Cannabis and Cannabinoids: Pharmacology and Rationale for Clinical Use

Abstract

It is now known that there are at least two types of cannabinoid receptors. These are CB₁ receptors, present mainly on central and peripheral neurones, and CB₂ receptors, present mainly on immune cells. Endogenous cannabinoid receptor agonists (`endocannabinoids'') have also been identified. The discovery of this `endogenous cannabinoid system'' has led to the development of selective CB₁ and CB₂ receptor ligands and fuelled renewed interest in the clinical potential of cannabinoids. Two cannabinoid CB₁ receptor agonists are already used clinically, as antiemetics or as appetite stimulants. These are D 9 - tetrahydrocannabinol (THC) and nabilone. Other possible uses for CB₁ receptor agonists include the suppression of muscle spasm/spasticity associated with multiple sclerosis or spinal cord injury, the relief of chronic pain and the management of glaucoma and bronchial asthma. CB₁ receptor antagonists may also have clinical applications, e. g. as appetite suppressants and in the management of schizophrenia or disorders of cognition and memory. So too may CB₂ receptor ligands and drugs that activate cannabinoid receptors indirectly by augmenting endocannabinoid levels at cannabinoid receptors. When taken orally, THC seems to undergo variable absorption and to have a narrow `therapeutic window'' (dose range in which it is effective without producing significant unwanted effects). This makes it difficult to predict an oral dose that will be both effective and tolerable to a patient and indicates a need for better cannabinoid formulations and modes of administration. For the therapeutic potential of cannabis or CB₁ receptor agonists to be fully exploited, it will be important to establish objectively and conclusively (a) whether these agents have efficacy against selected symptoms that is of clinical significance and, if so, whether the benefits outweigh the risks, (b) whether cannabis has therapeutic advantages over individual cannabinoids, (c) whether there is a need for additional drug treatments to manage any of the disorders against which cannabinoids are effective, and (d) whether it will be possible to develop drugs that have reduced psychotropic activity and yet retain the ability to act through CB₁ receptors to produce their sought-after effects.