Cannabis in Sports Medicine Certificate Program – by Ethan Russo, MD

The basic functions of the Endocannabinoid System, ECS, were summarized in 1998 by Professor Di Marzo as,“relax, eat, sleep, forget and protect.” The ECS is an essential regulator of bodily function in its many facets. Dr. Russo will go into detail discussing the scientific discovery of the ECS and the scientific data of the importance of understanding the ECS. It is also shown in the journal article Physicians-in-training are not prepared to prescribe medical marijuana by Evanoff et al, 89.5% of residents and fellows graduating from American medical schools felt they were not at all prepared to prescribe medical marijuana, 35.3% felt not at all prepared to answer questions, and 84.9% reported receiving no education in medical school or residency on medical marijuana. The report further outlined only 9% of medical school curriculums included content on medical cannabis. These statistics have changed little since 2017.

There is hardly any physiological process that is not affected by it to some degree: pain, movement, emotion, digestion, skin and even bone health. It is surprising then to realize that the ECS was totally unknown prior to three decades ago. The name derives from the fact that all higher animals harbor natural chemicals within that resemble in many respects the activity of tetrahydrocannabinol (THC), the phyto- (plant) cannabinoid that is the main psychoactive component of Cannabis sativa, sometimes derisively labeled as marijuana. Despite the prominence and importance of the ECS as an essential regulatory mechanism in the body’s biochemistry and physiology, the basic machinery of everyday life, knowledge of it remains quite limited among American physicians due to a dearth of appropriate education in medical schools.

What if endocannabinoid levels are too low? It has been theorized and subsequently borne out in subsequent research that numerous mysterious disorders fit the description of “clinical endocannabinoid deficiency” (CED). Noteworthy among these are migraine, fibromyalgia and irritable bowel syndrome (IBS or “spastic colon”). These disorders affect millions of otherwise healthy people who are plagued by chronic pain and other symptoms, leading to extensive medical tests and attempts at treatment, often to limited benefit. The idea is that this deficiency may lead to dysregulation of essential processes, resulting in increased susceptibility to certain diseases. Dr Russo discusses emerging studies on CED indicating that enhancing the ECS through cannabinoids could help alleviate symptoms of these conditions. Understanding the basic principles of the ECS and the implications of CED allows for a deeper appreciation of how targeting this system with both endogenous and exogenous cannabinoids may offer therapeutic benefits and pave the way for new treatment strategies in managing various health issues.

The cannabis plant, belonging to the Cannabaceae family, is known for its unique properties and diverse uses. It is typically classified into three primary species: Cannabis sativa, Cannabis indica, and Cannabis ruderalis, each exhibiting distinct characteristics in terms of growth patterns, cannabinoid profiles, and effects. Over millennia, cannabis has been cultivated for various purposes, including medicinal, recreational, and industrial applications. As societal perspectives on cannabis continue to evolve, the plant has gained recognition for its potential therapeutic benefits, leading to increased research and interest in its chemical composition. Understanding the cannabis plant’s biology, cultivation methods, and historical significance is essential for exploring its medical applications and the ongoing development of cannabis-related policies.

Cannabis sativa (“cultivated cannabis”) is an ancient medicinal plant that has been prohibited in the USA since 1937. Dr. Russo will provide an introductory focus on its botany, uses and cultivation practices, all topics that will be recurrent with more in-depth treatment as the course progress. Dr. Russo will discuss Cannabis Typology (Ernest Small), Type I: high THC chemovars, Type II: mixed THC/CBD chemovars, Type III: CBD-predominant chemovars, Type IV: CBG-predominant chemovars,Type V: Zero cannabinoid chemovars, Type VI?: THCV-predominant chemovars and phytocannabinoids from Russo and Marcu 2017 Cannabis pharmacology:  The usual suspects and a few promising leads. In addition to Dr. Russo taking a “deep dive” into explaining the components of the Cannabis Plant, he will also discuss Cannabis Synergy: The Entourage Effect, Cannabis Chemovars, Chemical  Ecology of Phytocannabinoids, Terpenoids, Landraces, and will Outline the Ideal Cannabis Classification Scheme. This module will prove to be invaluable for those that want to understand the components of the Cannabis Plant.

CBD, or cannabidiol, is one of the most extensively researched cannabinoids derived from the cannabis plant. Research has shown that CBD may possess a wide range of therapeutic properties, including anti-inflammatory, analgesic, anxiolytic, and anticonvulsant effects. How does CBD work? Dr. Russo will discuss how CBD interacts with receptors, ION channels, enzymes, and transporters. In addition, focused coursework on “CBD Mechanism of Action: Receptors” such as Cannabinoid Receptors, Glycine Receptors, GABA Receptors, GPR55 Receptor, Serotonin Receptor, Peroxisome Proliferator-activated Receptors, Adenosine Receptors, Opioid Receptors to give students a high level of understanding, but in terms that everyone will understand. So what does this mean for patients and ailment focused treatments? Dr. Russo will discuss topical applications to key findings for ailments such as MS and Epilepsy to impact on bone fractures.

Dr. Russo will review the recent study “Acute effects of cannabigerol on anxiety, stress, and mood: a double blind, placebo controlled, crossover, field trial“, by Carrie Cuttler, Amanda Stueber, Ziva D. Cooper & Ethan Russo. It is the first randomized placebo controlled clinical trial to investigate the effects of cannabigerol (CBG) on anxiety, mood, and stress and is a major step forward in demonstrating safety and efficacy of the molecule. This module will:

1. Review the history and basic science of CBG.
2. Review the recent Scientific Reports article by Cuttler et al. demonstrating anti-anxiety and anti-stress responses of CBG without impairment in a randomized controlled trial
3. Provide a greater understanding of the therapeutic benefits of CBG

Dr. Ethan Russo has been a key educator on the role of cannabis in pain management, particularly highlighting its potential as an opioid-sparing alternative in clinical settings. The facts. 2016 deaths from opioid overdose topped 64,000 in USA (NYT, 9/2/17), mostly fueled by fentanyl (540% increase in 3 years). The figure was 72,000 deaths in 2017, and has exceeded 100,00 more recently.2.5 million Americans have opioid use disorder (Hurd 2017)80 die each day from OD

80% start by misusing prescription opioids and there are 200 million opioid prescriptions/year written.  In this module, by integrating cannabis into pain management regimens, patients may experience reduced reliance on opioid medications, thus mitigating the risks associated with opioid use, such as addiction and overdose. Dr. Russo emphasizes that, through careful dosing and individualized treatment plans, medical cannabis can provide significant relief while minimizing side effects, ultimately contributing to a more balanced and safer approach to managing chronic pain conditions.

Cannabis use, while often beneficial for many medical conditions, can also lead to adverse events and undesirable effects, necessitating harm reduction strategies to ensure safe consumption. Common side effects include dizziness, fatigue, dry mouth, and cognitive impairment, particularly in individuals consuming high doses of THC. More serious risks exist for certain populations, including those with a history of mental health disorders or substance abuse, where cannabis use could exacerbate symptoms or lead to dependency. Harm reduction approaches focus on educating patients about responsible use, emphasizing the importance of starting with low doses and gradually titrating as needed to minimize negative effects. By providing clear guidelines and fostering open communication between healthcare providers and patients, harm reduction strategies aim to enhance the safety and efficacy of medical cannabis, ensuring that individuals can maximize its benefits while reducing potential risks to their health and well-being.

Dosing and titration are critical components in the effective use of medical cannabis, as individual responses to cannabinoids can vary significantly. Because cannabis products contain diverse concentrations of cannabinoids and terpenes, establishing an appropriate starting dose is essential for minimizing side effects and achieving therapeutic benefits. Many healthcare providers recommend a gradual titration approach, where patients start with a low dose and slowly increase it based on their response and tolerance. Dr Russo will use scientific data to discuss the “hazy” approach to dosing and titration. Studies such as Hazekamp et al. 2013. The medicinal use of cannabis and cannabinoids-An international survey on administration forms. J Psychoact Drugs 45(3):199-210 help provide learners with peer reviewed studies to support lessons. Legal implications are discussed, Standards for Cannabis Recommendation, to maintain compliance.

“Cannabis is the single most versatile herbal remedy, and the most useful plant on Earth. No other single plant contains as wide a range of medically active herbal  constituents.”

– Dr. Ethan Russo

When utilizing medical cannabis, various intake methods and therapeutic strategies are employed to optimize its benefits. Patients can choose from several methods, including inhalation (smoking or vaporization), oral ingestion (edibles, capsules, and tinctures), sublingual administration (sprays or tinctures placed under the tongue), topical applications (creams, balms, and patches) and suppositories. Each method offers distinct absorption rates, onset times, and durations of effects, making the choice dependent on the patient’s specific needs. In addition to the discussion on how to medicate, testing, reading labels, and terpenes will be outlined in greater detail. The importance of patient harm mitigation such as strategies for edibles “start low, go slow” will also be outlined.

Cannabis plays an increasingly important role in sports medicine, offering potential benefits for pain management, inflammation reduction, and recovery. When used responsibly through harm reduction principles, it can help athletes and active individuals minimize risks associated with misuse or overuse of traditional pharmaceuticals. Central to understanding how cannabis interacts with the body is the endocannabinoid system, a complex network that regulates pain, mood, immune response, and homeostasis. By understanding this system, healthcare providers and trainers can better tailor therapeutic approaches to enhance performance and recovery while promoting safe, informed use of cannabis as part of a holistic, harm-reduction strategy.

Cannabis has shown promise in helping manage symptoms associated with concussion, post-traumatic stress disorder (PTSD), and chronic traumatic encephalopathy (CTE). Its active compounds, cannabinoids, can modulate inflammation, reduce neural excitability, and alleviate pain, which are critical components in the brain’s response to injury. Additionally, cannabis’s neuroprotective and anti-inflammatory properties may support recovery processes and mitigate some of the long-term cognitive and behavioral symptoms linked to traumatic brain injuries. While research is ongoing, emerging evidence suggests that, when used responsibly and under medical supervision, cannabis can be a valuable component of a comprehensive approach to managing concussion-related conditions and neurodegenerative processes like CTE.