Marijuana in Epilepsy

1. Marijuana in Epilepsy Philippe Douyon, MD Epileptologist Northeast Regional Epilepsy Group

3. Objectives: • Brief overview of seizures/epilepsy • Endocannabinoid System • Mechanism of Action • Impact on the Brain/Theoretical role in Epilepsy • Politics of Marijuana

4. Seizure A sudden surge of electrical activity in the brain

5. Epilepsy: 2 or more unprovoked seizures Epilepsy is the fourth most common neurological disorder and affects people of all ages Epilepsy means the same thing as "seizure disorders"  Epilepsy is characterized by unpredictable seizures and can cause other health problems  Epilepsy is a spectrum condition with a wide range of seizure types and control varying from person-to-person

11. Medically Intractable Epilepsy • No single step in treatment defines intractability • After each drug failure, the statistical probability of seizure control by the next drug becomes lower, but it never approaches zero

13. Epileptic Encephalopathies • Dravet Syndrome • Lennox-Gastaut Syndrome • West Syndrome • Landau-Kleffner Syndrome

27. Howard compares his seizures to electricity and lightning. He asks, "What is it like to be split open from the inside by lightning?” He provides one answer: "The actual seizure was when the bolt touched flesh, and in an instant so atomic, so nearly immaterial, nearly incorporeal, that there was almost no before and after . . . and Howard became pure, unconscious energy"

29. Endogenous cannabinoids • CB1 regulates neuronal excitability • Neuronal hyperexcitability is associated with seizures • No studies –endogenous cannabinoid system in an intact model of epilepsy

30. CB1 receptors are concentrated in the hippocampus, association cortices, basal ganglia, cerebellum, spinal cords, and peripheral nerves CB1 receptors are notably absent from the thalamus and brainstem

34. Systematic review: Efficacy and safety of medical marijuana in selected neurologic disorders: Report of the Guideline Development Subcommittee of the American Academy of Neurology • Barbara S. Koppel, MD, FAAN, John C.M. Brust, MD, FAAN, Terry Fife, MD, FAAN, Jeff Bronstein, MD, PhD, Sarah Youssof, MD, Gary Gronseth, MD, FAAN and David Gloss, MD

35. Spasticity in patients with MS • Central pain and painful spasms in MS • Bladder dysfunction in MS • Involuntary movements, including tremor, in MS • Dyskinesias of Huntington disease, levodopa induced dyskinesias in PD, cervical dystonia, and tics of Tourette syndrome • Seizure frequency in epilepsy

36. Analytic Process • Searched Medline, EMBASE, PsychINFO, Web of Science, and Scopus • 1,729 abstracts • Surveys, case reports/series, non placebo-controlled trials were excluded • Reviewed the full text of 63 articles • 33 articles met inclusion criteria

37. Do cannabinoids decrease seizure frequency? • No Class I-III studies • 2 Class IV studies that did not demonstrate a significant benefit and did not show adverse effects over 3-18 weeks of treatment • Conclusion: “data is insufficient to supports or refute the efficacy of cannabinoids for reducing frequency”

38. The AAN review also concluded that there is not enough information to show if medical marijuana, including smoked medical marijuana, is safe or effective in these neurologic diseases: •Motor symptoms in Huntington’s disease •Tics in Tourette syndrome •Cervical dystonia (abnormal neck movements) •Seizures in epilepsy

39. There are safety concerns with medical marijuana use. Side effects reported in at least two studies were nausea, increased weakness, behavioral or mood changes, suicidal thoughts or hallucinations, dizziness or fainting symptoms, fatigue, and feelings of intoxication. There was one report of a seizure. Mood changes and suicidal thoughts are of special concern for people with MS, who are at an increased risk for depression or suicide. The studies showed the risk of serious psychological effects is about 1 percent, or one in every 100 people. In general, medical marijuana is prescribed as a treatment for use only when standard treatment has not helped.

41. “Don’t let my daughter die”

42. NJ Senate Bill 2842 • Prohibits limitations on number of strains of medical marijuana cultivated, and expands available means of packaging and distribution therof.** • Approved September 10th 2013

43. http://www.state.nj.us/health/medicalmarijuana/index.shtml

44. Alternative Treatment Centers (ATC) NJ

45. Alternative Treatment Centers (ATC) NJ

46. N.Y. / Region |​​NYT Now Connecticut Allows Medical Marijuana, but Sellers Encounter Hurdles By JOSEPH BERGERMAY 1, 2014 http://www.nytimes.com/2014/05/02/nyregion/medical-marijuana-is-legal-in-connecticut-but-not-yet-sold.html?_r=0

47. Medical marijuana could be legalized in New York this spring: advocates “Proponents of medical pot say newly revised legislation could be approved in Albany this year, which would make New York the 22nd state to legalize medical marijuana. Gov. Cuomo has hinted at his support, but opposition remains in the state Senate.” BY GLENN BLAIN  NEW YORK DAILY NEWS   Published: Sunday, April 27, 2014, 7:44 PM

49. Medical Marijuana Refugees