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It's an interesting time in Australia's medical cannabis landscape.Cannabis has a long global history, traversing prohibition and the ‘war on drugs’ to becoming a recognised therapeutic option for Australian patients.Discover cannabis throughout history, and its evolution in modern day healthcare. Empower yourself with the knowledge of the history of both social and medical history of medical cannabis in Australia and globally. Preview this module by watching the video above. Estimated Duration: 1 hour Access Duration: 12 months from date of purchase Learning Outcomes Upon completion of this module, you’ll be able to: Cannabis and its historical context: When, where and the discovery of the plants therapeutic properties occurred. The complex social attitudes affecting the plants status as a medicine throughout history. Where medical cannabis came from and where it is having the most impact now.

The medical cannabis landscape in Australia is rapidly evolving, with an increasing range of products available to meet diverse patient needs. This fundamental module offers a comprehensive introduction to medical cannabis products, including key classifications, routes of administration, and the therapeutic roles of cannabinoids such as THC and CBD. You’ll explore the endocannabinoid system (ECS) and learn how factors like onset of action, bioavailability, and duration of effect influence product selection and patient outcomes. Ideal for healthcare professionals new to the field, this module builds essential knowledge to support safe, effective integration of medical cannabis into patient care. Preview this module by watching the video above. Estimated Duration: 1 hour Access Duration: 12 months from date of purchase Learning Outcomes Upon completion of this module, you’ll be able to: Define endogenous and exogenous cannabinoids Summarise the role and function of the endocannabinoid system (ECS) Describe the properties of THC and CBD, including their potential therapeutic and medicinal effects Describe different medical cannabis product categorisations Identify, for different administration methods, speed of onset, bioavailability and duration of effects Explain considerations when selecting medical cannabis products to improve safety and efficacy for patients

This module explores the endocannabinoid system (ECS) and its critical role in the effects of medical cannabis. It examines the discoveries that shaped our understanding of the ECS, its primary components—such as CB1, CB2, and TRPV1 receptors—and the mechanisms of retrograde cell signaling, which underpins how cannabinoids influence physiological processes. Participants will learn about the role of ECS ligands and non-ligand mediators in cannabis pharmacology, the concept of endocannabinoid tone, and factors that can affect it. Clinical considerations are addressed to provide a deeper understanding of how the ECS informs the safe and effective use of medical cannabis in patient care. Preview this module by watching the video above. Estimated Duration: 1 hour Access Duration: 12 months from date of purchase Learning Outcomes Upon completion of this module, you’ll be able to: Describe the discoveries that shaped today's understanding of the endocannabinoid system (ECS) Explain the functions of the ECS, its main components, and how they interact Discuss the function and benefits of retrograde cell signalling Outline the roles and functions of cannabinoid receptors CB1 and CB2, and vanilloid receptor TRPV1 Identify ECS ligands and non-ligand mediators and describe their role in ECS function Define endocannabinoid tone and its influencing factors Discuss clinical considerations related to the ECS

When chronic pain from repeated injuries forced legendary basketballer Lauren Jackson into retirement, her journey to recovery became a complex challenge. But Lauren defied the odds, returning to the court to play in the Australian squad for the FIBA Women's Basketball World Cup in 2022. This case study explores the challenges faced by female athletes in high-impact sports, including the prevalence of bone stress and joint injuries, the impact of hormonal factors, and the complexities of chronic pain management. It also addresses how medical cannabis was incorporated in Lauren's treatments. Healthcare practitioners will gain insights into: The pathophysiology of common injuries in female athletes, including bone stress and joint injuries Potential benefits and limitations of medical cannabis in managing chronic pain and aiding recovery Considerations for incorporating medical cannabis into treatment plans alongside conventional therapies. Strategies for discussing medical cannabis with patients while prioritiding safety and minimising risks Explore the evidence and evaluate how medical cannabis might fit within a broader approach to managing chronic conditions and sports-related injuries. Preview this module by watching the video above. Estimated Duration: 1 hour Access Duration: 12 months from date of purchase Learning Outcomes Upon completion of this module, you’ll be able to: Explain the pathophysiology of common conditions and impact-based sporting injuries for female athletes and identify common management strategies Discuss the potential benefits and limitations of medical cannabis as a treatment option for symptoms of chronic sporting injuries and recovery from surgery Discuss the potential benefits and limitations of medical cannabis as a treatment option for symptoms of endometriosis Explain how medical cannabis treatment may integrate into and influence prescribed opioid treatment outcomes and effects Identify suitable candidates for medical cannabis treatment Devise treatment plans that consider patient safety and minimise risk Facilitate clinical discussions with patients around medical cannabis as a therapeutic option in the management of chronic conditions, impact-based sporting injuries and recovery from surgery Disclaimer: Lauren has a financial interest in a medicinal cannabis company. Lauren is not receiving any financial remuneration from SAGED for her involvement in this case study.

‘Unapproved’ products: Prescriber access pathways explained Published: October 2025 Accessing medical cannabis in Australia can feel complex—for both patients and healthcare practitioners.1 While demand for medical cannabis has grown steadily, it is still considered an ‘unapproved’ therapeutic good under the Therapeutic Goods Administration (TGA) for most conditions.1 This means that, in most cases, practitioners must first demonstrate that conventional, registered medicines have been tried or deemed unsuitable before turning to medical cannabis.2 Yet for many patients, especially those living with chronic pain, conventional treatments provide limited relief3—highlighting the importance of clear, workable access pathways to ‘unapproved’ products. So how does this work in practice? How do Australian practitioners access medical cannabis for their patients? Accessing medical cannabis in Australia There are two primary pathways for accessing medical cannabis in Australia, each with two sub-categories:4 Special Access Scheme Category A notification pathway Category B application pathway Authorised Prescriber Established History of Use pathway Standard pathway Each of these pathways is designed for different clinical scenarios and levels of oversight. Let’s break them down. 1: Special Access Scheme (SAS) Through the SAS, Australian-registered practitioners can apply to use an ‘unapproved’ medicine—such as medical cannabis—for an individual patient on a case-by-case basis.2 1.1: SAS-A – notification for a seriously ill patient SAS-A allows practitioners to prescribe an ‘unapproved’ medicine, such as medical cannabis, for patients who are seriously ill*.2 This is a notification pathway – which means prior approval from the TGA is not required.2 Compared with SAS-B applications, SAS-A notifications are submitted less frequently.5,6 *Seriously ill is defined as: someone who is ‘seriously ill with a condition from which death is reasonably likely to occur within a matter of months, or from which premature death is reasonably likely to occur in the absence of early treatment’.2 1.2: SAS-B – application for all other patients SAS-B allows qualified practitioners to prescribe an ‘unapproved’ medicine for patients who don’t meet the Category A definition.2 When seeking approval to prescribe an unapproved medical cannabis product under the SAS-B pathway, the practitioner must provide clinical justification.4 This justification should be succinct yet comprehensive, and include:4 A summary of the patient’s symptoms and/or diagnosis Details of prior treatments or procedures that have been trialled or considered, with reasons why therapeutic goods currently included in the Australian Register of Therapeutic Goods (ARTG) are not clinically appropriate An appraisal of the anticipated clinical benefits of the proposed treatment weighed against the potential risks The SAS does not limit applications to specific medical conditions.4 The key requirement is that the prescriber has the necessary knowledge of the patient’s condition and of the product they wish to use.4 SAS-B is an application pathway – which means an approval letter must be obtained from the TGA before the product can be supplied to the patient.2 2: Authorised Prescriber (AP) Registered practitioners can apply to the TGA to become APs of certain medical cannabis products for groups of patients they care for.7 Approval lasts up to five years, and while practitioners don’t need to notify the TGA each time they prescribe, they must provide reports every six months.7 Additional approvals are only needed if the product isn’t already on the Established History of Use list.7 2.1: AP – Established History of Use pathway The TGA’s Established History of Use lists set out which medical cannabis products and conditions have a recognised track record.4 This applies only to Category 1 (CBD ≥98%), Category 2 (CBD ≥60% and <98%), and Category 3 (CBD <60% and ≥40%) oral liquids or capsules for a select few conditions, including refractory chronic pain, anxiety, cancer pain, sleep disorders and autism spectrum disorder.8 For these, doctors can become APs without needing Human Research Ethics Committee (HREC) approval or specialist college endorsement.4 2.2: AP – Standard pathway For medical cannabis products not included on the TGA’s Established History of Use lists, doctors can apply to become APs via the Standard pathway.4 To do so, doctors must first obtain approval from an HREC or endorsement from a specialist college, before lodging their application with the TGA.4 HREC approval or specialist college endorsement includes:9 Applying in writing to an HREC or specialist college for endorsement Providing evidence to justify use of the unapproved therapeutic good Details about the doctors’ training and experience Description of the unapproved therapeutic good the doctor intends to prescribe Clinical justification for use of the unapproved therapeutic good To find an HREC, check the list of HRECs registered with the National Health and Medical Research Council.9 If an HREC is unavailable, endorsement can be sought from a specialist college.9 The specialist college must have expertise relevant to the condition being treated. The list of specialist colleges can be found here.9 The infographic below summarises medical cannabis access pathways most commonly accessed in Australia. Download this infographic here To apply for the SAS or AP pathway, visit: https://compliance.health.gov.au/sas/ Need help deciding which pathway suits your practice needs? Get step-by-step assistance with your SAS-B or AP application from a SAGED Prescriber Support Specialist. Click here for support. Use of the SAS and AP pathway Despite being labelled as complex and time-consuming,1 the TGA’s dashboard shows that the SAS and AP pathway are well utilised, highlighting ongoing patient demand. In 2024 alone, registered practitioners submitted 177,751 SAS-B applications,6 although the SAS-A pathway was less frequently used with 376 SAS-A notifications.5 Over the same period, the TGA granted 22,066 AP approvals, with 407,434 treatments initiated under these approvals between July and December 2024.10,11 Leading conditions for medical cannabis prescription According to the SAS-A and SAS-B dashboards, chronic pain is the leading condition for which medical cannabis is accessed in Australia, followed by anxiety,5,6 reflecting their significant health burden. The Australian Institute of Health and Welfare reported that in 2016, 1.6 million (1 in 5) Australians aged ≥45 years were living with chronic pain.12 Current pharmacological treatments are often limited in effectiveness, with fewer than 20% of patients achieving ≥50% pain relief.3 In light of these limitations, it is estimated that around 600,000 Australians self-medicate with medical cannabis—most commonly for chronic pain.3 The most common conditions for SAS-A notifications and SAS-B applications in 20245,6 Summary Although the regulatory framework for accessing medical cannabis is perceived as complex time-consuming,1 the SAS and AP pathways provide routes for doctors to access unapproved products for their patients.4 The SAS enables case-by-case approvals, with SAS-A reserved for seriously ill patients2 and SAS-B requiring a clinical justification for all other patients.2,4 The AP pathway allows longer-term prescribing for groups of patients, with applications made via either the Established History of Use pathway or the more rigorous Standard pathway, which requires ethics or specialist college approval.4,9 Despite perceptions of complexity,1 these mechanisms are being used extensively.5,6,10 With 1 in 5 Australians over 45 living with chronic pain—and conventional treatments often falling short—medical cannabis may offer an additional therapeutic option, particularly when conventional treatments provide limited relief.3,12

Frances’ journey with fibromyalgia: Medical cannabis for chronic pain associated with fibromylagia Published: September 2025 Disclaimer: This is an anonymised patient case study, written with patient consent. The decision-making in this case study was undertaken by a doctor. The information in this document does not constitute medical advice or treatment recommendations. The use of cannabis based medications is the responsibility of a qualified medical professional who may initiate treatment after reviewing a patient's medical history. Most medical cannabis products are unapproved medicines and are regulated by the Therapeutic Goods Administration (TGA) Special Access Scheme (SAS), for which individual responses may vary. Meet Frances Frances* (pseudonym) is a 32-year-old woman living with fibromyalgia – one of an estimated 3–5% of Australians affected by this chronic condition, which is characterised by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties.1,2 Frances is seeking treatment for persistent pain, poor sleep and daily fatigue related to fibromyalgia. Despite trialling a range of conventional medications, she has experienced only limited relief. Her ongoing pain and exhaustion significantly affects her ability to work, exercise, and maintain daily life. Fibromyalgia presents with a variety of symptoms, including widespread pain, sleep disturbance, fatigue, headaches, mood disorders and irritable bowel syndrome (IBS) and is more common in women than in men.1,2,3 These symptoms often overlap with other conditions such as anxiety, depression, and chronic fatigue syndrome.1,3 Many people living with fibromyalgia describe conventional medical treatments as only partly effective, with burdensome side effects.2,3 Current management usually combines lifestyle and self-management strategies with medications such as antidepressants (e.g. duloxetine), anticonvulsants (e.g. pregabalin) and analgesics.2,3 However, many patients, like Frances, continue to struggle with persistent pain and impaired quality of life despite best-practice care. Frances’s consultation with her doctor Ongoing pain and fatigue, alongside variable responses to standard pharmacological treatments, led Frances and her healthcare team to consider other strategies. Use of medical cannabis is increasingly reported by patients with chronic pain conditions, with some users citing improved pain intensity, sleep, and overall wellbeing.4 These trends highlight the potential role of cannabis-based therapies as adjuncts in managing chronic pain conditions such as fibromyalgia.4 This case study explores how Frances’s medical team carefully assessed her presentation, medical history, risk factors, and possible drug interactions before initiating medical cannabis as part of her management plan. Frances’s doctor collected the following information: Patient information and presentation Presenting condition: Fibromyalgia Age: 32 years Symptoms Widespread musculoskeletal pain – particularly dull back ache Baseline back ache flares to sharp pain during physical exertion Insomnia with frequent night waking leading to daytime fatigue Anxiety – rapid heartbeat, clammy hands Pain assessment Position: Diffuse – neck, shoulders, hips but mainly lower back Type: Chronic with flare-ups after exertion or stress Severity Good days: 4–5/10 Bad days: 7–8/10 Triggers: Exertion, stress, lack of sleep, cold weather Personal and family medical history Medical history Fibromyalgia – diagnosed 2 years ago Generalised anxiety disorder Family history Grandfather – myocardial infarction Allergies: None known Current and past medications and treatments Current medications Amitriptyline – for nerve pain Tramadol Multivitamin Past treatments Sertraline for anxiety (ceased 3 years ago) Morphine and fentanyl during recent hospital admission Buprenorphine patches (ceased 1 year ago) Non-pharmacological treatments Stretches and regular exercises using cross trainer at home Sleeps supported with full body pillows Meditation and breathing exercises Specialist and other healthcare involvement Rheumatologist Ongoing GP management – last seen 6 weeks ago Psychologist Lifestyle factors Smoking: Never Alcohol: Nil Driving: THC liability verbalised Workplace drug testing: N/A Exercise: Stretches and regular exercises using cross trainer at home Support network: Lives with partner and child, parents are supportive Previous use of cannabis Black market cannabis flower intermittently since age 15 years – ceased 1 year prior, nil side effects noted Preferred treatment form: oils Frances' risk assessment & treatment plan Risk assessment Anxiety Given Frances’ history of generalised anxiety disorder, her doctor noted the importance of monitoring mood closely. While CBD may reduce anxiety, THC can in some cases exacerbate it.5 Regular reviews to monitor mood and anxiety symptoms A “start low, go slow” dosing approach6 Driving Inform Frances of the Therapeutic Goods Administration (TGA) guidance that patients must not drive while being treated with medical cannabis that contains THC, noting that measurable concentrations of THC can remain detectable in saliva for many hours after administration.7 Drug interactions CBD may inhibit CYP2C19, CYP2D6 and CYP3A4, which metabolise tramadol and amitriptyline.8 Careful titration and monitoring for side effects such as drowsiness were advised Treatment plan After reviewing Frances’s presentation and history, her doctor developed a personalised treatment plan for fibromyalgia symptom relief. Treatment goals Reduce baseline pain (particularly back pain) Manage pain flares Reduce anxiety Reduce insomnia Initial products prescribed Full spectrum balanced oil (THC 10 mg/mL, CBD 10 mg/mL) Start 0.1 mL twice daily Increase by 0.1 mL every to two days until symptom control is reached Maximum daily dose 3.0 mL Full spectrum indica-dominant oil (THC 20 mg/mL, CBD 1 mg/mL) Start 0.1 mL nocte After two days increase by 0.1 mL Increase by 0.2 mL every 2 days until symptom control is reached Maximum daily dose 1 mL Risk management plan Symptom diary – to record pain scores, doses, sleep quality, and side effects Pre-treatment Depression Anxiety Stress Scales (DASS) assessment – repeated at follow-ups Close monitoring for sedation, dizziness, or gastrointestinal upset Follow-up plan 4- and 8-week reviews, with monitoring of pain, sleep, mood, and functional status Treatment outcomes At 8 weeks: Frances was using 0.3 mL balanced oil in the mornings (already the maximum dose) and reported limited benefit, indicating that this formula was not strong enough to address her symptoms The full spectrum indica-dominant oil has assisted with sleep - Frances is currently using 0.2 mL at night Actions Replace the 10:10 balanced oil with a 25:25 balanced oil (THC 25 mg/mL, CBD 25 mg/mL) Continue with the indica dominant oil nocte Keep up the symptom diary What the research says Exploring the science in Frances’ case, what is the relationship between medical cannabis, the endocannabinoid system, and fibromyalgia? The endocannabinoid system (ECS) – comprising CB1 and CB2 receptors, endocannabinoids, and enzymes – plays a key role in modulating pain, sleep, mood, and immune responses.9 Research suggests that fibromyalgia may be linked to a concept called endocannabinoid deficiency, which may lead to heightened pain sensitivity, poor sleep, and mood disturbances.10,11 CB1 receptors in the brain and spinal cord regulate pain perception, sleep, and mood9 CB2 receptors in immune cells modulate inflammation and pain signalling9 It has been proposed that cannabinoids such as CBD and THC may help restore ECS balance and reduce fibromyalgia symptoms, preferably using a gentle approach with standardised whole-cannabis extracts.10 Clinical evidence for medical cannabis remains limited but is growing: Small randomised controlled trials and a large observational study report that medical cannabis can reduce symptom severity and improve quality of life in patients with fibromyalgia.11 A randomised clinical trial with nabilone, a synthetic cannabinoid, has shown improvements in sleep in patients with fibromyalgia compared to the standard amitriptyline therapy.12 Key Takeaways Fibromyalgia is a complex, multifactorial condition that imposes a substantial burden on quality of life and conventional treatments often provide incomplete relief.1,2 Emerging evidence suggests a role for the endocannabinoid system in fibromyalgia pathophysiology.10 While clinical trials remain limited, cannabinoids, particularly CBD and low-dose THC, may help reduce pain, improve sleep, and enhance wellbeing in select patients.4,10 Frances’s case illustrates how a careful, individualised, and evidence-informed approach – including risk assessment, slow titration and structured follow-up – can support safe and effective access to medical cannabis. Disclaimer: Medical cannabis products may be associated with adverse events. For more information please contact medinfo@saged.com.au. Medical cannabis products are not suitable for use during pregnancy or breastfeeding, for anyone with a history with psychotic disorders, or for those with unstable cardiovascular disease. Treatment for patients under 18 years is recommended under the guidance of a paediatrician. Patients should not drive or operate machinery while being treated with some forms of medical cannabis.

Medical cannabis for chronic non-cancer pain: A practical guide for doctors Published: September 2025 Introduction Chronic non-cancer pain (CNCP) remains one of the most significant challenges in Australian healthcare with one in five Australians experiencing chronic pain.1,2 Historically defined as continuous or recurrent pain that persists for a period of longer than three months 2,3, CNCP is a persistent, multifactorial condition arising from diverse pathophysiological mechanisms and shaped by cultural, psychological, and individual experience.2 It is estimated that between 20 and 40% of patient presentations to general practitioners involve chronic pain, making it one of the most common conditions encountered in primary care.2 Data from the Bettering Evaluation and Care of Health (BEACH) initiative has shown that most presentations of CNCP relate to musculoskeletal conditions such as osteoarthritis and lower back pain, however one in five presentations is neurological.2 Beyond the individual burden, CNCP has a broader societal impact, contributing to disability, unemployment, and significant healthcare costs.1,3-5 Standard pharmacological approaches - including paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, antidepressants, and particularly opioids - often fail to provide adequate long-term relief. 2,5,6 Opioids remain widely prescribed, but evidence for their long-term benefit in CNCP is limited, while risks of dependence, tolerance, overdose, and death are well established.4,7 Non-drug approaches such as physiotherapy and psychological interventions play important roles but are not universally effective.8 Against this backdrop, medical cannabis (MC) has emerged as a therapy of growing interest, offering an adjunctive option for patients who have exhausted conventional treatments.3,5 Evidence for efficacy Evidence supporting medical cannabis in CNCP, whilst limited, is steadily accumulating.3,5 It is theorised that the key active cannabinoids in MC exert complementary analgesic and anti-inflammatory actions: tetrahydrocannabinol (THC) by blocking nociceptive stimuli, and cannabidiol (CBD) by exerting anti-inflammatory and calming effects.3 A 2017 meta-analysis by the Therapeutic Goods Administration (TGA) concluded that medical cannabis was more likely than placebo to produce reductions in pain intensity and to achieve clinically meaningful improvements of 30–50% in pain scores.5,9 While there remains a lack of large randomised controlled trials (RCTs) investigating MC in CNCP, real-world evidence from large cohorts has contributed to the overall body of evidence: Author & Location Study Type & Population Duration Major findings Arkell et al10Australia Real World EvidenceN = 3148 15 months After commencing MC treatment, patients reported significant improvements relative to baseline on all 8 domains of the SF-36, and these improvements were mostly sustained over time (p<0.001) Bar-Lev Schleider et al11Israel Real World EvidenceN = 9985 6 months Prior to treatment initiation: 62.0% of patients reported their pain intensity of 8–10After 6 months of MC treatment:5.0% of patients reported a pain intensity of 8–10 (p<0.001) Safakish et al12Canada ObservationalN = 751 12 months MC treatment associated with improvements in pain severity and interference (p<0.001) observed at 1 month and maintained over 12-months.Significant improvements were also observed in the SF-12 physical and mental health domains (p<0.002); headaches, fatigue, anxiety, and nausea (p<0.002).In patients who reported opioid medication use at baseline, there were significant reductions in oral morphine equivalent doses (p<0.0001) Vickery13 et alAustralia Real World EvidenceN = 3961 2 years Statistically significant improvements (p<0.001) across all outcomes were sustained for over two years, including: clinical global impression; pain interference and severity; mental health scores for depression, anxiety, stress; insomnia; health status scores for physical functions and emotional well-being However, the evidence is not uniformly positive. Some trials have failed to demonstrate the benefit of MC in CNCP. De Vries et al., in a placebo-controlled trial of THC tablets for chronic abdominal pain, found no difference in pain reduction between active treatment and placebo.14 Similarly, Campbell and colleagues, in a study of patients using illicit cannabis in conjunction with prescribed opioids, found no evidence of improved outcomes or reduced opioid use.15 Although this data was collected over a four-year period, the lack of guidance from medical practitioners on optimal use of cannabis for CNCP could have contributed to less than optimal outcomes.15 Interestingly, a number of studies reported an opioid sparing effect in subjects who took medically prescribed cannabis concomitantly with opioid therapy.3,5,12 Taken together, the evidence base suggests that while medical cannabis is not universally effective in CNCP, it could offer benefit for some patients when used as part of an integrative approach.5 Limitations of the evidence Despite promising findings, limitations remain. The majority of positive evidence comes from longer-term large observational and real-world studies, however they are highly heterogeneous in terms of formulation composition, cannabinoid ratios, and delivery methods, whilst the lack of placebo controls may lead to overestimation of MC’s benefits.3 Safety and tolerability As with any therapy, safety is a key consideration. Across clinical trials and observational studies, the most frequently reported adverse effects included fatigue, somnolence, dizziness, cognitive impairment, dry mouth, gastrointestinal upset, and increased appetite. 3 Severe adverse events are rare but do occur, including hallucinations, dysphoria, and cardiovascular complications.3 Long-term safety data remain limited, although recent large-scale studies demonstrated that over 1-2 years of MC treatment, adverse effects, while frequent, were generally mild in nature.10,13 Nevertheless, caution should be exercised in vulnerable populations (see Patient Selection below). Patient selection Deciding which patients are appropriate candidates for medical cannabis is central to safe and effective prescribing.16 MC may not be suitable for all patients with CNCP, and careful consideration of risks, benefits, and alternatives is essential. Additionally, caution is advised in patients with a personal or family history of psychosis, those with unstable cardiovascular disease, and younger adults under the age of 25, due to neurodevelopmental concerns. Pregnant and breastfeeding women should also avoid cannabinoid therapy.3,16,17 Administering medical cannabis in CNCP Beyond the general TGA "Guidance for the use of medicinal cannabis in Australia”, which recommends a ‘start low go slow’ approach to MC dose titration16, there are few guidelines for the dosing and titration of MC in CNCP. A recent consensus-based review sought to define dosing and titration protocols for oral MC in CNCP. The consensus of twenty global experts across nine countries developed three such treatment protocols based on patient factors such as susceptibility to MC, adverse effects and prior cannabis use history: Routine protocol - recommended for most patients (unless sensitive to MC or requiring rapid pain relief).17 *Refer for expert consultation if considering >40 mg/day THC (Adapted from Bhaskar et al. 2021) Conservative protocol - recommended for patients more sensitive to MC’s effects (e.g.frail, complex co-morbidities).17 *Refer for expert consultation if considering >40 mg/day THC (Adapted from Bhaskar et al. 2021) Rapid protocol - recommended for patients in severe pain, requiring palliation, or with a significant history of prior cannabis use.17 *Refer for expert consultation if considering >40 mg/day THC (Adapted from Bhaskar et al. 2021) Breakthrough pain - The authors also made provision for the use of inhaled dried flower MC (either balanced THC:CBD or THC dominant) to be considered for patients experiencing breakthrough pain.17 Integrating medical cannabis into multimodal pain care Medical cannabis should not be viewed as a standalone therapy but as one element of a multimodal pain management plan.1,5 Comprehensive care should incorporate physiotherapy, cognitive behavioural therapy, lifestyle modifications, and social support alongside pharmacological measures.1,5 Within this framework, MC may provide incremental improvements in pain relief, mood, sleep, and overall quality of life, enhancing the effectiveness of other interventions.3,5 Summary Medical cannabis represents an emerging option for the management of chronic non-cancer pain.3,5 While it is not a panacea, evidence suggests that it may provide meaningful improvements in pain, quality of life, and function for selected patients, with an acceptable safety profile.510,13 For some patients, it may reduce reliance on opioids and other medications, and may offer a safer long-term alternative.3,5,12 Prescribers should approach cannabis with the same clinical rigour as any other therapy: starting with careful patient selection, initiating treatment at low doses, monitoring closely, and discontinuing if ineffective.15 When integrated into a multimodal pain management strategy, MC has the potential to enhance outcomes and provide relief for patients whose options have been limited.5 As research expands, doctors may gain greater clarity on optimal formulations, dosing strategies, and long-term outcomes. In the meantime, thoughtful, evidence-informed prescribing may help patients achieve the desired benefit from this evolving therapeutic tool. Disclaimer: Medical cannabis products may be associated with adverse events. For more information please contact medinfo@saged.com.au. Medical cannabis products are not suitable for use during pregnancy or breastfeeding, for anyone with a history with psychotic disorders, or for those with unstable cardiovascular disease. Treatment for patients under 18 years is recommended under the guidance of a paediatrician. Patients should not drive or operate machinery while being treated with some forms of medical cannabis.

Understanding Medical Cannabis Formulations: A Primer for GPs Published: August 2025 Australian general practitioners (GPs) who prescribe medical cannabis are faced with a diverse and rapidly evolving range of formulations to choose from. Beyond selecting a product with the appropriate cannabinoid profile for their patient's presentation, GPs must also consider the route of administration and formulation type, which could significantly impact onset, duration, tolerability, and patient adherence.1,2 This primer explores the key medical cannabis dosage forms currently available, their pharmacokinetic profiles, patient considerations, and practical prescribing tips to help guide formulation decisions. Overview of medical cannabis formulations The two primary active compounds in medical cannabis, Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD), are available as various dosage forms.1,3 Each has distinct benefits and limitations, depending on the therapeutic goal and patient-specific factors.1 The most commonly available forms include: 1. Oral formulations: oils, pastilles, capsules Oral formulations, including oils, and softgel capsules, are the most commonly prescribed medical cannabis products in Australia.4 Oils typically come in bottles with graduated droppers, allowing for flexible dosing. Capsules and pastilles offer convenience and fixed doses.1 Pharmacokinetics: Onset: 60 -180 minutes1Peak effect: 2-4 hours5Duration: 6-8 hours1 Pros and Cons: Pros Cons Discreet and convenient to administer1 Patients with dexterity challenges may find oils difficult to administer9 Suitable for chronic conditions requiring longer-lasting relief1,5 Delayed onset may limit use for acute symptom control1 Slower onset and lower peak concentrations may potentially reduce risk of intoxication6,7,8 Low bioavailability due to first pass metabolism5 Prescribing tips: Start with a low dose, titrate slowly (e.g. “start low and go slow”).1 Oral absorption can be enhanced by administering in the presence of fats and oils thus ideally taken with food.1 2. Inhaled formulations: vaporised dried flower or inhalation oils Medical cannabis can be inhaled via a medical vaporiser device which delivers vapour containing cannabinoids and terpenes to the lungs.9 Smoking is not an approved method for medical cannabis administration in Australia.5 Use of a registered medical vaporizer device reduces exposure to potentially toxic compounds of cannabis smoke and helps to reduce variability in the cannabinoid content delivered.9 Pharmacokinetics: Onset: 5-10 minutes1Peak effect: 15-30 minutes5Duration: 2-4 hours1 Pros and Cons: Pros Cons Rapid onset may be useful for episodic or breakthrough symptoms1 Shorter duration of action than oral formulations with variable bioavailability7 Dose titration is patient-guided - patients stop when symptom relief is achieved (within daily THC limits)9 Not suitable for patients with respiratory disease (e.g. asthma, chronic obstructive pulmonary disease)2 Lack of first-pass metabolism may improve cannabinoid absorption6 May be associated with compliance issues10 Prescribing tips: Inhaled forms may be useful as an adjunct to oral formulations for conditions like chronic pain with breakthrough flares.1 Ensure patients have access to a TGA-approved vaporiser (details: TGA website).5,6 3. Oromucosal sprays These sprays are administered under the tongue or inside the cheek for mucosal absorption.10 Currently there is only one such product available in Australia (nabiximols THC 27mg: CBD 25mg oral spray), which is TGA-approved for spasticity in multiple sclerosis.12 Pharmacokinetics: Onset: 15-45 minutes1Peak effect: 1-2 hours10Duration: 6-8 hours1 Pros and Cons: Pros Cons Faster onset than oral ingestion1 May cause local irritation (dry mouth, oral ulcers) 12 Suitable for patients with swallowing difficulties 8 Can be more expensive than other forms 1 Fixed metred dosing facilitates dose titration and may be easier to administer than some oral formulations 5 TGA-approved for patients with multiple sclerosis only.12 * *Patients may be able to access via Special Access or Authorised Prescriber scheme for other conditions Prescribing tips: Consider oromucosal sprays when rapid symptom relief is needed but inhalation is contraindicated, such as in patients with respiratory disease.2,10 Six to eight sprays of nabiximols are generally required for symptomatic relief with a daily limit of 12 sprays.11 4. Topical preparations Topical formulations such as creams, ointments, or gels are suitable for localised symptoms such as dermatological conditions or arthritis pain.1 They exert their actions locally rather than systemically.1 THC is not well absorbed via the skin however CBD and the minor cannabinoid cannabinol (CBN) are much more permeable than THC.5 Pharmacokinetics: Onset: 5-120 minutes13Peak effect: variable 13Duration: variable13 Pros and Cons: Pros Cons May be useful for localised pain or inflammation 13 Limited clinical evidence to support efficacy1 Low risk of intoxication or systemic side effects13 Local side effects such as contact dermatitis13 Steady delivery of active compounds over prolonged period13 Variable absorption through the skin barrier13 Administration tips: Topical preparations should not be applied to broken skin.14 Advise patients not to rub the topical preparation into the skin vigorously.14 Factors to consider when choosing a formulation 1. Symptom profile and onset requirements Acute symptoms → inhaled or oromucosal.1 Chronic conditions → oral formulations.1 Mixed profiles → combination therapy.1 2. Patient preference and practicality Some prefer oils, capsules for discretion. Others prefer inhaled forms for feedback. Consider dexterity, cognition, access to devices. 3. Safety and contraindications Avoid inhaled in respiratory disease.2 Avoid THC in pregnancy, unstable CV disease, psychiatric history.5 Watch drug interactions with hepatic enzymes.5 4. Dosing control and titration Oral oils: flexible but delayed onset.1,10 Capsules/pastilles/sprays: consistent dosing.1,13 Inhaled: rapid but variable.1,8 Summary Clinicians prescribing medical cannabis have a considerable array of dosage forms to choose from. Understanding the factors that influence formulation selection may be central to safer more effective patient care.1,2 Choosing the most appropriate dosage form may enhance therapeutic outcomes, minimise side effects, and improve adherence.1,2 By familiarising themselves with the available formats (oral, inhaled, oromucosal, topical) and considering patient-specific needs and preferences, GPs may be better positioned to deliver personalised and evidence-informed care in this emerging therapeutic area. This article is intended for educational purposes and does not replace clinical judgment or regulatory requirements. Disclaimer: Medical cannabis products may be associated with adverse events. For more information please contact medinfo@saged.com.au. Medical cannabis products are not suitable for use during pregnancy or breastfeeding, for anyone with a history with psychotic disorders, or for those with unstable cardiovascular disease. Treatment for patients under 18 years is recommended under the guidance of a paediatrician. Patients should not drive or operate machinery while being treated with some forms of medical cannabis.

Cannabinoid Hyperemesis Syndrome: An Emerging Challenge in Patient Care Published: August 2025 Cannabinoid Hyperemesis Syndrome (CHS) is a condition increasingly observed among long-term users of cannabis.1,2 Despite cannabis being proposed for its antiemetic effects, this very same compound has been linked to CHS, a condition marked by recurring nausea, vomiting and abdominal pain, often severe enough to require emergency medical care.1,3 Increasing awareness and understanding of CHS among both patients and clinicians may play a key role in promoting safer, more effective treatment outcomes as early recognition and management of this syndrome may reduce the risk of potentially serious sequelae.1,2,4 What is Cannabinoid Hyperemesis Syndrome? Cannabinoid Hyperemesis Syndrome is a condition characterised by cyclical episodes of nausea, intractable vomiting, and abdominal pain following prolonged cannabis use.1 First described in 2004, CHS remains underdiagnosed and often mistaken for other gastrointestinal conditions such as cyclic vomiting syndrome (CVS).1,3 According to the Rome IV diagnostic criteria, CHS is defined by: Stereotypical episodic vomiting similar to CVS in onset and duration A history of prolonged cannabis use Relief of symptoms with sustained cannabis cessation.5 An additional defining feature of CHS is that patients often find relief through taking very hot showers or baths.1 Whilst the exact pathophysiology of CHS is not yet fully elucidated, it appears to be linked to the overstimulation of CB1 endocannabinoid receptors in the endocannabinoid system (ECS) by the cannabinoid tetrahyrdocannabidiol (THC), leading to changes in the body’s emetic control centres in the central nervous system and brainstem.1,2 Another proposed mechanism involves THC binding to the TRPV1 (transient receptor potential vanilloid 1) receptors, which is involved in pain and temperature perception and regulation of gut motility.1,2 Paradoxically, while low doses of cannabis exert antiemetic effects through ECS modulation and hypothalamus-pituitary-adrenal (HPA) axis suppression, chronic use of cannabis containing high-strength THC may have the opposite effect, leading to overstimulation of the ECS — one of the proposed mechanisms behind CHS.1,3,4 Cannabinoids at a Glance The two primary cannabinoids are: THC (Tetrahydrocannabinol): The psychoactive compound that binds to CB1 receptors in the central nervous system, and is believed to influence appetite, mood, pain, and nausea.2,6 CBD (Cannabidiol): A non-intoxicating cannabinoid with a weaker affinity for CB1/CB2 receptors, more commonly associated with anti-inflammatory and immunomodulatory effects.2,6 How common is CHS? The true prevalence of CHS is difficult to ascertain and likely underreported.1,2 This is partly because CHS symptoms overlap with other conditions, and in some jurisdictions, stigma and legal concerns around cannabis use lead patients to withhold disclosure of their medical cannabis use from healthcare providers.1,7 However, recent data highlight a growing concern: A study in a United States urban hospital estimated that 32.9% of chronic users of cannabis (20+ days/month) met the criteria for CHS, which extrapolates to approximately 2.75 million cases annually in the United States.7 In Australia, a six-year retrospective review undertaken at a Melbourne emergency department identified 142 CHS-related visits. The median patient age was 31 years, with nearly 69% male, highlighting its prevalence among younger adults.8 With cannabis potency and use increasing worldwide, the incidence of CHS may be expected to rise unless proactively addressed.1-3 Stages and management of CHS Patients experiencing CHS typically present to the emergency department whilst demonstrating acute gastrointestinal symptoms.7 However, according to the American Gastroenterological Association, CHS progresses through four distinct stages:2 Prodromal Phase – Early symptoms such as nausea, anxiety, and abdominal discomfort, often lasting months.2,3 Hyperemesis Phase – Acute onset of relentless vomiting, abdominal pain, dehydration, and compulsive hot bathing.2,3 Recovery Phase – Symptoms improve once cannabis use is stopped.2,3 Interepisodic Phase – Asymptomatic period between episodes; symptoms often return with cannabis reinitiation.2,3 Treatment strategies There is currently no specific pharmacological treatment for CHS. The current cornerstone of management is immediate and sustained cannabis cessation.1,9 Other strategies include: IV fluids and electrolyte correction to manage dehydration9 Hot showers or baths, which may provide temporary relief1 Antiemetics – though many are ineffective in CHS1 Capsaicin cream (a TRPV1 agonist) applied topically to the abdomen has shown some benefit in acute settings1,9 Importantly, failure to recognise and treat CHS can lead to serious complications, including electrolyte and fluid imbalance, renal failure and, in rare cases, death.1,10,11 Is CHS permanent? CHS appears reversible with cannabis cessation.1 Case studies have widely shown that symptoms resolve once cannabis use is stopped.12,13 However, due to limited long-term studies, it remains unclear whether some individuals may develop persistent or recurring symptoms even after cessation.12,13 Implications for medical cannabis use To date, CHS has been primarily associated with chronic recreational use of high-dose THC products.14 However, as medical cannabis becomes more widespread, and as higher-potency THC formulations become more accessible, it is possible that CHS may be increasingly observed among users of medical cannabis.1,2,15 Currently, there is insufficient data to draw conclusions about CHS prevalence in patients using medical cannabis. However, the following precautions are advised: Educate patients about the signs and symptoms of CHS before initiating treatment.4,15 Prescribe the lowest effective dose, especially with high-strength THC products.4,6 Consider CBD-dominant options where appropriate, as CBD has not been linked to CHS.14 Establish a thorough patient history of cannabis use, including prior and current recreational use, as past heavy use appears to increase risk.1,4,15 Summary Cannabinoid Hyperemesis Syndrome represents a growing but still under-recognised adverse consequence of long-term cannabis use.1,2 While it may seem contradictory that cannabis — which has proposed antiemetic effects — can cause intractable vomiting, this reflects the complex and dose-dependent biphasic nature of cannabinoid pharmacology.4 For healthcare professionals, particularly those prescribing medical cannabis, awareness and vigilance are essential.1,4,15 Patient education, careful product selection, and prompt cessation in response to symptoms could potentially reduce risks and improve patient outcomes.1,4,14,15 As the legal and medical landscape around cannabis continues to evolve, understanding CHS may be central to ensuring safe and responsible use of this emerging therapy. Disclaimer: Medical cannabis products may be associated with adverse events. For more information please contact medinfo@saged.com.au. Medical cannabis products are not suitable for use during pregnancy or breastfeeding, for anyone with a history with psychotic disorders, or for those with unstable cardiovascular disease. Treatment for patients under 18 years is recommended under the guidance of a paediatrician. Patients should not drive or operate machinery while being treated with some forms of medical cannabis.

Gina’s Story: Endometriosis, the Endocannabinoid System, and Emerging Approaches to Care Published: August 2025 Disclaimer: This is an anonymised patient case study, written with patient consent. The decision-making in this case study was undertaken by a doctor. The information in this document does not constitute medical advice or treatment recommendations. The use of cannabis based medications is the responsibility of a qualified medical professional who may initiate treatment after reviewing a patient's medical history. Most medical cannabis products are unapproved medicines and are regulated by the Therapeutic Goods Administration (TGA) Special Access Scheme (SAS), for which individual responses may vary. Meet Gina (pseudonym), a 38-year-old woman living with endometriosis—one of an estimated 10% of Australian women affected by this chronic condition, which involves the growth of endometrial-like tissue outside the uterus.1 Gina is seeking treatment for ongoing gastrointestinal and pain-related symptoms associated with endometriosis. Despite trialling a range of conventional medications, she’s experienced limited relief—particularly for her chronic pain, which significantly affects her ability to work and maintain daily functioning. Endometriosis is a condition that can cause a wide range of chronic pelvic pain symptoms, including dysmenorrhea (painful periods), dyspareunia (pain during intercourse), fatigue, dyschezia (pain during bowel movements), and dysuria (pain during urination).1 It may also co-occur with other conditions such as irritable bowel syndrome, rheumatoid arthritis, psoriasis, anxiety, depression, and chronic fatigue syndrome.1 Despite the substantial burden of endometriosis, many patients consider conventional medical treatments to be suboptimal—often citing limited efficacy and unwanted side effects.1 Current management typically involves a combination of medical and/or surgical interventions, including hormonal therapies, non-opioid and opioid analgesics, and neuropathic pain agents.1 While surgery can be effective, it carries high costs, long wait times, and high recurrence rates—often leading to the need for repeat procedures.1,2 Gina’s consultation with her doctor Limited access to surgery and variable responses to pharmacological treatments, have led patients with endometriosis to self-management strategies.1 Cannabis use—both prescribed and non-prescribed—is increasingly reported, with some individuals noting improvements in symptom severity.1 These trends highlight a need for more research into cannabis-based therapies as potential adjuncts in endometriosis care.1 This case study explores how Gina’s medical team carefully assessed her clinical presentation, medical history, potential psychological and cardiovascular risk factors, and possible drug interactions before initiating medical cannabis to support her pain management and overall wellbeing. Gina’s doctor collected the following information: Patient information and presentation Personal and family medical history Current and past medications and treatments Specialist and other healthcare involvement Lifestyle factors Discover Gina’s patient profile below. Presenting condition Female, aged 38 years Presenting condition – endometriosis Symptoms Excruciating dysmenorrhoea since menarche Vomiting, diarrhoea and nausea Low appetite and weight loss Headaches Pain assessment Position – lower abdomen Quality – severe, accompanied by sweating, crying or doubling over in pain Type – intermittent sharp pains and general abdominal tenderness Radiates – to arms or legs Severity Good days – 6–8/10 Bad days – 10/10 Timing – menstruation and ovulation Triggers – stress Personal and family medical history Medical history Endometriosis (stage 4) – diagnosed in 2019 Pericarditis post coronavirus – diagnosed 2022* Generalised anxiety disorder and depression – diagnosed 18 years prior Vitamin D deficiency Allergies Latex Medical history (family) Maternal aunt – endometriosis *This may be a risk factor for medical cannabis.3 Current and past medications and treatments Current medications Drospirenone – 4 mg/day Past medications Tapentadol Physiotherapy sessions – with minimal benefit Remedial massage sessions – with minimal benefit Specialist and other healthcare involvement Cardiologist review of pericarditis – referred back to GP care after diagnosis Lifestyle factors Smoking – No Social considerations Driving – drives to work 2 days per week and on occasional weekend trips THC roadside liability understood: Yes Workplace drug testing – N/A Operates heavy machinery – N/A Previous use of cannabis Use – non-prescribed cannabis daily between 2016 and 2019 Administration – flower via joint or pipe Amount – 2 g per day Effects – reduced pain, relieved bowel cramps, assisted with sleep Assessing risks After reviewing Gina’s profile, her doctor notes potential risk factors relating to her anxiety, cardiovascular health, driving and previous use of non-prescribed cannabis. Below, explore Gina’s potential risk factors and how her doctor managed them. Anxiety Given Gina’s diagnosis of generalised anxiety disorder, her doctor monitored her closely, with regular check-ins to assess mood and anxiety symptoms. As THC can cause feelings of altered mood and anxiety, it should be administered with caution in individuals with anxiety disorder.4 Her doctor ensured that Gina understands the potential mood-related side effects and equipped her with strategies to manage them effectively if they occur. Additionally, she emphasised the importance of starting on a low dose and gradually increasing the dosage as specified in the treatment plan. Cardiovascular health Before prescribing medical cannabis products, her doctor confirmed that Gina’s cardiovascular health is stable by: Reviewing previous cardiac assessments and reports from Gina’s cardiologist Obtaining approval from Gina’s cardiologist and consulting Gina’s regular GP before commencing treatment Monitoring Gina’s electrocardiogram and vital signs throughout the course of her treatment This is of particular importance as cannabis products with THC can cause tachycardia, and is not advised for patients with a history of angina or myocardial infarction.4 Driving As Gina drives to work occasionally, her doctor ensured that Gina is aware of the laws around driving. Current medical cannabis prescribing legislation does not exempt patients from THC-related drug-driving offences.4 THC can impair driving performance and increase crash risk—particularly in occasional users—with effects lasting up to eight hours after oral dosing.5 Patients using THC-containing products should avoid driving and other safety-sensitive tasks, especially during treatment initiation and shortly after each dose.5 In contrast, there is no evidence that CBD impairs driving.5 Patients taking CBD-only medicines can lawfully drive if they are not impaired.5,6 Non-prescribed use of cannabis Gina’s doctor is also concerned about her previous use of non-prescribed cannabis. Cannabis acquired on the black market is unlikely to achieve the desired results and can cause unpredictable and severe adverse reactions as it may contain hazardous ingredients and contaminants—such as microbes, heavy metals and pesticides.7,8 Devising a treatment plan After reviewing Gina’s presentation and medical history, her doctor created a treatment plan to help Gina manage her endometriosis symptoms. Developing a risk management and follow-up plan Gina’s doctor provided her with a risk management plan which included symptom tracking and monitoring of adverse effects, as well as follow-ups scheduled at 4 to 8 weeks to review progress and adjust treatment as needed. Discover Gina’s risk management and follow-up plan below Risk management plan Asked Gina to keep a symptom diary to record pain scores, doses and other symptoms Informed Gina of how to report and respond to adverse effects Conducted a pre-treatment Depression Anxiety Stress Scales (DASS) assessment and will follow up at each check-in Advised Gina to start low and go slow Reviewed Gina’s cardiovascular reports and test results, and obtained cardiologist and GP support before commencing treatment Follow-up plan Follow-ups scheduled for 4- and 8-weeks after initial treatment Review progress and adjust plan as required Monitor cardiovascular results Monitor psychiatric state via DASS results (conducted at each appointment) At 4 weeks: Gina reported that the CBD oil was moderately effective but not as effective as the inhaled product. In response, her doctor prescribed a different oil with the following profile and dosage instructions: THC 10 mg/mL : CBD 10 mg/mL Start: 0.1 mL twice a day After 2 days: increase by 0.1 mL Every 2 days thereafter: increase by 0.2 mL to full symptom control Maximum daily dose: 3.0 mL At 8 weeks: Gina shared that she found the new oil effective, and uses 1.5 mL daily. Gina and her doctor agreed to touch base again in 4 weeks. Exploring the Science in Gina’s Case What Is the Relationship Between Medical Cannabis, the Endocannabinoid System, and Endometriosis? Gina’s doctor has prescribed her with medical cannabis; understanding its proposed mechanism could provide insight into why it may have a role in Gina’s care. Studies have shown that cannabinoid receptors (CB1 and CB2) are highly expressed in ovaries with endometriosis, compared with stromal tissues surrounding the lesion.10,11 As cannabinoid receptors have been implicated in the management of chronic pain and inflammation, these findings suggest that medical cannabis may offer a targeted approach for managing endometriosis-related pain and inflammation at the lesion site.10,11 A recent literature review found that compared to conventional strategies such as analgesics and heat therapy, medical cannabis offered symptom relief for individuals with endometriosis.10 This flow diagram illustrates the potential key therapeutic targets within the endocannabinoid system that interact with cannabis compounds.10 Adapted from Cummings et al. 202410 However, there remains a lack of randomised controlled trials specifically evaluating medical cannabis efficacy for endometriosis-related pain.10 This gap in evidence highlights an important direction for future research—particularly in light of emerging findings that a dysregulated endocannabinoid system may contribute to the pathophysiology of endometriosis.10 Key Takeaways Endometriosis remains a complex condition that significantly impacts quality of life.1 While conventional treatments can help, many patients—like Gina—continue to experience debilitating symptoms despite best-practice interventions.1 Emerging evidence suggests a potential role for the endocannabinoid system in modulating inflammation, pain, and other symptoms associated with endometriosis.10,11 Though clinical research is still developing, the expression of cannabinoid receptors in endometriotic tissue, alongside promising patient-reported outcomes, highlights the potential role of medical cannabis as an adjunctive therapy in selected patients.10,11 Gina’s case illustrates how a personalised, cautious, and evidence-informed approach—grounded in thorough risk assessment and multidisciplinary collaboration—can support safe access to medical cannabis. As with any therapeutic decision, individual patient factors, clinical history, and shared decision-making remain central to guiding care. Adverse event monitoring: Medical cannabis products may be associated with adverse events. For more information please contact medinfo@saged.com.au. Medical cannabis products are not suitable for use during pregnancy or breastfeeding, for anyone with a history with psychotic disorders, or for those with unstable cardiovascular disease. Treatment for patients under 18 years is recommended under the guidance of a paediatrician. Patients should not drive or operate machinery while being treated with some forms of medicinal cannabis. Veeva job code: MONT-SGD-2025-0014Date of preparation: July 2025

Patient Conversations: Why Cultural Safety Matters in Medical Cannabis Prescribing Published: July 2025 As medical cannabis becomes an increasingly accepted therapeutic option in Australia, healthcare professionals should consider not only the clinical aspects of prescribing, but also the cultural safety of their practice. For many patients, particularly Aboriginal and Torres Strait Islander peoples and those from culturally and linguistically diverse (CALD) communities, engaging with the healthcare system can carry risks of misunderstanding, harm, and marginalisation if cultural needs are not recognised and respected.1,2 What exactly is “Cultural Safety”? Cultural safety is a patient-led concept that focuses on whether individuals feel respected, heard, and safe during healthcare encounters.3 It goes beyond merely being aware of cultural differences (i.e. "cultural awareness”) and requires healthcare professionals to reflect on their own biases, power, and privilege while actively adapting their care to meet the needs of the patient’s cultural identity and lived experience.4 Ultimately, it is the patient, not the healthcare professional, who determines whether an experience is culturally safe.3 Why is this important for medical cannabis? Medical cannabis use can be influenced by personal, cultural, legal, and social factors. Patients may have concerns regarding stigma, legality, or family and community expectations.5 For some, complementary medicines may resonate with cultural healing traditions.6 For others, medical cannabis may invoke social stigma from within their communities.6 For Aboriginal and Torres Strait Islander peoples, the impacts of colonisation, systemic racism, and intergenerational trauma can contribute to distrust of mainstream healthcare.1 For CALD communities, differing views about health, medicine, and healing may shape how medical cannabis is perceived.6 Practical considerations for culturally safe medical cannabis prescribing Stigma Acknowledge the historical criminalisation of cannabis and its disproportionate impact on some communities6,7: Be prepared to address patient concerns about legal issues, confidentiality, and fear of judgement. Recognise that concerns around stigma may be heightened among Aboriginal and Torres Strait Islander peoples and CALD patients, who may have previously experienced discrimination within healthcare and legal systems.8,9 Creating a safe, non-judgemental space is essential. This involves using inclusive and respectful language, and reassuring patients about the confidentiality of their care, and the legal and clinical appropriateness of prescribed medical cannabis.8 For Aboriginal and Torres Strait Islander patients, it is important to understand the impact of intergenerational trauma and to approach care with cultural humility and respect for their lived experiences.9 Access and equity Understand that cost, geographic barriers, and language barriers can impact access to medical cannabis.10 Share options and advocate for equitable prescribing pathways, such as the Compassionate Access Schemes offered in some states11 and through selected medical cannabis organisations. Provide translated information where available, engage with interpreters, and guide patients through application processes.8 For Aboriginal and Torres Strait Islander patients, consider the added importance of family and community in decision-making and support models: Collaborate with Aboriginal Health Workers or Aboriginal Community Controlled Health Services (ACCHSs) to provide culturally appropriate care.9 Cultural perceptions Some patients may see cannabis as an extension of traditional medicine6, while others may associate it with substance misuse or illegality6: Approach these discussions with curiosity, not assumptions. Explore patients’ beliefs about healing and medicine, and be open to integrating their cultural practices with medical care where safe and appropriate.8 For Aboriginal and Torres Strait Islander patients, acknowledge the importance of connection to Country, spiritual wellbeing, and traditional healing, and consider these when framing discussions about treatment.9 Supporting cultural safety with SPIKES When introducing sensitive treatments like medical cannabis, healthcare professionals can enhance cultural safety by using structured communication tools. One such tool, the SPIKES framework, was originally developed to aid communication of ‘bad news’ in healthcare12, and can be applied to fostering effective communication with diverse patients. Adapted from Buckman 2005 Summary Medical cannabis may offer symptom relief for some patients when clinically appropriate, but how it is introduced matters. Culturally safe practice, guided by structured, empathetic communication models such as SPIKES12, ensures that care is not only clinically sound but also respectful, empowering and patient-centred.3 Cultural safety isn’t a checkbox; it is an ongoing commitment to reflection, understanding, and partnership. Every conversation is an opportunity to make healthcare a safer, more inclusive space for all. Job code: MONT-SGD-2025-0005 | Date of preparation: July 2025

Managing Respiratory Depression Risk: Exploring CB1 Receptors and Safe Co-Prescribing in Pain, Anxiety, and Palliative Care Published: July 2025 Medical cannabis has gained increasing attention as a therapeutic option for managing pain, anxiety, and symptoms in palliative care. Respiratory depression—particularly associated with opioids and some anxiolytics—remains a significant safety consideration in these settings.1,2 Unlike these medications, cannabinoids do not significantly affect brain stem respiratory centres, due to the low density of CB1 receptors in those areas.3,4 This article explores the mechanisms behind this effect and considers the implications for co-prescribing medical cannabis alongside other agents used in symptom management. Understanding CB1 receptor distribution Cannabinoids exert their effects primarily through two receptors: CB1 and CB2.3,4 CB1 receptors are abundant in brain regions involved in mood, memory, pain, and motor control, while CB2 receptors are more prominent in organs and in the immune system.3,4 However, a key finding in neuropharmacology demonstrated that CB1 receptors are only minimally present in the brain stem, the part of the brain that regulates vital functions such as breathing and heart rate.3,4 In contrast, opioid receptors are densely concentrated in the brain stem.1 When opioids bind to these receptors, they can depress the respiratory centres, reducing the drive to breathe and leading to potentially fatal respiratory depression.1 Due to the lack of significant CB1 receptors in the brain stem, cannabinoids such as tetrahydrocannabinol (THC) do not suppress respiratory function in the way opioids do.5 This fundamental difference means: Medical cannabis use is not associated with respiratory depression.5 Unlike opioids and benzodiazepines, medical cannabis does not pose the same risk of fatal overdose via respiratory failure.5 Simplified diagram demonstrating CB1 receptor distribution in the brain.Figure adapted from Kayser et al. 20196 This safety profile is supported by clinical and preclinical studies showing that medical cannabis, even when used in combination with other medications, does not increase the risk of respiratory suppression that is seen with some other central nervous system (CNS) depressants.5,7,8,9 Implications for pain management Opioid medications form the mainstay of pain management in severe and some chronic pain conditions. They carry a well recognised risk of respiratory depression, overdose and dependence.1,9 Medical cannabis offers several potential benefits in this context: Opioid-sparing effect: Medical cannabis can reduce opioid dosage requirements by providing complementary analgesic effects via different mechanisms.5,7,8,9 Reduced respiratory risk: Lower opioid doses decrease the likelihood of respiratory depression, making the overall pain management regimen safer.8 Multimodal pain relief: Medical cannabis can alleviate different types of pain (e.g. neuropathic, inflammatory) via multiple complementary mechanisms, potentially improving pain control when combined with opioids.10,11 Despite these benefits, co-prescribing medical cannabis and opioids should be undertaken with careful medical supervision and opioid dose adjustment to avoid amplification of common opioid side effects, such as sedation and constipation.11 Considerations for anxiety Anxiety disorders are commonly treated with benzodiazepines and other anxiolytic medications, which also carry risks of sedation and respiratory depression.2,12 Medical cannabis could serve as an either adjunctive or alternative treatment in some patients due to: Anxiolytic effects in certain medical cannabis strains or formulations, especially those higher in cannabidiol (CBD).13 The risk of respiratory depression from benzodiazepines, especially with higher doses.2 The potential to lower benzodiazepine dosages, reducing the risk of developing side effects and/or dependence.7 Due to inter-patient variability in response to CNS medications and medical cannabis, a personalised approach with close monitoring is advised. High-THC products (>10%) may exacerbate anxiety or cause psychoactive effects in some patients.13 CBD is thought to mitigate THC-induced anxiety, highlighting the importance of selecting products with an appropriate THC:CBD ratio, particularly in patients with a history of anxiety.13 Additionally, cannabinoids may inhibit CYP450 enzymes, potentially affecting the metabolism of concurrent medications, including anxiolytics.11 Prescribers should assess drug interactions to minimise the risk of adverse effects such as excess sedation. The role of medical cannabis in palliative care Palliative care patients commonly present with complex symptoms requiring multidrug regimens, including opioids for pain, benzodiazepines or other sedatives for anxiety and agitation, antiemetics for nausea, steroids, and other supportive therapies.14 While clinical evidence on the efficacy of medical cannabis in palliative symptom management remains inconclusive, preclinical studies and case reports suggest potential benefits in managing: Pain relief without increasing respiratory depression risk8, especially in patients with chronic pain.15 Anxiety and insomnia, which are common concerns in palliative care and are frequently reported as having a negative impact on patients’ quality of life.15 Nausea and poor appetite, thereby reducing the risk of malnutrition and cachexia.14,15 Co-prescribing medical cannabis with opioids and other CNS depressants in palliative care requires careful dosing and patient monitoring but could offer a viable adjunctive therapeutic approach in this patient group.16 Broader safety considerations for medical cannabis While medical cannabis has a low risk of respiratory depression5, potential cognitive impairment, psychoactive effects, and possible interactions with other prescribed drugs should all be taken into account when co-prescribing medical cannabis.17 More rigorous clinical trials are needed to develop standardised guidelines for medical cannabis use in combination with other medications, particularly in complex conditions such as those found in palliative care. Summary The low density of CB1 receptors in the brain stem is thought to underlie the lack of respiratory depression associated with cannabinoid use3,4, in contrast to opioids and benzodiazepines which have a strong association with respiratory sequelae.1,2 Given its distinct pharmacological profile, medical cannabis may be considered as an adjunct in pain management, anxiety treatment, and palliative care, particularly where minimising respiratory depressant effects is a clinical priority. Whilst careful co-prescribing and patient-specific considerations remain essential, medical cannabis has the potential to improve therapeutic outcomes while minimising the risk of one of the most significant side effects associated with conventional medications for these conditions. Job code: MONT-SGD-2025-0001 | Date of preparation: July 2025

Understanding Medical Cannabis Strength: A Guide for Healthcare Professionals Published: July 2025 When prescribing medical cannabis, it’s essential to understand and accurately communicate the “strength” of the product. However, the lack of standardisation in the way cannabis strength is represented can lead to confusion, complicating safe prescribing, patient education, and effective transitions between products.1 In this article, we will simplify the key concepts used to describe medical cannabis strength and highlight how these terms impact clinical practice. Methods of Describing Medical Cannabis Strength Current methods for expressing medical cannabis strength are determined by the amount of the two primary cannabinoids, CBD (cannabidiol) and THC (tetrahydrocannabinol) in a product. THC is considered the primary psychoactive component, whilst CBD is thought to modulate THC’s effects.2 The dose at which THC’s psychoactive properties become clinically apparent is generally regarded to be 5 mg.3 Medical cannabis strength can be described in different ways, each with its unique meaning: Total Cannabinoid Content (mg) This measurement describes the actual amount of THC and/or CBD per unit, such as per capsule, gummy, or spray. For example, a capsule might contain 5 mg of THC and 5 mg of CBD. Total cannabinoid content is the most clinically meaningful way to describe cannabis product strength and aligns with the dosing nomenclature used for other medications. For example, a drug may be prescribed with a specific dose in milligrams (such as 5 mg of morphine), and cannabis dosing follows this same principle. Cannabinoid Ratios (e.g. CBD:THC) This ratio describes the balance of two primary cannabinoids in a product. For example, a product with a 20:1 ratio has 20 parts CBD for every 1 part THC. The ratio can help you quickly compare products but doesn’t indicate the actual dose of THC or CBD. For instance, both a 1:1 product containing 2.5 mg of each cannabinoid and one containing 25 mg of each would have the same ratio but differ in dose. Therefore, clinical decisions must reference the exact quantities or percentages of the cannabinoids, not just the ratio. Potency (%) Potency refers to the percentage of a product’s weight that consists of THC or CBD. For instance, a product labeled as 15% THC means each gram of dried flower contains 150 mg of THC. Potency is often used to describe the strength of products like oils, tinctures, and flower, helping to compare their strength quickly. This is especially helpful when assessing products used for inhalation or topical application. Patient tolerance - a key factor affecting dosage and strength Tolerance to cannabis varies significantly from patient to patient.4 Cannabis-naïve patients (first-time users or those with limited experience) are much more sensitive to cannabinoids.4 Therefore, it’s essential to start with a low dose and gradually increase as needed.1 Conversely, experienced users may require higher doses to achieve the desired effect and may benefit from short breaks in therapy to reduce the likelihood of developing tolerance.4 Prescribers should always consider the patient's history when determining dosage.1 TGA Categorisation In Australia, the Therapeutic Goods Administration (TGA) classifies medical cannabis products based on their CBD content.5 This classification can be confusing as it reflects only the proportion of CBD in the product, not its THC or other cannabinoid content. For example, products in the "CBD dominant" category may still contain significant amounts of THC, which could have psychoactive effects. The TGA categorises products into five categories based on CBD percentage: Category 1: ≥98% CBD (Schedule 4) Category 2: ≥60% and <98% CBD (Schedule 8) Category 3: ≥40% and <60% CBD (Schedule 8) Category 4: CBD 2%-<40% (Schedule 8) Category 5: <2% CBD (Schedule 8)5 The categorisation system does not indicate the total strength or amount of THC, which can lead to misunderstandings in clinical practice. Standardising Cannabis Dosing Unlike opioids, where doses are standardised using measures such as oral morphine equivalents (OME), medical cannabis currently lacks a universally accepted standard dosing unit. Researchers have proposed using THC content as a common measure, such as defining a “standard THC unit” as 5 mg of THC6, which is considered a typical psychoactive dose.3 However, this concept is not yet universally adopted, as cannabis contains multiple active compounds, and individual factors (such as patient tolerance) play a significant role in how patients respond to cannabis.6 Clinical Implications and Best Practices Healthcare professionals should focus on the actual quantities of THC and CBD when determining dosages. This ensures safe and effective prescribing. When prescribing, always refer to the total milligrams (mg) of THC and CBD in the product, as this reflects the actual dose a patient will receive. Consider the patient’s tolerance when determining the appropriate dose. Cannabis-naïve patients should start with low doses and increase gradually. Be cautious with TGA categorisation: A product in the "CBD dominant" category may still have enough THC to cause psychoactive effects, so it’s essential to check the cannabinoid breakdown, not just the CBD percentage. Summary The strength of medical cannabis is described in multiple ways - through ratios, potency percentages, and total milligrams - making it vital for healthcare professionals to understand the clinical implications of each. To ensure accurate dosing and patient safety, always refer to the total amount of THC and CBD in the product, and consider patient factors such as experience and tolerance. As the medical cannabis market evolves, the need for clearer and more standardised labeling becomes increasingly important for effective prescribing and patient education. By adhering to these best practices, healthcare professionals can reduce medication errors, improve patient outcomes, and promote best practices in prescribing and dispensing medical cannabis.

The Endocannabinoid System and Clinical Care: Relevance Beyond Cannabis Published: July 2025 While many healthcare professionals are familiar with well-established physiological systems such as the sympathetic nervous system, which governs the body’s fight-or-flight response, fewer are aware of the more recently identified endocannabinoid system (ECS).1 The ECS has been increasingly recognised for its role in a range of regulatory functions, including pain modulation, immune response, stress and emotional regulation, appetite, body weight, and the control of nausea and vomiting.2 Yet, the ECS is not traditionally covered in medical education as highlighted by the Chief Scientific Officer of the Australian National Institute of Complementary Medicine: “I gave a talk at a hospital in Queensland late last year where I asked everyone in attendance—some 130 nurses, doctors, et cetera—whether they had had any training in the endocannabinoid system during their undergraduate training, and not one hand was raised.”3 Why isn’t the ECS taught in medical school? The ECS is relatively new in the context of medical science. The primary cannabinoid receptors—CB1 and CB2—were only identified in 1988 and 1993, respectively.4 Similarly, the two most well-characterised endocannabinoids, anandamide (AEA) and 2-arachidonoylglycerol (2-AG), were discovered in 1992 and 1995.4 This recency has contributed to its omission from traditional medical curricula, which can take years to evolve. Cannabis, which interacts with the ECS,5 has a long history of medical use, dating back over 5,000 years.6 However, by the mid-20th century, it was no longer viewed through a medical lens but instead reclassified as a prohibited substance under the United Nation’s Single Convention on Narcotic Drugs.6 This shift in legislation didn’t just criminalise its use—it also severely limited research.6 With tight restrictions on access to cannabis for scientific purposes, progress on understanding its potential therapeutic benefits, including its interaction with the ECS, stalled for decades. So what exactly is the ECS — and why it matters The ECS is a cell-signaling system composed of three primary components:Endocannabinoids—such as AEA and 2-AG—are lipid-based messengers naturally produced by the body that activate cannabinoid receptors.5 Cannabinoid receptors—CB1 and CB2—are primarily located in the central nervous system and the peripheral immune system, respectively, though both are also found in other tissues throughout the body.5 Enzymes—fatty acid amide hydrolase (FAAH) and monoacylglycerol lipase (MAGL)—are responsible for breaking down endocannabinoids.5 Endocannabinoids are released on demand by the body in response to physiological stimuli.7 Such stimuli may include: stress, obesity, food presentation, exercise, inflammation and tissue injury.2 The figure below outlines various stimuli reported to influence endocannabinoid levels and their observed effects from clinical studies: In neurons, endocannabinoids are released in response to stimuli (such as those mentioned above) and exert their effects through a process called retrograde signalling.12 They are synthesised in the postsynaptic neuron and travel backward across the synapse to bind to receptors on the presynaptic terminal, where they inhibit further neurotransmitter release.12 Emerging research suggests that deficient endocannabinoid signalling, collectively referred to as clinical endocannabinoid deficiency syndromes, may be involved in the pathogenesis of some diseases, including migraine, irritable bowel syndrome, depression, multiple sclerosis and Parkinson’s disease.13 This has led to growing interest in strategies to modulate levels of AEA and 2-AG, including targeting the enzymes that degrade them.13 Pain and inflammation A study by Ramsden et al. offers intriguing insights into the relationship between diet, endocannabinoid tone, and headache severity.14 In participants with chronic headaches, increasing omega-3 intake while reducing omega-6 fats led to lower circulating levels of 2-AG.14 Interestingly, this shift was accompanied by a reduction in headache hours, hinting at the ECS as a potential therapeutic target in managing chronic headaches.14 Stress and anxiety Research into the ECS and psychological trauma has revealed a complex picture.  Hill et al. found that individuals with post-traumatic stress disorder (PTSD) following the World Trade Center attack had low circulating levels of 2-AG compared to healthy controls.15 In contrast, Hauer et al. found the opposite trend in war refugees with PTSD, observing elevated levels of 2-AG compared to controls.16  These differing results suggest that the ECS may respond to psychological trauma in distinct ways depending on the context and intensity of the experience.16 While short-term ECS activation might serve as a protective mechanism during acute stress, prolonged or overwhelming trauma could lead to dysregulation—either depletion or overactivation—of this system.16 Looking ahead Although historically overlooked in medical education,3 the endocannabinoid system is now recognised as one of the key regulators of physiological balance—with roles spanning pain, inflammation, stress, mood, appetite, and immune function.2 As the clinical relevance of endocannabinoid signalling continues to be uncovered, research is rapidly advancing into ECS-targeted therapies—offering novel options for managing complex and chronic conditions, particularly amid growing patient interest in cannabis-based treatments.1,6,7 This evolving understanding carries practical implications for clinical care. While some patients may benefit from cannabis-based treatments, others may experience side effects or find them unsuitable.17 A deeper understanding of the ECS may allow healthcare professionals to identify alternative or adjunctive strategies, and support patient-centred decision-making.3,18,19 As with all areas of clinical science, ongoing research, cautious interpretation of emerging data, and patient-centred dialogue will be key to integrating ECS knowledge into thoughtful, responsible practice. Learn more about the ECS and its clinical implications with this fundamental module or our flagship accredited Medical Cannabis Fundamentals courses for doctors, nurses and pharmacists.