Medical Cannabis

In 2017, when the Misuse of Drugs Law (2017 Revision) was passed into law, cannabis extracts (such as those containing THC and CBD) became legal for possession and medical use when prescribed by a medical doctor licensed to practice in the Cayman Islands.

Cannabis flower is illegal in the Cayman Islands. The only legal forms are concentrates available as oils (available in capsule and liquid formats) and vaporiser cartridges.

Cannabis remains a "Part I of Schedule I" controlled drug in the Cayman Islands. Such drugs are formally referred to as "hard drugs" in Cayman's legislation.

Cannabis remains illegal in any form or quantity when not obtained from a pharmacy in the Cayman Islands with a prescription from a medical doctor licensed in the Cayman Islands.

It is illegal to travel internationally with cannabis, even when obtained legally in another jurisdiction.

It remains illegal to travel internationally with cannabis even when it is obtained legally in a visitor's home country.

Any visitor using medical cannabis should ideally reach out to a licensed medical doctor in Cayman prior to their visit to establish a reliable plan to ensure seamless continuity of their treatment during their visit.

Dr. Kwinter is proud to provide outstanding medical care to Cayman's residents and visitors. This includes appropriately providing access to safe, high-quality medical cannabis.

For assistance obtaining medical cannabis during your visit to the Cayman Islands, please book an appointment, or call us at 1-345-623-1000. Dr. Kwinter provides pre-travel virtual consultations to streamline the process for visitors.

There is evidence that cannabis can provide relief from pain for patients with various conditions. Some recent studies in this area are summarized below.

Recent publications:

Medical Cannabis for Chronic Nonmalignant Pain Management
Curr Pain Headache Rep. 2023 Apr;27(4):57-63. doi: 10.1007/s11916-023-01101-w. Epub 2023 Mar 10. PMID: 36897501; PMCID: PMC9999073.
"This paper demonstrates that medical cannabis use provides adequate pain management. Patients suffering from chronic nonmalignant pain may benefit from medical cannabis due to its convenience and efficacy."

Therapeutic Potential of Cannabis, Cannabidiol, and Cannabinoid-Based Pharmaceuticals
Pharmacology. 2022;107(3-4):131-149. doi: 10.1159/000521683. Epub 2022 Jan 28. PMID: 35093949.
"In general, data support a role for cannabis/cannabinoids in pain, seizure disorders, appetite stimulation, muscle spasticity, and treatment of nausea/vomiting."

Medical Cannabis for Gynecologic Pain Conditions: A Systematic Review
Obstet Gynecol. 2022 Feb 1;139(2):287-296. doi: 10.1097/AOG.0000000000004656. PMID: 35104069.
A systematic review of 16 studies that evaluated nonpregnant adult women who used cannabinoids for gynecologic pain conditions (e.g. chronic pelvic pain, vulvodynia, endometriosis, interstitial cystitis, and malignancy). Study types included randomized controlled trials, cohort studies, and cross-sectional studies.
Most women ingested or inhaled cannabis and used cannabis multiple times per week, with dosages of THC and CBD up to 70 mg and 2,000 mg respectively. 61-95.5% reported pain relief. The average decrease in pain after 3 months of treatment was 3.35+/-1.39 on the 10-point visual analog scale.
Result: Most women reported that cannabis improved pain from numerous gynecologic conditions.

Medical cannabis or cannabinoids for chronic non-cancer and cancer related pain: a systematic review and meta-analysis of randomised clinical trials
BMJ. 2021 Sep 8;374:n1034. doi: 10.1136/bmj.n1034. PMID: 34497047.
Analysis of 32 trials with 5174 adult patients, of which 29 studies compared medical cannabis or cannabinoids to placebo. Medical cannabis was administered orally in 30 of the studies, topically in 2. Clinical populations included non-cancer pain (28 studies) and cancer related pain (4 studies).
Result: Small to very small improvement in pain relief, physical functioning, and sleep quality with only transient side-effects including cognitive impairment among others.

Cannabis and cannabinoids in cancer pain management
Curr Opin Support Palliat Care. 2020 Jun;14(2):87-93. doi: 10.1097/SPC.0000000000000493. PMID: 32332209.
"Recent findings: A cohort study using nabiximols on advanced cancer pain in patients already optimized on opioids, over 3 weeks, demonstrated improved average pain score. A large observational study of cancer patients using cannabis over 6 months demonstrated a decreased number of patients with severe pain and decreased opioid use, whereas the number of patients reporting good quality of life increased."

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington (DC):
National Academies Press (US); 2017 Jan 12. PMID: 28182367.
"There is conclusive or substantial evidence that cannabis or cannabinoids are effective: For the treatment of chronic pain in adults"

Insomnia is one of the most common conditions treated with medical cannabis. Given the typical time of administration and favourable safety profile of cannabis compared to other sedatives there is a strong argument for cannabis as treatment for this indication.

Recent publications:

An investigation of cannabis use for insomnia in depression and anxiety in a naturalistic sample
BMC Psychiatry. 2022 Apr 28;22(1):303. doi: 10.1186/s12888-022-03948-6. PMID: 35484520; PMCID: PMC9052466.
"In terms of perceptions, individuals with depression, anxiety, and both conditions who use cannabis for insomnia report significant improvements in symptom severity after cannabis use. The current study highlights the need for placebo-controlled trials investigating symptom improvement and the safety of cannabinoids for sleep in individuals with mood and anxiety disorders."

Medical cannabis and cannabinoids for impaired sleep: a systematic review and meta-analysis of randomized clinical trials.
Sleep. 2022 Feb 14;45(2):zsab234. doi: 10.1093/sleep/zsab234. PMID: 34546363.
"Conclusion: Medical cannabis and cannabinoids may improve impaired sleep among people living with chronic pain, but the magnitude of benefit is likely small."

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington (DC):
National Academies Press (US); 2017 Jan 12. PMID: 28182367.
"There is moderate evidence that cannabis or cannabinoids are effective for: Improving short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnea syndrome, fibromyalgia, chronic pain, and multiple sclerosis (cannabinoids, primarily nabiximols)"

Like other psychoactive medicine, cannabis can produce relaxation and elevated mood, alleviating generalized anxiety, social anxiety, and depression. There is evidence that cannabis can improve additional mental health conditions including post traumatic stress disorder.

Some patients report unequivocal improvement while others report exacerbations of symptoms. There are multiple factors that can account for the inconsistent results. It is likely that there exists a relatively narrow therapeutic window for mental health effects where small doses have positive effects and large doses cause negative effects. The precise blend of cannabinoids and terpenes in specific products may generate diverse effects in different individuals. It is also likely that there is inconsistency in response due to patient factors given the multifactorial causes of mental health conditions. One intriguing theory along these lines is that of a potential "endocannabinoid deficiency" among some patients with mental health symptoms that are improved with cannabis.

Patients who have found that their mental health symptoms are improved from non-medical cannabis may benefit from switching to a medical cannabis product, which comes from a safe source and can be dosed in a reproducible manner.

Patients who have not yet had a trial of medical cannabis for a mental health condition are cautioned to "start low and go slow" and to have close follow-up to maximize their likelihood of success.

References:

Medicinal cannabis for psychiatric disorders: a clinically-focused systematic review.
BMC Psychiatry. 2020 Jan 16;20(1):24. doi: 10.1186/s12888-019-2409-8. PMID: 31948424; PMCID: PMC6966847.
"There is currently encouraging, albeit embryonic, evidence for medicinal cannabis in the treatment of a range of psychiatric disorders."

Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-naïve social phobia patients.
Neuropsychopharmacology. 2011 May;36(6):1219-26. doi: 10.1038/npp.2011.6. Epub 2011 Feb 9. PMID: 21307846; PMCID: PMC3079847.
"Pretreatment with CBD significantly reduced anxiety, cognitive impairment and discomfort in their speech performance, and significantly decreased alert in their anticipatory speech."

There is evidence of safety of medical cannabis in the Parkinson's Disease (PD) patient population. To date evidence of benefit is limited. Variability of effect is high in this patient population, as patients with PD often experience multiple symptoms, which may be helped with cannabis to different degrees. More research is required.

References:

Effects of Cannabis in Parkinson's Disease: A Systematic Review and Meta-Analysis
J Parkinsons Dis. 2022;12(2):495-508. doi: 10.3233/JPD-212923. PMID: 34958046.
Five randomized controlled studies utilizing oral capsule cannabis administration showed no significant safety issues. The studies showed, to varying degrees, improvement in anxiety, tremor, dyskinesia, functioning and wellbeing of PD patients. Eighteen non-randomized studies showed additional side effects including cough (in groups that smoked cannabis) and very small numbers of cases of psychosis (<1%), restlessness, hallucinations and confusion.

There have been more than a dozen randomized controlled clinical trials demonstrating the efficacy of cannabis treatment for spasticity associated with multiple sclerosis. The American Academy of Neurology released evidence-based guidelines for physicians recommending a cannabis oral extract containing both THC and CBD for the treatment of spasticity and pain in patients with multiple sclerosis.

References:

Summary of evidence-based guideline: complementary and alternative medicine in multiple sclerosis: report of the guideline development subcommittee of the American Academy of Neurology
Sleep. 2022 Feb 14;45(2):zsab234. doi: 10.1093/sleep/zsab234. PMID: 34546363.
"Clinicians might offer [oral cannabis extract (OCE)] to patients with MS to reduce patient-reported symptoms of spasticity and pain (excluding central neuropathic pain) (Level A) and might counsel patients that this symptomatic benefit is possibly maintained for 1 year (Level C), although OCE is probably ineffective for improving objective spasticity measures (short-term) or tremor (Level B).
Clinicians might offer THC to patients with MS to reduce patient-reported symptoms of spasticity and pain (excluding central neuropathic pain) (Level B). Clinicians might counsel patients that this symptomatic benefit is possibly maintained for 1 year (Level C), although THC is probably ineffective for improving objective spasticity measures (short-term) or tremor (Level B)."

There are many patients who report the ability to tolerate and control side effects of chemotherapy when using cannabis products. Symptoms that can improve and in some cases resolve include anorexia, nausea, vomiting, peripheral neuropathy, fatigue, insomnia, stress, anxiety, and depression.

Emerging evidence also suggests that cannabis may have immunological and antineoplastic effects. This is still controversial. There are many theories regarding the possible mechanisms of this and it is an important area of active research.

References:

Should oncologists trust cannabinoids? Front Pharmacol. 2023 Jul 13;14:1211506. doi: 10.3389/fphar.2023.1211506. PMID: 37521486; PMCID: PMC10373070.

Cannabis use prevalence, patterns, and reasons for use among patients with cancer and survivors in a state without legal cannabis access.Support Care Cancer. 2023 Jun 29;31(7):429. doi: 10.1007/s00520-023-07881-6. PMID: 37382737; PMCID: PMC10351025.

Cannabis for cancer - illusion or the tip of an iceberg: a review of the evidence for the use of Cannabis and synthetic cannabinoids in oncology. Expert Opin Investig Drugs. 2019 Mar;28(3):285-296. doi: 10.1080/13543784.2019.1561859. Epub 2018 Dec 29. PMID: 30572744.

Contraindications are considered firm reasons to avoid specific treatments. There are several contraindications to the prescription of medical cannabis. These include:

• Unstable cardiovascular disease
• Respiratory disease [if inhaling cannabis]
• Personal or strong family history of psychosis/bipolar disorder
• Pregnant, planning on becoming pregnant, or breastfeeding
• Under 25 years of age*
• Current or past cannabis use disorder*
• Current or past substance use disorder*

*Identified as relative (partial) contraindications in the source cited. However, favouring the precautionary principle, Dr. Kwinter views these as strong contraindications.

Source:

"Is medical cannabis safe for my patients?" A practical review of cannabis safety considerations. Eur J Intern Med. 2021 Jul;89:10-18. doi: 10.1016/j.ejim.2021.05.002. Epub 2021 May 31. PMID: 34083092.

It is well established that cannabis products can, with a dose-dependent effect, cause impairment of memory, attention, and processing speed. Long-term studies have shown that heavy use beginning at younger ages is a risk factor for neurocognitive deficits.

To some degree the short term adverse cognitive effects of cannabis can be mitigated by strain selection that favours products that contain lower amounts of THC, the primary psychoactive ingredient in cannabis.

Regarding long-term cannabis use, a landmark study from New Zealand followed a representative cohort of 1,037 individuals for 27 years from age 18 to 45, with 94% retention of participants. The concerning conclusions of the study was that "Long-term cannabis users showed cognitive deficits and smaller hippocampal volume in midlife. Research is needed to ascertain whether long-term cannabis users show elevated rates of dementia in later life."¹

It is largely because of this study and the knowledge that certain regions of the brain are not finished their primary development until 25 years of age that many medical doctors consider age under 25 years to be a contraindication to the use of medical cannabis.

References:

1) Long-term Cannabis Users Show Lower Cognitive Reserves and Smaller Hippocampal Volume in Midlife Am J Psychiatry. 2022 May;179(5):362-374. doi: 10.1176/appi.ajp.2021.21060664. Epub 2022 Mar 8. PMID: 35255711; PMCID: PMC9426660.

2) Adverse Effects of Recreational and Medical Cannabis Psychopharmacol Bull. 2021 Jan 12;51(1):94-109. PMID: 33897066; PMCID: PMC8063125.

Separate from its effects on cognition, cannabis has been found to rarely trigger psychotic symptoms. It is believed that this is more likely to occur in patients with pre-existing mental health conditions such as schizophrenia or bipolar disorder. Although infrequent, this adverse effect is typically cited as the reason that preexisting personal or strong family history of psychosis or bipolar disorder are contraindications to the use of medical cannabis.

References:

Rates and correlates of cannabis-associated psychotic symptoms in over 230,000 people who use cannabis Transl Psychiatry. 2022 Sep 6;12(1):369. doi: 10.1038/s41398-022-02112-8. PMID: 36068202; PMCID: PMC9448725.
"Taken together, acute self-limiting psychotic symptoms in the context of cannabis use may occur in about 1 in 200 PWUC's lifetime. Some individuals could be particularly sensitive to the adverse psychological effects of cannabis, such as young individuals or those with pre-existing mental health vulnerabilities."

In 2019 there was an outbreak of cases of a condition now known as E-cigarette or Vaping product Use-Associated Lung Injury (EVALI). Investigations found that THC and/or vitamin E acetate was in the majority of affected patients, either by history or confirmed by toxicology. Vitamin E acetate was a diluent widely used to dilute THC-containing e-cigarettes between 2018 and 2019. Vitamin E acetate is now known to alter lung surfactant function and cause respiratory impairment.¹

According to the CDC: "Vitamin E acetate is strongly linked to THC-containing products used by EVALI patients."²

Additionally, "Vitamin E acetate is strongly linked to the EVALI outbreak; it has been detected in product samples tested by FDA and state laboratories and in lung fluid samples from patients tested by CDC from geographically diverse states. Vitamin E acetate should not be added to any e-cigarette, or vaping, products. In addition, any substances not intended by the manufacturer should not be added to e-cigarette, or vaping, products, including to products purchased through retail establishments."²

"The weekly number of hospital admissions for EVALI reported to CDC peaked at 215 during the week of September 15, 2019 (Figure 1). Since then, the number of cases reported each week has continued to steadily decline."²

Figure 1. Number of patients (N = 2,398) with e-cigarette, or vaping, product use-associated lung injury (EVALI) by week of hospital admission - United States, February 10, 2019-January 14, 2020²

References:

1) E-cigarette, or vaping, product use-associated lung injury: a review. Pneumonia. 2020 Oct 25;12:12. doi: 10.1186/s41479-020-00075-2. PMID: 33110741; PMCID: PMC7585559.

2) Update: Characteristics of a Nationwide Outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injury — United States, August 2019-January 2020. MMWR Morb Mortal Wkly Rep 2020;69:90-94. DOI: http://dx.doi.org/10.15585/mmwr.mm6903e2.

Additional factors that must be taken into consideration before prescribing medical cannabis include:

• Concurrent mood or anxiety disorder
• Risk factors for cardiovascular disease
• Tobacco use
• E-cigarette use
• Severe liver dysfunction/disease
• Medications associated with sedation or cognitive impairment
• Driving or safety sensitive occupations*
• Older adults
• Safe storage of medical cannabis to prevent diversion
• Drug interactions (see section titled "Safety Issues: Drug Interactions")

*It should be emphasized that this includes providing child-care as a parent, teacher or other individual in a position of responsibility or authority. By comparison, the impairment of attention, memory, and judgement by cannabis should not be viewed as any less serious or significant than the effects of alcohol.

Source:

"Is medical cannabis safe for my patients?" A practical review of cannabis safety considerations. Eur J Intern Med. 2021 Jul;89:10-18. doi: 10.1016/j.ejim.2021.05.002. Epub 2021 May 31. PMID: 34083092.

Prior to considering a therapeutic trial of medical cannabis, patients should be forthcoming with their physician regarding any use of common depressants, such as alcohol, opioids, antipsychotics, benzodiazepines, tricyclic antidepressants, or antiepileptics, which may worsen sedation & cognitive impairment when coingested with cannabis.

Additionally, there are many drugs that may potentially interact with THC and/or CBD due to interaction with enzymes involved in drug metabolism. This requires careful medical management. These drugs include:

• Alprazolam
• Amiodarone
• Amitriptyline
• Aripiprazole
• Atorvastatin
• Azole antifungals
• Buprenorphine
• Caffeine
• Carbamazepine
• Cimetidine
• Citalopram
• Clarithromycin
• Clobazam
• Clopidogrel
• Clozapine
• Cyclosporine
• Dabigatran
• Diazepam
• Digoxin
• Diltiazem
• Duloxetine
• Erythromycin
• Escitalopram
• Esomeprazole
• Estrogens
• Fluconazole
• Fluoxetine
• Fluvoxamine
• Grapefruit
• HIV protease inhibitors
• Imipramine
• Isoniazid
• Loperamide
• Macrolides
• Melatonin
• Metronidazole
• Mifepristone
• Mirtazapine
• Moclobemide
• Norclobazam
• Olanzapine
• Ompeprazole
• Pantoprazole
• Phenobarbital
• Phenytoin
• Rifampin
• Rosuvastatin
• Sertraline
• Simvastatin
• Sirolimus
• St. John's wort
• Sulfamethoxazole
• Tacrolimus
• Theophylline
• Ticlopidine
• Valproic acid
• Verapamil
• Warfarin
• Zopiclone

Source:

"Is medical cannabis safe for my patients?" A practical review of cannabis safety considerations. Eur J Intern Med. 2021 Jul;89:10-18. doi: 10.1016/j.ejim.2021.05.002. Epub 2021 May 31. PMID: 34083092.

As with ethanol, some over the counter medications, and many prescription drugs that have psychoactive effects, misuse of cannabis can result in a clinical disorder. This is uncommon in mature adults but is relatively common in cannabis users aged 25 years and younger.

The prevalence of cannabis use disorder seen in many countries among young people is often why age under 25 years is considered a contraindication to medical cannabis.

Source:

Key Substance Use and Mental Health Indicators in the United States: Results from the 2021 National Survey on Drug Use and Health U.S. Department of Health and Human Services

Adverse effects observed in large scale studies of cannabis use include:

• Dizziness (8-13%)
• Dry mouth (7-10%)
• Nausea (3-10%)
• Fatigue (6%)
• Diarrhea (2%)
• Disturbance in attention (2%)
• Vomiting (2%)

Source:

Medical cannabis and cannabinoids for impaired sleep: a systematic review and meta-analysis of randomized clinical trials. Sleep. 2022 Feb 14;45(2):zsab234. doi: 10.1093/sleep/zsab234. PMID: 34546363.

Medical cannabis in the Cayman Islands is available in oral ingested (oil drops or capsules) and inhaled vaporiser formats. Patients who are candidates for medical cannabis should consider the dosage form that is most appropriate for their condition. In general, conditions with persistent symptoms such as chronic pain are best managed with oral oil or capsules, which are slower in onset but have longer durations of action. Conversely, patients with conditions that require fast-action such as for the initiation of sleep, or to treat nausea or migraines should generally consider inhaled vaporized cannabis, which is faster acting but has a shorter duration of action.

It is generally recommended that patients using THC-containing medical cannabis should not drive or engage in safety-sensitive activities for at least 4 hours after inhalation, 6 hours after oral ingestion or 8 hours, if euphoria is experienced.¹

References:

1) "Is medical cannabis safe for my patients?" A practical review of cannabis safety considerations. Eur J Intern Med. 2021 Jul;89:10-18. doi: 10.1016/j.ejim.2021.05.002. Epub 2021 May 31. PMID: 34083092.

If you have questions about medical cannabis please schedule an appointment with Dr. Kwinter at the Cayman Medical Center. Dr. Kwinter has extensive experience prescribing medical cannabis with positive results for many conditions. He is a member of the UK Medical Cannabis Clinicians Society and regularly participates in educational activities to keep up with the latest developments in cannabis research including knowledge of the most effective products for specific conditions.

If you are planning to visit Cayman and are a medical cannabis user in your home country, please book a virtual appointment with Dr. Kwinter if you would like his help to ensure that you can safely and seamlessly access a comparable medical cannabis product during your visit.

For more information about Cannabis from high-quality sources, visit the Cannabis Educational Resources page.