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Patient Handbook
Foreword Big Island Grown s production facility located on the Hamakua Coast has set new standards in the State for medical cannabis cultivation The fully automated facility incorporates clean room technologies to ensure a pathogen free environment Optimal growing environments tailored to the strains maximize the plants expression of cannabinoids and terpenes The data is collected and evaluated to produce desired repeatable results said Dylan Shropshire Chief Production Officer This is the first step in standardizing cannabis medicine Education at Big Island Grown Dispensaries uniquely incorporates information about how a patient s medicine is grown and manufactured at the facility There is an opportunity to connect the dots for patients and provide information about growing methods and cultivation practices that went into the product they are consuming as medicine especially when operating within a vertical system said Jaclyn Moore Pharm D Chief Compliance Officer We are here to provide a Farm to Patient experience for every patient that comes through our doors Big Island Grown is a Big Island based medical cannabis provider Our focus is on providing the highest quality cannabis medicine patients can depend on and healthcare providers can have confidence in their patients consuming We are absolutely dedicated to providing an exceptional patient experience
Table of Contents 329 Cardholder Information 1 How We Grow 3 Visiting Our Locations and House Rules 4 How Cannabis Works 5 Various Methods of Consuming Cannabis 7 Limiting Side Effects and Potential Drug Interactions 9 Sources 11 Quick References 13 Patient Journal Entry Page 18
Cardholder Information Outlined below is information about Hawaii s Medical Cannabis Program This is not an all inclusive list of rules or regulations The current Hawaii Department of Health eligible conditions are as follows ALS Cancer Glaucoma Lupus Epilepsy Multiple Sclerosis Rheumatoid Arthritis HIV AIDS PTSD or a chronic or debilitating disease that produces one or more of the following cachexia or wasting syndrome severe pain severe nausea seizures severe or persistent muscle spasms including those characteristic of MS or Crohn s disease A patient caregiver can register a grow site with the DOH when applying renewing their medical cannabis registration and may cultivate up to 10 plants Each plant must be labeled with 329 registration number and expiration date A patient may purchase up to 4 oz per 15 day period and 8 oz per 30 day period This includes all purchases from all dispensary locations combined A patient or caregiver must have a valid 329 registration card on their person at all times when possessing medical cannabis A patient must not use medical cannabis in a way that endangers the health or well being of another person A patient must not use medical cannabis for purposes other than medical use as permitted by law A patient must not use medical cannabis in any moving vehicle at any work place on any school grounds or in any other public place including public parks beaches recreation centers
Travel Restrictions Hawaii Revised Statutes specifically state that any transportation of medical cannabis on island must be in a sealed container that is not visible to the public Inter island transportation by any means or for any purpose between a qualified patient or primary caregiver and any other entity or individual including an individual who is a qualified patient or primary caregiver is prohibited with the exception of the following The transportation of up to one gram of medical cannabis between patient or caregiver and a certified laboratory is allowed for testing purposes IF the patient or caregiver has a secured an appointment for the testing b obtained confirmation of the appointment that includes the specific date and time for the appointment and c has the confirmation for the secured confirmed appointment available during transport The Department of Homeland Security has stated the Transportation Security Administration s TSA position on cannabis is as follows Possession of marijuana and cannabis infused products is illegal under federal law TSA officers are required to report any suspected violations of law including possession of marijuana and cannabis infused products TSA s screening procedures are focused on security and are designed to detect potential threats to aviation and passengers Accordingly TSA security officers do not search for marijuana or other illegal drugs but in the event a substance that appears to be marijuana or a cannabis infused product is observed during security screening TSA will refer the matter to a law enforcement officer
How We Grow Utilizing today s cutting edge hydroponic growing techniques automated irrigation dosing system and eco friendly organic coco coir media we are able to maximize our ability to produce a consistent quality product Putting years of experience and research into perfecting our proprietary nutrient blend proves to offer superior grade medical cannabis products with elevated cannabinoid and terpene levels providing the best quality medicine and experience for our patients All products used throughout the cultivation process are rigorously tested and heavily scrutinized to provide a consistent standard of quality that surpasses medical standards and patients expectations With recent major advances in indoor lighting options we are utilizing the most up to date technology available for maximum yield and quality Implementing strict data collection protocols allows our cultivation team to continually adjust to always better our growing strategy In order to uphold the DOH s strict testing standards for contamination we have implemented cleanroom protocol procedures to avoid any possible pest or microbial contamination Cleanrooms are typically associated with the pharmaceutical and tech industries Big Island Grown has implemented procedures and equipment to maintain air quality humidity and temperature Ultimately the goal is to control airborne contamination utilizing advanced applications designed to filter out chemical vapors microbes dust and other airborne contaminants Some advanced features include airlock entry for employee access and a requirement for all employees to wear protective clothing inside allowing our cultivation team to produce the cleanest highest grade medical Cannabis for our patients
Visiting Our Locations House Rules Locations in Hilo Kona and Waimea Big Island Grown is dedicated to providing patients with an exceptional experience while visiting our retail locations We appreciate your cooperation and willingness to adhere to our house rules 1 Any patient or caregiver must present both a valid 329 card issued by the Hawaii Department of Health and a valid government issued photo ID every time they enter the dispensary 2 You must be 18 years or older to enter If you are a patient and under the age of 18 your legal guardian or caregiver will need to present their valid 329 card and make purchases on your behalf 3 All patients and or caregiver s information will be validated through the Hawaii Department of Health database prior to entering our secure retail locations 4 Patients and or Caregivers may not purchase cannabis for anyone other than themselves as governed by state law They also may not purchase greater than the limit allowed by state law This limit is currently 4 oz every 15 days This is calculated by utilizing the weight of cannabis flower used in the preparation of all products 5 Hawaii State Law prohibits the use of medical cannabis on the dispensary property This includes the building itself as well as the parking lot of the dispensary This policy will be strictly enforced by our security personnel 6 The dispensary reserves the right to refuse service to anyone who appears intoxicated and or displays unsafe aggressive threatening and or disrespectful behavior 7 Weapons of any kind are not allowed on dispensary property 8 The use of cell phones is strictly prohibited while inside our retail locations No pictures audio and or video may be taken at any time This is to ensure the confidentiality and safety patients and staff
How Cannabis Works Our bodies naturally accept cannabis as medicine To understand how this works we first need to understand the vast system in our bodies called the endocannabinoid system It is within this system that our bodies naturally create chemicals like those found in cannabis It is theorized that the purpose of this system is to maintain homeostasis in the body 1 Deficiencies within this system can lead to a variety of health problems 2 When our bodies are deficient in these naturally occurring substances we can supplement with cannabis Just as deficiencies within this system can lead to health issues maintaining a healthy endocannabinoid system can help prevent and treat and variety of ailments 3 The endocannabinoid system spans throughout the entire body It is comprised of receptors on cells two of which are known as CB1 and CB2 as well as chemicals anandamide and 2 AG 4 Think of CB1 and CB2 receptors as targets when endocannabinoids hit these targets this affects the internal processes of these cells The endocannabinoid system effectively regulates various cell functions and processes throughout the body 5 This all sounds very complicated and it is However we begin to get a better understanding of this system and how important it is when we discuss exactly what the endocannabinoid system controls within the body The endocannabinoid system plays a crucial role in perceiving and responding to stress controls energy metabolism regulates the entire nervous system regulates how we perceive pain controls inflammation controls intestinal processes regulates liver function reproductive function cardiac function bone development motor functions and immune system functions and responses It even plays a role in how our bodies fight against cancer 6 7 8 14 It is theorized that there are over 100 different cannabinoids produced within cannabis plants 9 The two most studied and the ones we will discuss within are THC and CBD THC whose chemical name is tetrahydrocannabinol is an intoxicating compound known to produce the high that users experience when using cannabis The plant actually produces what is known as THCA a non intoxicating compound that when it is heated via combustion or vaporization converts into THC Similarly plants naturally produce CBDA and again when
heated this compound coverts to CBD THC besides causing intoxication can also alleviate neuropathic pain reduce muscle spasticity decrease nausea and increase appetite 1 7 10 There are many other potential health benefits currently being studied around the world CBD or cannabidiol has been shown to offer a multitude of potential health benefits as well all without producing an intoxicating effect 11 It is theorized that CBD can act as an anti inflammatory anti epileptic neuroprotectant and anxiolytic and is currently being studied in a multitude of other clinical applications 12 There are other active compounds in cannabis known as terpenes 13 Terpenes are aromatic compounds found in cannabis products that give each strain its own individual smell and taste Most of these compounds are not unique to cannabis but they can have profound effects on the patient when present in cannabis formulations 6 It is theorized that patient s different experiences with different strains of cannabis may be primarily due to varied concentrations of various terpenes found in each individual strain 7 9 We will outline the most common terpenes found in cannabis and their potential benefits below This is by no means an exhaustive list as there have been over 140 terpenes identified within the cannabis plant 13 Myrcene sedating muscle relaxant hypnotic analgesic anti depressant anti inflammatory 9 16 Alpha pinene bronchodilating anti inflammatory 9 16 Limonene anxiolytic antidepressant anti bacterial 9 15 Linalool sedative anxiolytic analgesic anticonvulsant 9 Beta caryophyllene anti fungal anti bacterial anti inflammatory anti proliferative 9 15 17 Humulene anti inflammatory anti bacterial 18 Alpha terpineol anti bacterial sedative 15
Various Methods of Consuming Cannabis Below we will outline the most common ways to consume cannabis and outline the typical time of onset and duration of effect We will also address pros and cons in some cases as well as summarize typical starting doses Inhalation Smoking and or Vaporizing 19 Typical onset seconds 10 minutes Duration 1 4 hours Smoking is the most common way patients consume cannabis It has a moderate bioavailability Doses can be easily titrated to effect and its rapid onset are considered recognized benefits Smoking can cause general lung irritation so vaporizing is considered an easy and safer alternative to smoking Many patients perceive effects within a few puffs which allows patients to have a high degree of control over dosing Oral Ingestion 19 Typical onset 30 90 minutes Duration 6 8 hours Edible cannabis products have a delayed onset This is where following the motto start low and go slow is imperative THC is converted by the liver to a much more psychoactive form following ingestion which can cause patients to have considerable adverse effects if too high of a dose is consumed 19 20 Sublingual 19 Typical onset 15 60 minutes Duration 1 4 hours Sublingual dosing has become a common way of ingesting cannabis products The bioavailability is high The effects start rapidly and potentially last longer than smoking The dosing is more reliable and more consistent than edible products
Topical 19 Topical preparations of cannabis can be very helpful to patients and rarely cause any psychoactivity or high They can be used to help decrease pain and inflammation locally They can typically be applied liberally and often Suppository 19 21 While not a dosage form used in most patients suppositories are another way to utilize cannabis Anecdotal patient reports suggest little to no intoxication from this form of administration 21 More research is needed to determine the specific bioavailability of cannabis via suppository Suppositories can be utilized in patients who want to target the lower torso specifically or by patients who have damaged or altered upper GI tracts
Limiting Side Effects and Potential Drug Interactions Side effects are possible with cannabis use The severity of symptoms can range from very mild to very intense depending on a variety of factors It should be noted that lethal overdoses of cannabis do not occur 22 and severe side effects are very rare 19 Most side effects that can occur will cause patient discomfort for a relatively short period of time and then pass The response to medical cannabis and potential severity of side effects can vary widely from patient to patient To mitigate potential side effects the motto start low and go slow should be used 19 You can always increase your dose of cannabis but once taken you can t take it away Side effects can range from dry eyes dry mouth dizziness drowsiness increased heart rate decreased blood pressure decreased blood sugar lack of balance increased appetite decreased motor function decreased cognitive abilities and short term memory loss to panic attacks and exacerbations of psychosis symptoms 19 23 It should be noted that many of the more severe side effects occur in patients that ingest high dose edible products The liver converts delta 9 tetrahydrocannabinol what we call THC to 11 hydroxy delta 9 tetrahydrocannabinol 11 hydroxy THC is estimated to be over 3 times more potent than THC which explains the increased potential for side effects with edible products 24 If you are currently taking prescription drugs or supplements you should discuss cannabis use with your physician and or pharmacist There are potential drug interactions possible with a variety of pharmaceuticals when combined with cannabis To assess the possibility of potential drug interactions your doctor or pharmacist will need to know that THC is metabolized by CYP3A4 and CYP2C9 and CBD is metabolized by CYP3A4 CYP2C9 and CYP2C19 25 Pharmaceuticals that inhibit these systems can increase THC and CBD levels while pharmaceuticals that induce these systems can decrease THC and CBD levels It should also be noted that THC is a CYP1A2 inducer and CBD is an inhibitor of CYP3A4 and CYP2D6 25 Many classes of medications fall into these categories for potential interactions with cannabis Consuming cannabis while taking these medications is not
contraindicated however proper monitoring and potential dosage adjustment should be discussed and monitored by a physician Examples of common drug classes that may have potential drug interactions are as follows this list is not inclusive SSRI s Benzodiazepines Chemotherapy Anti Retrovirals Antidiabetic drugs Immunosuppressants Antibiotics Antifungal drugs Blood pressure and or cholesterol drugs If you are currently taking a medication that is designated as having a narrow therapeutic index it is even more critical that you tell your physician about your medical cannabis use These types of medications have an even higher chance of needing to be dose adjusted when used with cannabis Examples are as follows this list is not inclusive Phenobarbital Carbamazepine Valproic Acid and anti convulsants in general Warfarin or blood thinners in general Digoxin Lithium or other anti psychotics and or mood stabilizers in general Cyclosporine or other immunosuppressive drugs in general Levothyroxine or other thyroid medications in general Theophylline
Sources 1 Jarvis Sabrina Sean Rassmussen and Blaine Winters Role of the Endocannabinoid System and Medical Cannabis The Journal for Nurse Practitioners 13 8 2017 525 531 2 Russo E 2018 Clinical Endocannabinoid Deficiency CECD can this concept explain therapeutic benefits of cannabis in migraine fibromyalgia irritable bowel syndrome and other treatment resistant conditions Neuro Endocrinol Lett 29 192 200 3 Mouhamed Yara et al Therapeutic Potential of Medicinal Marijuana An Educational Primer for Health Care Professionals Drug Healthcare and Patient Safety Volume 10 2018 45 66 4 Endocannabinoid binding to the cannabinoid receptors what is known and what remains unknown Current medicinal chemistry vol 17 14 2010 1468 86 5 Lisboa S F et al The Endocannabinoid System and Anxiety Vitamins and Hormones 2017 193 279 6 Chakravarti Bandana Janani Ravi and Ramesh K Ganju Cannabinoids as Therapeutic Agents in Cancer Current Status and Future Implications Oncotarget 5 15 2014 n pag 7 Fine Perry G and Mark J Rosenfeld The Endocannabinoid System Cannabinoids and Pain Rambam Maimonides Medical Journal 4 4 2013 n pag 8 Battista Natalia et al The Endocannabinoid System An Overview Frontiers in Behavioral Neuroscience 6 2012 n pag 9 Russo Ethan B Taming THC Potential Cannabis Synergy and Phytocannabinoid Terpenoid Entourage Effects British Journal of Pharmacology 163 7 2011 1344 1364 10 Rudroff Thorsten and Jacob Sosnoff Cannabidiol to Improve Mobility in People with Multiple Sclerosis Frontiers in Neurology 9 2018 n pag 11 Suryadevara Uma et al Pros and Cons of Medical Cannabis Use by People with Chronic Brain Disorders Current Neuropharmacology 15 6 2017 n pag 12 Cannabinoids in the Treatment of Epilepsy Hard Evidence at Last Journal of epilepsy research vol 7 2 61 76 31 Dec 2017 doi 10 14581 jer 17012 13 Ol h Attila Zolt n Szekanecz and Tam s B r Targeting Cannabinoid Signaling in the Immune System High Ly Exciting Questions Possibilities and Challenges Frontiers in Immunology 8 2017 n pag 14 Schwarz Rico Robert Ramer and Burkhard Hinz Targeting the Endocannabinoid System as a Potential Anticancer Approach Drug Metabolism Reviews 50 1 2018 26 53 15 Bicas J L et al Evaluation of the Antioxidant and Antiproliferative Potential of Bioflavors Food and Chemical Toxicology 49 7 2011 1610 1615 16 Cannabinoids in the management of difficult to treat pain Therapeutics and clinical risk management vol 4 1 2008 245 59 17 Dahham Saad et al The Anticancer Antioxidant and Antimicrobial Properties of the Sesquiterpene Caryophyllene from the Essential Oil of Aquilaria Crassna Molecules 20 7 2015 11808 11829 18 Fernandes Elizabeth S et al Anti Inflammatory Effects of Compounds Alpha Humulene and Trans Caryophyllene Isolated from the Essential Oil of Cordia Verbenacea European Journal of Pharmacology 569 3 2007 228 236 19 Goldstein Bonni Cannabis Revealed How the World s Most Misunderstood Plant Is Healing Everything from Chronic Pain to Epilepsy Bonni Goldstein 2016
20 Romero Sandoval E Alfonso Ashley L Kolano and P Abigail Alvarado V zquez Cannabis and Cannabinoids for Chronic Pain Current Rheumatology Reports 19 11 2017 n pag 21 Israel Solomon Legal Cannabis Suppositories Are Coming to Canada but with Strict Potency Limits Are Recreational Cannabis Lounges in Canada s Future The Leaf Cannabis News 8 Aug 2018 www theleafnews com news legal cannabis suppositories are coming to canada but with stric t potency limits 490368621 html 22 Cannabis and Cannabinoids National Cancer Institute www cancer gov about cancer treatment cam hp cannabis pdq link _88_toc 23 Vigil Jacob M et al Associations Between Medical Cannabis and Prescription Opioid Use in Chronic Pain Patients A Preliminary Cohort Study Ed Kent E Vrana PLOS ONE 12 11 2017 e0187795 24 Lemberger Louis et al Comparative Pharmacology of 9 Tetrahydrocannabinol and Its Metabolite 11 OH 9 Tetrahydrocannabinol Journal of Clinical Investigation 52 10 1973 2411 2417 25 Fugh Berman Adriane et al Medical Cannabis Adverse Effects and Drug Interactions Medical Cannabis Adverse Effects and Drug Interactions Government of the District of Columbia Department of Health doh dc gov sites default files dc sites doh publication attachments Medical 20Cannabis 20Adverse 20Effects 20and 20Drug 20Interactions_0 pdf
Quick References Big Island Grown website http www bigislandgrown co Hawaii Department of Health Contact Information http health hawaii gov medicalcannabisregistry https health hawaii gov medicalcannabisdispensary medicalcannabis doh hawaii gov 808 733 2177 Medical Cannabis Program 4348 Waialae Avenue 648 Honolulu Hawaii 96816
Source Elemental Wellness
Source SC Labs
Patient Journal Entry Page Date Strain Strain Label with Labs Symptoms I m Experiencing Severity of Symptoms Before Consumption 1 10 Blood Sugar Blood Pressure Before Consumption Method of Consumption Dose Other Medications I m Currently Taking Effects of Consumption Severity of Symptoms After Consumption 1 10 Blood Sugar Blood Pressure After Consumption General Notes