tr>
</thead>
<tbody>
<tr>
<td style="text-align: left;">Myrcene</td>
<td style="text-align: left;">anti-oxidant, sedating, analgesic, muscle relaxant, anti-inflammatory</td>
<td style="text-align: left;">Lemon grass, bay leaves, cardamom, basil</td>
</tr>
<tr>
<td style="text-align: left;">Limonene</td>
<td style="text-align: left;">wound healing, anti-inflammatory, anti-oxidant, anti-cancer, viral infection, anti-anxiety</td>
<td style="text-align: left;">Lemon ring, ajwain, bolivian coriander</td>
</tr>
<tr>
<td style="text-align: left;">β-Caryophyllene</td>
<td style="text-align: left;">anti-inflammatory, anti-cancer, neurodegenerative and metabolic diseases, immunomodulatory, anti-anxiety, anti-depression, anti-oxidan</td>
<td style="text-align: left;">Clove, rosemary, black pepper, lavender</td>
</tr>
<tr>
<td style="text-align: left;">Terpinolene</td>
<td style="text-align: left;">anti-oxidant, anti-cancer, anti-inflammatory, sedative, pain</td>
<td style="text-align: left;">Sage, apple, cumin, tea tree, pine and fir trees</td>
</tr>
<tr>
<td style="text-align: left;">α-Pinene</td>
<td style="text-align: left;">anti-inflammatory, anti-oxidant, anti-cancer, bronchodilator, anti-anxiety</td>
<td style="text-align: left;">Conifers, Spanish sage,</td>
</tr>
<tr>
<td style="text-align: left;">Humulene</td>
<td style="text-align: left;">anti-inflammatory, anti-cancer, depression, anti-anxiety, digestive disorders</td>
<td style="text-align: left;">Sage, ginseng</td>
</tr>
<tr>
<td style="text-align: left;">Linalool</td>
<td style="text-align: left;">anti-anxiety, analgesic, anti-convulsan</td>
<td style="text-align: left;">Lavender</td>
</tr>
</tbody>
</table>
References
<ul>
<li>Nuutinen T. Medicinal properties of terpenes found in Cannabis sativa and Humulus lupulus. Eur J Med Chem. 2018;157:198–228.</li>
<li>Russo EB. Taming THC: Potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. Br J Pharmacol. 2011;163:1344–64.</li>
</ul>

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Terpenes

There are specific traveling guidelines and regulations to keep in mind while traveling in and out of Canada with medical cannabis. Documentation is critical to avoid hassles while traveling with medical cannabis. 
When travelling within Canada
Patients authorized to use medical cannabis may travel with their medicine provided they always keep documentation with them. Every province or territory have their own laws related to the use of cannabis; it is advised that you familiarize yourself with the laws of the province or territory you are going to visit and follow the laws in that jurisdiction. 
When traveling outside of Canada
Although, cannabis is legal for adults in Canada, the import/export of cannabis and cannabis-related products (including those containing CBD) across the Canadian border is still prohibited. This prohibition is:
<ul>
<li>irrespective of the amount of cannabis being carried</li>
<li>applicable even if someone has the authority to use cannabis for medical purposes (any form), including CBD</li>
<li>even if one is traveling to or from an area where cannabis has been legalized or decriminalized</li>
</ul>
Patients must contact the visiting country's embassy or the consulate regarding permission to carry cannabis-based medicines. Aviation security may verify documentation. Thus, allow plenty of time before traveling outside of Canada to determine authorization and means of obtaining permission, if applicable. Criminal offense charges could be faced by anyone traveling to other countries and possessing any amount of cannabis, including edible cannabis and cannabis topicals and extracts. This rule applies to all countries, whether cannabis is legal there or not. If one tries to travel internationally with cannabis, including CBD products, one may face severe criminal consequences. One could also be denied access to other countries in the future.
When entering Canada
If you are entering Canada and possesses cannabis in any form, you must declare it to the Canada Border Services Agency. Not claiming cannabis in possession at the Canadian border is a serious criminal offense. Additionally, receiving or delivering cannabis in any form into or out of Canada by mail or courier is unlawful. Unauthorized purchases (online or other) from outside Canada will be confiscated at the border, and one could be arrested and prosecuted
Kindly refer to travel guidelines and laws of the country one wishes to visit before carrying any amount or form of cannabis.
References
<ul>
<li>Cannabis and the border. Cannabis in Canada – Get the facts. Government of Canada. Available at: <a href="https://www.canada.ca/en/services/health/campaigns/cannabis/border.html">https://www.canada.ca/en/services/health/campaigns/cannabis/border.html</a></li>
<li>Patient Access – Medical Cannabis. Available at: <a href="https://www.patientaccess.ca/travel-tips/">https://www.patientaccess.ca/travel-tips/</a></li>
</ul>

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Traveling with medical cannabis

The use of cannabis may lead to interaction with several drugs. Even though cannabis is generally well-tolerated at a lower dose, bidirectional events could be possible due to concomitant administration of drugs.1,2 Generally, co-administration of two or more drugs with similar or dissimilar actions may lead to drug interactions, e.g., warfarin with aspirin.2 Drug interactions involving cannabis and cannabinoids may vary considerably in their clinical significance considering the variability in product potencies, ratios of cannabinoids, route of administration etc.1
Before using cannabis for medicinal purposes, patients must notify their healthcare practitioners about their usage of the prescription, non-prescription drugs or herbal products. Especially when using:
<ul>
<li>drugs causing drowsiness such as medications for pain, allergy or cold, sleeping pills, tranquilizers, or anti-seizure medications.</li>
<li>antiretroviral drugs used for HIV/AIDS, stomach acid inhibitors, certain antidepressants, antibiotics, antifungal, heart medications, and Saint John's Wort.3</li>
</ul>
The information on drug interaction(s) with cannabis is limited, hence caution should be exercised, and response to the treatment (when using cannabis with certain drugs) should be monitored closely, especially in the elderly population and those with kidney and liver conditions or other chronic diseases. We advise you to talk to your healthcare practitioner to know more about drug interactions with cannabis and how to manage it (if any).
References
<ol>
<li>Health Canada, &quot;Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids, 2018&quot;. Available at: <a href="https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html">https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html</a> </li>
<li>Alsherbiny MA and Li CG. Medicinal cannabis—Potential drug interactions. Medicines. 2019:6;3.</li>
<li>Health Canada, “Consumer Information - Cannabis (Marihuana, marijuana),”. Available at <a href="https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/info/cons-eng.pdf">https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/info/cons-eng.pdf</a> </li>
</ol>

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Can I take medical cannabis along with my other medications?

The potential therapeutic and risk/benefit ratio associated with cannabis use depends essentially on the amount of cannabis used and the concentration of cannabinoids in the product, age of the patient and their medical condition, prior experience with cannabis or cannabinoids, and the use of other prescription or non-prescription drugs.
As per the guideline(s) provided by Health Canada, you should not use cannabis if you are:
<ul>
<li>an individual &lt;25-year-old</li>
<li>an individual allergic to any cannabinoid</li>
<li>an individual with severe kidney, liver, heart, or lung disease</li>
<li>an individual with a family/personal history of severe mental disorders such as schizophrenia, psychosis, depression, or bipolar disorder</li>
<li>a pregnant woman, a woman planning to get pregnant, or is breast-feeding</li>
<li>a man wishing to start a family</li>
<li>an individual with a history of alcohol, drug abuse, or substance dependence</li>
</ul>
We strongly recommend that you talk to your healthcare practitioner if you fall into any of the above categories. There may be other conditions where cannabis should not be used, but which are unknown due to limited scientific information. Kindly contact your healthcare practitioner for further details.
References
<ul>
<li>Health Canada, "Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids, 2018". Available at: <a href="https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html">https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html</a></li>
<li>Health Canada, “Consumer Information - Cannabis (Marihuana, marijuana),”. Available at <a href="https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/info/cons-eng.pdf">https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/info/cons-eng.pdf</a></li>
</ul>

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Who should not use cannabis?

My journey in cannabis

Information on side effects associated with the therapeutic use of cannabis and cannabinoids is limited due to paucity of established scientific evidence. Side effects are usually observed with high dose of cannabis or cannabinoids.1 Though there is no scientifically defined dose of cannabis, generally, a low dose is well-tolerated with infrequent side effects. A higher-dose or an overdose is often associated with short- or long-term side effects.1 Some well-known side effects associated with the use of cannabis and cannabinoids may include euphoria, spontaneous laughter and excitement, increased appetite, and dry mouth.1,2 Other recognized side effects associated with short-term and long-term use of cannabis are described as below: 1-3
Short-term use
<ul>
<li>fatigue, dizziness, headache, drowsiness, feeling faint or lightheaded</li>
<li>disturbances in attention and impaired memory, concentration, and ability to think and decide</li>
<li>disorientation, confusion, feeling &quot;too high,&quot; feeling an extreme slowing of time</li>
<li>nervousness, suspiciousness, anxiety episodes resembling a panic attack, paranoia (loss of contact with reality), hallucinations</li>
<li>impairment in motor skills and perception, altered bodily perceptions, loss of control of bodily movements, falls</li>
<li>hypersensitivity reactions (contact dermatitis/hives)</li>
<li>fast heartbeat</li>
</ul>
Long-term use
<ul>
<li>increased risk of triggering/aggravating psychiatric and/or mood disorders (anxiety, schizophrenia, depression, psychosis, bipolar disorder)</li>
<li>increased risk of developing respiratory infections or chronic cough (when smoking)</li>
<li>negative impact on cognitive functions (ability to think and decide)</li>
<li>lead to a decrease in one or more of the effects of cannabis (tolerance)</li>
<li>withdrawal-type symptoms upon abrupt discontinuation of its use</li>
<li>psychological dependence (addiction) characterized by impaired control over drug use, compulsive use, continued use despite harm, and craving</li>
</ul>
The above list of short-term and long-term side effects is not complete. Should you experience any unexpected side effects while taking cannabis for medical purposes, it is advised that you stop consuming cannabis immediately, and contact your health care practitioner or visit the emergency department of your nearest hospital.
References
<ol>
<li>Health Canada, &quot;Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids, 2018&quot;. Available at: <a href="https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html">https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html</a> </li>
<li>Health Canada, “Consumer Information - Cannabis (Marihuana, marijuana),”. Available at <a href="https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/info/cons-eng.pdf">https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/info/cons-eng.pdf</a> </li>
<li>Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA. 2015;313(24):2456–73.</li>
</ol>

Image-CanEduArticles-18652_side-effects-of-cannabis-and-cannabinoids

Side effects of Cannabis and Cannabinoids

Cannabinoids are a diverse class of organic compounds that interacts with specific targets found in the body known as cannabinoid receptors.1 These cannabinoid receptors are involved in the regulation of many functions in the body including brain and nervous system activity, heart rate and blood pressure, digestion, inflammation, immune system activity, perception of pain, reproduction, wake/sleep cycle, regulation of stress etc.1 Cannabinoids when classified according to their origin can be either endocannabinoids (made naturally by our body) or phytocannabinoids (produced by the cannabis plant) or synthetic cannabinoids (produced in the lab).2
More than 100 cannabinoids are found in the cannabis plant.2 The two commonly known phytocannabinoids are ∆9-tetrahydrocannabinol (THC) and cannabidiol (CBD).2 THC is the primary constituent of cannabis responsible for the euphoric effect i.e. &quot;high&quot; feeling, while CBD is a non-euphoric component of the cannabis plant and does not cause a high. Apart from THC and CBD, other phytocannabinoids include cannabigerol (CBG), cannabinol (CBN), cannabichromene (CBC), tetrahydrocannabivarin (THCV), etc.2 These phytocannabinoids are present in inactive state in the plant and requires heating to be activated. Phytocannabinoids are normally extracted and reformulated for medical use e.g. oils, capsules, sublingual spray, topical creams.
Cannabis and cannabinoids have been implicated for potential use in various medical conditions including but not limited to:
<ul>
<li>severe refractory nausea and vomiting associated with cancer chemotherapy</li>
<li>loss of appetite and body weight in cancer patients and patients with HIV/AIDS</li>
<li>pain and muscle spasms associated with multiple sclerosis</li>
<li>chronic non-cancer pain (mainly neuropathic)</li>
<li>severe refractory cancer associated pain</li>
<li>insomnia and depressed mood associated with chronic diseases (HIV/AIDS, chronic non-cancer pain)</li>
<li>symptoms encountered in the palliative/end-of-life care setting.1</li>
</ul>
The potential therapeutic and adverse effects associated with cannabinoids depends on multitude of factors e.g. concentration of cannabinoids, patient’s age and medical condition, previous experience with cannabis etc.1 We strongly advise you to consult your healthcare practitioner to identify the most appropriate cannabinoid to manage your medical condition.
References
<ol>
<li>Health Canada, “Consumer Information - Cannabis (Marihuana, marijuana),”. Available at <a href="https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/info/cons-eng.pdf">https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/info/cons-eng.pdf</a> </li>
<li>Health Canada, &quot;Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids, 2018&quot;. Available at: <a href="https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html">https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html</a> </li>
</ol>

Image-CanEduArticles-18650_cannabinoids

Cannabinoids

Cannabis (marihuana, marijuana) is an annual plant that is frequently found in temperate and tropical climates.1,2 It is one of the oldest plants used for medicinal purposes. It is a dioecious plant, i.e., having separate male and female plants.2 The male plants produce flowers full of pollen, whereas female plants produce large resin-filled flowers. The female plants, when not pollinated, are used for medicinal purposes.
The common species of the cannabis plant are ─ Cannabis sativa, Cannabis indica, and Cannabis ruderalis; however, there is still much debate surrounding the classification of cannabis due to the wide variation in its gene pool.2 Most of the medically used cannabis is a hybrid of sativa and indica cultivars due to extensive breeding programs. Cannabis sativa is a thin-leaved plant that flowers under certain light conditions and is tall with growth up to 5–18 feet with widely spaced branches.2 It tends to produce high amount of THC and is described as having an uplifting and energetic effect. Cannabis indica is shorter (2–4 feet tall), with a denser branch structure and broad leaves.2 Cannabis indica may have sleepy and relaxing effects. Cannabis ruderalis is principally used in hybrids; is smaller than Cannabis sativa, usually (≤2 feet), with auto-flowering characteristics i.e. flowers appear as a result of plant age rather than the light conditions.2
The commonly associated names with cannabis include Ganja, Grass, Ma, Hashish, Hemp, Indian Hemp, Pot, Bhang, and Weed.
References
<ol>
<li>Health Canada, &quot;Information for Health Care Professionals: Cannabis (marihuana, marijuana)and the cannabinoids, 2018&quot;. Available at: <a href="https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html">https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionalscannabis-cannabinoids.html</a>.</li>
<li>Gloss D. An overview of products and bias in research. Neurotherapeutics. 2015;12:731–34.</li>
</ol>

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