ADVANCES In Therapeutic Uses Of MEDICAL Marijuana | Mark Hyman & Misha Kogan

Unfortunately, in a lot of situations, cannabis problems come only to two things: the price and logistics. We're entering the era where it's just going to be one of our common tools.

Let's talk about what the top clinical indications, what are the top reasons you're going to use it, what are the conditions you treat, and what are you seeing in your practice? Right.

So we mentioned pain, Nausea, insomnia, spasticity. It doesn't have to be multiple sclerosis related spasticity. I think any spasticity. Actually quite often when a person has a sudden locked in muscles, for example, let's say a neck, you can actually apply topical sometimes it's really effective. All kinds of skin conditions. Lately I find things like psoriasis, things like even like literally herpes flares.

You mean it helps reduce the skin lesions or just prevents symptoms?

No, it actually actually treats underlying problems and you know it's not it's more complex than just THC CBD we don't actually exactly know which molecule is more important but I often even use it for like a typical eczema in older age I often use it now as a first line just to you can even start with just trying CBD creams sometimes even those work so you know all kinds of skin conditions I actually think well the way I use it.

Topically for the skin condition and use it you use THC as well as CBD for the skin condition yeah So.

For psoriasis, I like to use mix, so I like to use more THC than CBD. For eczema, I start with just CBD, and sometimes that's enough, sometimes you have to add THC. I had a long-standing crack in the lip, which was from just cold sore from herpes. I had it for about two decades, and it would flare in the winter when I go skiing, especially when the lips get dry. and took about three months, twice a day, application of low concentration THC, and now it's been, what, six, five, six years? I don't know, like the problem completely went away.

Amazing. Incredible.

So it has, definitely THC has antiviral properties. So you literally can use it on low-grade topical infections at almost no risk. If it doesn't work, you have time to try something else.

What else?

Lots of different gastrointestinal problems. IBS, preferably irritable bowel syndrome, preferably in the form where it goes down to swallowing form, in edible form, shockingly in inflammatory bowel disease. So Crohn's and Ulcerative Colitis. You can use it orally, but actually if the disease is mostly in the rectal area, you can use suppositories. It's a very effective method. The data for that is mixed, but there's a lot of people who try IBD can be very persistent and very poorly controlled even with new biologic drugs. And biologic drugs have a lot of risks and side effects and high costs. So I had a good number of patients in whom IBD has been controlled just using cannabis alone. It sounds crazy, but I think cancer is probably one of the most controversial topics we can spend a whole hour talking about.

Yeah, well let's talk about that for a minute because I've been in this world and one of the things that I've heard people say is that it can be CBD and other concentration specific forms, specific plants can be effective in cancer. Is there any data about that or what do we have?

There's very little data. I think we have kind of an early data, we have a little bit of positive data in a brain cancer. We have a lot of data in preclinical. If you take a pitcher dish and you put the cancer cells on and then you put cannabinoids, literally almost all cancers get killed off. Now, how does that translate into what's happening in our bodies is very hard to figure out. Unfortunately, cancer translation science generally is slow. But I will tell you, those of us who use cannabis heavy in the practice, It's just the patients find us and often they will do things without our, you know, they'll just do things, right? And they'll come in to check in with us. And I'll tell you, the most crazy cures I've seen in my practice, they're all cannabis. Yeah, they all have cannabis. That wasn't the only thing the patients were using. Don't get me wrong.

It's always other.

So was it just CBD or a combination? It's, no, it has to be some THC. The ratios are not very clear. I tend to think that it's much more complex than just THC and CBD. We do know that acidic forms, which call CBD and THCA, have anticancer property. And then even some of the newer molecules that we're just beginning to grow in our practice like CBG, for example, can have a greeenol with a G, like in Georgia. So, even molecule like that one has some clear anticancer properties. Nobody truly understands yet. I know there are experts with way more knowledge than me who do this much more in their practice. But I just don't think that there's evidence enough to put that into mainstream. It's happening whether we want it or not. I think there has to be research and it's happening slowly. I use it for almost all cancer patients, but not for cancer itself. I simply use it because Well, think of it this way, right? Most patients, they're going to have some cancer-related pain. They're going to have some cancer-related nausea. They may or may not have anxiety and insomnia. But think about this. If I were to recommend the medications for this, it's at least four pills. And here I have one product that can control it all. The dosing can be precise. The route of administration can be variable and according to the patient's liking. And guess what? You know what the side effect is, right? somewhat slightly getting high. So in literature, it's a side effect. I'm yet to see any cancer patients tell me, yeah, I really sort of, it's a bad side effect. It's not. I mean, people who overdose occasionally, it happens all the time, by the way, when you forget to mix the bottle or you just take a little too much. It's not like it's gonna kill you. It may be very unpleasant and people can't function once they get a hold of the understanding what happened. and this never happens again, it often turns out into funny stories. I have plenty of those. One of my favorite ones, I get a call from our emergency room attending saying, Dr. Kogan, one of your favorite patients claims she's dead and she wants to talk to you. And I'm like, if she's dead, how can she talk to me? She's like, well, I'm telling you, talk to her, she's dead. So yeah, she was using a bottle very appropriately, but it went on vacation, the bottle was standing, things drifted to the bottom in oil. So, she didn't mix it very well. Took the same dose but from the bottom got overdosed. And, you know, so this is really.

A safe drug that what you're saying is what are the risks and the side effects?

Extremely safe.

Are there any downsides? We know reading about, you know, kids who use regular pot, have their cognitive function, ADD and behavioral issues. Is there any merit to that, you know, the old kind of potheads who.

Would sit around and do nothing and just goof off and Well, I mean, nothing has no side effects. Even cucumbers, as we say in Russia, right? I mean, you can die from anything if you use it the wrong way. Long story short, there's tons of side effects. I mean, you have to really understand the medicine of it pretty well to know some of them. Heavy, heavy use of THC in youth is a bad news because the brain doesn't mature right. We know that. There's long list of that's conclusive. That says if the teenager starts heavily using cannabis, the outcome is probably going to be quite not good. Much higher risk of schizophrenia, higher risk of accidents, higher risk of the brain being sort of, as you said, we think of it as a pothead, but actually the way the brain on chronic cannabis looks, it's very specific. It's sort of like this downing impact suppression of lots of normal cognitive function which leads to this sort of appearance of pothead. So, I mean, heavy users. Now, interestingly, all of that is a critical point. All of that comes from THC. What happens when you start putting a lot of CBD in the mix? Let's say you're using only one to one THC to CBD ratio. Most of us think that all the side effects go away. So, part of the recreational future, I think, is going to be If you use products that have some CBD, is that going to nullify some of this long-term negative brain effects?

Yeah, but Misha, kids who smoke pot are smoking pot, they're smoking the whole plant. They're not having isolated THC, so they're getting CBD.

Well, most of the recreational products are still almost pure THC. And the reason is simple. The CBD in a certain, the more CBD there is, the more different the high is going to be. In fact, often there will be no high. if you have certain ratio that's way towards CBD, let's say 20 to 1, you may have very little high or no high. You may still have high if there's a high dose enough of THC. So the question is, should we gradually transition entire recreational industry to have CBD? You know, that's a hard philosophical question. Good luck transitioning anything that makes a lot of money, right?

Yeah, right.

But that's a very, in my mind, that's the main long-term concern? Is this kind of a heavy use of THC non-medically recreationally in terms of side effects and mental health?

Have we seen these kids having other issues like personality disorders or bipolar disease or depression?

Yeah, I was just reviewing article from Jama that came in June this year that basically shows any use of regular use of cannabis dramatically increased suicidality by like 40% and suicidal ideation. And they looked at the whole data. But if you carefully go back and you look how they looked at this, it appears very simple that we just have a rapid increase in suicidality in all of the population of the United States. And that has predates the COVID by the way. So it's like till between 2008-2019. So the suicidality and depression is on a on the rise. So a lot of people try to self-medicate. In fact, I often see people who are chronic users coming to me because they've been trying to follow the literature and they're using it for depression, for PTSD, for anxiety. The problem when it's often non-medically guided use, they get pure THC recreationally, they often use products that are too strong and you can have a very beneficial impact with much lower doses, with much less side effects. So it's a problem of lack of education and it's also a problem of lack of access to ease of access to the medical products. Instead, people turn off into recreational without good, good managed advice or good recommendations. And partially, you know, I hope they read my book.

Yeah, of course. Well, it was so comprehensive, Misha. And, you know, you address some things that are very confusing for people. I mean, you talk about the science behind behind it. You talk about the sort of social and political aspects. You talk about the medical benefits of it. But you also talk about, you know, sort of the landscape out there now. And I remember when I was in college, it was like, you get Maui Wowie or Sensi-Mion or whatever, you know, like the, where it came from. And that was like your brand. And now you go into one of these, you know, legalized marijuana stores and it's overwhelming. It's like picking wine, you know, like where does it come from and what is it? And, or it Do you want to inhale? Is it edible? Is it topical? Is it a vapor? Is it, like, is it, you want to pre-roll? Do you want to stick it up your butt?

What?

And what's the ratio of this and that? Does it make you sleepy or is it, is it indica or CBD or is it sleepy or happy or party or, I mean, it's overwhelming and I think, I mean, I'm no novice here, but I definitely find it overwhelming and I wonder how you guide people into which delivery mode you should use and which is the best for which thing?

Right. Right. And, you know, that's overwhelming for you. Think of some of my patients who are over 75, 85, or 95, and they've never tried it or they tried it 30 years ago and have no recollection. So, yeah, I usually start most of the patients with a sublingual full extract, what we call FICO full extra cannabis oils. They tend to be most easy to control. You can start with just a couple of drops under the tongue. Absorption bypasses the liver, so you don't have the problem of hyperactivation of THC. That edibles can give a lot of people, if they're not experienced, very strong high for a very long time, and that can be very unpleasant and can just basically kind of psychologically prevent from trying something again. So I almost always start either from with topical, rectal, or with sublingual. Sublingual is by far most common. topical oral, topical oral, topical sublingual, or rectal. So I often, if the patient comes in with something pelvic, like a pelvic pain, you know, like ulcerative colitis, we very often would try suppositories straight up because cannabis systemic absorption of rectal is sort of always been in question. And I do think there is some, but it's just not as much as with world and sublingual. But if you have a localized problem, that's, so I have the three mantras with cannabis. Start low, go slow, and deliver it where it needs to go. That third one, I think, is unfortunately not as commonly understood out there. So if you have a lesion on the skin, put it there. You know, if you have a lesion in the pelvic area, okay, well, so you can put it vaginally or you can put it rectally.

But what if you have anxiety or nausea or pain or sleepish?

You can put it in nausea or pain. that sounds more like neurological issue, right? So well put it under the tongue, right? Put it under the tongue. Vaping or smoking, a lot of people do, I'm not opposing to them, but those tend to have a lot more side effects. We didn't kind of actually discuss that, right? So yeah, I want to vape, smoking, you're taking in a smoke high temperature, you're probably gonna have at least some damaging lung impacts, even if the evidence is not necessarily clear that you're gonna, well there's no evidence that you'll cause lung cancer, no matter how heavy you smoke cannabis.

But, you know, you can cause chronic cough, pneumonitis, and so forth. Does it cause the same kind of problems as smoking, vaping, tobacco?

In other words, does it cause pneumonitis and so forth? To much, much lesser degree. It definitely can cause chronic cough and bronchitis, but it doesn't seem to cause kind of lung cancer or, you know, like interstitial pneumonia. Although, right, we had this scare right at the onset of COVID when we had people who were using black market cannabis. They had this sudden bad lung disease and a lot of people, some people died, young people. So this has nothing to do with cannabis. Evali, it's called, I forgot what it stands for. It's basically a long inhalation injury from probably vitamin E acetate, which is a reservant in the illegal cartridges.

So we don't know for sure about inhale than what it does to the lungs like we do for vaping, right?

Well, it doesn't matter actually whether you vape or smoke. Both generally can come at the high temperature, although there are vapors now that have much lower temperatures. So, those are better.

That's what we used to use bongs for, remember?

Well, volcano has been around forever, right? It's like a complex vaporizer that can precisely control the temperature. That's actually often used in research because it's so precise. volcano has been one of the most common vaporizers in research. So, I mean, the funny thing is that most of the prior use, recreational use, is coming from inhaled routes. So a lot of the research simply coming from that area because you just have a lot more people doing it this way.

Yeah.

But I think the future of cannabis is really not in inhaled products. I think the future is in sublingual, oral capsules, topical, rectal, people will keep using inhaled, smoking, whole flower, vaping. There's nothing wrong with that. And, you know, I just, especially in my practice where a lot of people over 65, I have a hard problem, hard time initiating somebody on inhaled product if I know that it's going to cause cough and especially if they already have some lung disease like asthma, it's not necessarily first route. But for certain things, it's gut-scent. Let's say you have a severe nausea and you really can't put anything in the mouth. like, what else are you going to do?

Well, that's what happened to me. I couldn't eat. I was throwing up all the time.

Yeah. We're entering the era where it's just going to be one of our common tools and pretty much for almost all the medicine. I have no doubt that, by the way, it won't be an alternative plant medicine in, say, a decade. It'll just be another tool in a standard allopathic model. I mean, it's already, if you look around how it's getting integrated, it's way bigger than any of our branches of integrative holistic medicine. I mean, most of the pain doctors are already aware of it. Most of them have some kind of a flow that they can get patients to get the cannabis. Like I give you an example of my own pain clinic at UW five, six years ago, I told them, look, you guys have to look into this. I'm happy to come give you a grand rounds and we can review this in detail and guess what? I mean, they're all, oh, no, no, no, no, no. We have everybody sign contracts that they can't use any substance. I'm like, that's not any substance that's controlling your pains. No, no, no.

So.

And then, you know, as they have accumulated. So I'm giving them round rounds in a couple of weeks as an example. So I think there's a, a rapid uptick in, in acceptance. What's interesting, there's still zero clarity on how you're going to teach the students about. How are we going to carefully educate the public? If you look around most of the information out there, it's actually not academic. Majority of information that people are getting is from commercial sources and some of them are good. You know, like LiF-Li is a not that I'm trying to advocate for anything here, but you know, there are lots of good resources, but they're scattered, they're not academically supported or academically backed.

Backed.

Right. And, you know, and I think that's, that's not a change. And a lot of people are going to listen to that.

So what is, what is the research base for medical marijuana? I mean, it's being used clinically a lot. It's used recreation a lot. Is there an evidence base? You know, we talk about evidence-based medicine, which has issues, but as there is good research looking at the, the benefits and the risks. of medical marijuana.

Yeah, I mean, I think the evidence is rapidly growing. We still have a problem, I'll start from the other end, we still have a problem with the fact that, you know, it's still a controlled substance. It's still DEA Schedule 1 substance, so the research is limited. Like, you can't actually, it's really hard to get federal dollars to study this, and although actually it has been changing, but still the clinical research is lacking. But despite that, there's actually a lot of evidence. So, into 2017, I'm just gonna speak to most independent evidence. In 2017, National Academies of Sciences and Medicine came out with a really important report. It was literally was called, you know, medical cannabis report on medical cannabis efficacy. And they concluded, I mean, they put a significant conclusion. They said that the four chronic pain in adults, medical cannabis gets grade A recommendation. Wow. If we look at all of our meds that we have, Or opioids, they're not even grade B. They're like grade C minus. Yeah.

Really?

Yeah, for pain. And, you know, like an Advil and Tylonol, I think, get in grade B. Here you had talent, and here you had cannabis with grade A recommendation. That's incredible. Well, it's incredible, but it didn't get too widely known. I mean, people in our own field, of course, everywhere I go, that's one of the key slides because nobody's gonna argue with National Academies of Sciences conclusion, right? But since there's been a lot even more data, NIH actually routinely now holds workshops on cannabis and sort of allowing the clinicians and researchers look into most updated evidence. So there's definitely a rapid shift.

So you're saying there's NIH research on this now?

There's a lot of NIH research. Yeah, most of it's still bench research or preclinical, but there is a lot more money going into that because there is a There's been calls some, probably a year ago or more, probably more than that already. There have been multiple calls for proposals for a basic understanding of endocannabinoid system. And I think that's the part where, you know, for our clinical evidence-based medicine, right, before you can study something clinically, you have to say, look, there is a clear knowledge of understanding of mechanism of action. Right? And we can arguably say we know all this already, but you know the science has to take its own steps.

Interesting. So, you know, I want to get into some of the, what the research shows around the benefits, but you know one of the interesting things that you touched on was the endocannabinoid system. So for those listening, the reason medical marijuana works is it's tapping into a biological system that already exists in our bodies and brains. And it's called the endocannabinoid system. So, can you talk just a little bit about that, Misha, and what it does, what it's for, and what the benefits of the system are to our health?

Right, right. Well, I think that's actually critical we talk about this because that's the core understanding of how actual exogenous or cannabis from plant works, right?

So, and by the way, this system was named after cannabis, right? And so it's like the doctors discovered it in a way and they named it after the molecule that they realized was working on it, which isn't like the only reason it's there.

That's right. You actually have to sort of, well, let's talk about that first and then we'll, because I have one philosophical point that I think you're going to have a great take on this. So we all have, just like we have an endorphin system, so the endogenous opioids, we have this endogenous cannabinoid system. It's actually a lot older and a lot more complicated and a lot more important compared to the endorphin system. Why? That's not necessarily clear, but it appears that it's just more rudimentary and historically it appeared in our evolution first. So it's one of the oldest regulatory systems in our body. We have literally, so the tetrahydrocannabinoid, which everybody after recreationally, the THC, right? We have molecules in our body that are very similar. Anandamide is a good example. It's probably one of the more common. It's not the only one. We have multiple similar molecules internally, and we make them. We literally make our own cannabis constantly in our body. Then there are a set of receptors. The more commonly known ones are CB1 and CB2. So you can think of them like a, it's a gross analogy. It's not necessarily 100% accurate, but it's a good one. key and a lock. So your key is our endogenous cannabis molecules, or let's say anandamide and the lock of the CB1 and CB2 receptor. So when you open the lock, something occurs, like your door opens and then you have a cascade of effects. So if you're open CB1 receptor, then you have some kind of likely neurologic impact, so say pain control or some anxiety, Decrease in anxiety, better sleep, those kind of things. If you open CB2 receptors, which are on the periphery, you can have immune upregulation, so a better stronger immune system. You can have metabolic improvement, like your certain metabolic parameters can improve. You can have your bones lay down more bones so that their bones are stronger. So the impact, the list of impacts that occurs when this happens is so long, we'll sit here and we'll have a whole lecture on this. Bottom line, it affects almost the entire system. Almost every cell in our body except for one area has the CB1 or CB2 receptors. Here where the sort of the most crazy and amazing mystery comes in except for one area and that's the brainstem. So it turns out in the brainstem which controls our breathing, there's not as many CB1 receptors. So no matter how much cannabis you take in, your breathing is not gonna get suppressed compared to if you take a lot of opioids then we know all about that. It's going to happen, right? So why that happens, nobody knows. The second mystery, that's what I really want to touch on. Think about this. We co-evolved with a plant which is a weed, meaning it grows everywhere, right? There's weeds, there's a reason why they call it a weed, right? So how come we co-evolved on this earth together with a plant that allows us to have this fascinating interaction with it? And we sort of we're coming back to the plan's been used for thousands of years. In fact, it may be the oldest documented medical tool we have on Earth. If you go back to some of the original Chinese medicine works, it's been listed there as one of the first Chinese medicine herbs. And it's not a lot, it's not discussed on a lot of circles. It's kind of hard to appreciate, right? But it's there. It's there as one of the original herbs that they've used. And, you know, and then over the centuries it was used in different ways and then it finally kind of end up in more modern civilized civilization. But it almost feels like we're now.

Re- yeah, but here's a question for you. So in opioid system, we have receptors for the opioids, like narcotics, right? Heroin, morphine, and that's because we have our own system of pain control called endorphins, right? That bind to those receptors. Is there a similar set of molecules in the body that naturally occur? It's almost our natural marijuana, right? As the endorphins are our natural opioids. So, what are those molecules and what role do they play and how do they work?

Well, I think for listeners, anandamide is probably the most important one to remember. There's a long list of those anandamide, right? That's probably the it's one of the most common, it's one of the best understood. What's interesting that in addition to this sort of endocannabinoid system with a through cannabis receptors, let's call them what they are, CB1, CB2, there may be others too, by the way, there are lots of other impacts. So the plant has other active molecules. Terpenes, I'm sure we'll talk about this. It has flavonoids and all of them also have some impact. In fact, there's a lot of research now going into terpenes because turns out that if you just isolate THC and you take it in, the effect is going to be limited. If you combine that impact with what terpenes can do, suddenly you have whole lot more complex interaction with the body. Yeah, yeah, yeah. that's where I think the gold of cannabis will be. And that's why I'm not worried much about sort of farmer taking all of it over, because recreating some of this interactions, what we often call an entourage effect, is very difficult.

Yeah. I mean, that's a typical, typical efforts of medicine, which is to find something that works to reduce it to the one molecule and to isolate it, reproduce it and distribute it and Market it and Patent.

Right.

And what you're saying is really important to underscore, which is that it's the complex interaction of all the plant molecules and phytochemicals in marijuana that make it work. So if you just take any one of them out, it may be synergistic effects that you can't reproduce by just isolating it as a single drug.

Right, right, right, right, right. The simple example is, so, you know, in historically we had this sativa and indica strains. We're trying to sort of walk away from this because it's actually more confusing than anything.

Oh really?

Yeah, well because the, well it's really based on terpene contents and since most of the modern strains are now hybrids or many of them, this separation of, is a indica, is it sativa, is it two parts indica, one part sativa, it just confuses everything. So you're really gonna, in the future it's gonna be, you're gonna look at the label and you're gonna say, okay well there's X amount of THC and there's this concentration and then there's these terpenes. so you're going to have some kind of a key on a label that says, you know, it's a predominantly relaxing terpenes like, say, linalool. And it will allow you to say, okay, well, that's probably good for sleep or for anxiety, because that's what it's going to help with. So that's the future. And that's how we're beginning to think. We're looking at, okay, this terpene is going to mix this way, and it's going to have this kind of. total entourage effect, and that's what we're going to clinically use it for.

I think you just said a very important phrase, the entourage effect. It's the entourage of all the molecules in the plant that has the benefit, not just an isolated component. So, let's get down into the details of this because I shared my story about its effect for me. But, what are the most robust research findings on the therapeutic effects of cannabis?

Yeah, so I mean, definitely the pain I mentioned already, I think in terms.

Of pain you talked about.

Yeah, I think in terms of overall evidence, I think there's just most of it. And probably second closest is nausea, especially when nausea comes in settings of some kind of a cancer, whether it's a nausea from chemotherapy or a nausea from cancer itself, doesn't matter. But that seems like there's really robust evidence. And the third, I think, is multiple sclerosis related specificity. So those are the three original big ones that were in the National Academies or NAS report. I think there's honestly underscoring and there's tons of evidence for insomnia. I think it's just not really, we don't have like one large control study to say this, but if you kind of look at collective amount of evidence and more importantly what we actually see in practice, we see that in my opinion efficacy of cannabis for sleep is way over 90%. 60%? I mean, I don't know.

It's true. And it's way more effective than all the other sleep medications which are so.

Much more addictive that all the meds, you know, it's unbelievable. And it's so much safer. Like if you, well, you know, you know me, I'm geriatrician. So half of my practice, people over 65. And, you know, insomnia in my practice used to be like one of the hardest thing to deal with because I know I don't want to write for any drugs for sleep. and then cognitive behavioral therapy is not covered by insurance if I send them for acupuncture. It's also often not covered even though it's a great tool. And so I didn't have my toolbox was sort of all non-pharmacological I couldn't give anything to people and if I would give something then like maybe trazodone, I was always like writing the script with shaking hands. Am I doing more harm than benefit? So suddenly, you know, in 2011-12 I started seeing what cannabis can do and it was just It's just turned my practice completely upside down in about two or three years. Like, I just stopped talking about almost anything if the patient is really suffering. I said, okay, we got to try cannabis first and we'll see what happens.

So are you all your nursing home patients smoking pot and listening to 'Breakin' the Dead'?

Well, I wish. No, not quite yet. That's a whole separate. You just opened the can of worms that if we go there, it's not gonna come out of it. Well, actually, it's interesting that it's shifting. I was, you know, I wasn't expecting that nursing homes and assisted living facilities will sort of start actually opening up. I thought it would be sort of like, forget it, we're never going to talk about this. No, actually, in the states where it's medically illegal, there's gradual shift, there's gradual movement. And some facilities are actually very, those who have a really open mind in medical directors. A couple of years ago, American Directors Association, it's AMDA, AMDA, so they are the kind of docs who run nursing homes organization. They actually put out extremely supportive comment. When I read it, I almost fell off the chair. It was one of the most supportive comments saying, yeah, we have to assure that if in our state cannabis is allowed, that any interested patient will have some safe access, of course, considering the safety of others in the facility. That's the difficult part. A, if you're going to light up in the nursing home, the fire hazard. If you're not lighting up, what else? I mean, how do you store something in schedule one? Unfortunately, in a lot of situations, cannabis problems come only to two things: the price and logistics and nothing else, and not the efficacy.

So, in terms of the efficacy, a lot of people are reluctant to use it in practice. A lot of misinformation. Can you share a little bit about how people can learn about this in the right way and what the most important things you've seen clinically from this are? There's sort of two separate questions in there.

Yeah, well, I think outside of insomnia, to be honest with you, it's still not my first choice for a lot of things. So, I think I'm assuming that the patient who's coming to try it or thinking about it trying sort of either exhausted other things or simply they just feel like their symptoms not controlled enough by other things. So, I mean, I think, well, first the condition for which you're going to use it should be evidenced. You know, there are lots of hype out there with CBD that it treats pretty much everything under the sun. And I will actually tell you that in contrast to evidence for THC, evidence for CBD is dramatically more limited. and maybe outside of anxiety and high doses for some forms of insomnia, there's not just that much evidence. All of the evidence for CBD is for THC. Yeah, but the evidence, but if you look into, you know, I walked into Walmart to get something, or was it, no, Walgreens. I walked into Walgreens a couple of weeks ago to get something. I'm walking along the lines to find and there you have it, CBD of every kind, Walgreens. And it's their brand.

I know, it's everywhere. You can buy it at the gas station.

Right, right. Well, you know, what happens is simple. Certain things for which it tends to work, let's say you have one or two things. Let's say you have a bruise, and so putting CBD on a bruise can actually ease it up, or there's a placebo effect. But next thing you know, now it's getting translated all over. over the place. Anyway, so bottom line, you gotta start with what's evidenced. Next, you have to figure out logistics. Logistics sometimes where things bug down. So let's say one of your listeners is not in a state where it's legal. Well, that creates a significant challenge. If you still want to try it, you're gonna have to travel to a legal state and then cross the lines, which is actually federal crime, to bring the cannabis from one state to another. A lot of people don't want to get involved because it feels It feels like you're violating policies, even though it's to be honest.

But there's medical marijuana that you can.

Prescribe as a doctor, right?

Right.

Well, but again, it's only for the residents of the given state. I mean, I can prescribe it to anybody. Let's say the patient travels to my state and I feel appropriately to say, you should be, but there's no way for me to recommend it. If I try to recommend, they're not going to get it because they can't obtain the card. So in every state, it's not like if I write, let's say, I don't know, oxycodone prescription, it goes straight to the pharmacy. Here, patient is separated from physician completely. So you have to get a medical card, which is always authorized by a state. So you have to follow the state guidelines to get the card. If you're not a resident, well, you're out of luck. You can't get it. So then once you get a card, then you have to identify dispenser and go there. And if your doctor tells you, okay, get this and that, okay, great, but most doctors don't tell you that. They simply say, well, go and talk to the butt tender, as we call them, right? So go talk to them.

It's like the lady in the vitamin store who's recommending your medicine.

Exactly. And some of those ladies are really good.

They know a lot.

And they probably know more than some doctors. Well, not probably for sure, but some of them are clueless. They're like high school students. not that I have one, but that's not the. No point being is it's a dramatic. There's just no, no standardization across the field. It's a maturing business. I think in the future it'll self-regulate better. And I think there's already some states that took really hard, like Connecticut and Maryland, for example, and others. So they took really hard. They say, look, you've got to have some kind of an educational director in Connecticut, you actually have to have a pharmacist on stuff in every dispensary. So it's a pharmacist who's going to sort of guide the products, guide the education of the dispensary. It sort of has to happen this way. If we're saying that this is medical, it has to look medical, right? And it shouldn't look like alcoholic beverages. Okay, so I'm going to say something and I I hope somebody from district government is listening. So get a load of this. In District of Columbia, where my main license is, I don't know who was the miracle worker who said, oh, why wouldn't we move cannabis into alcoholic beverages industry? So literally when patient applies for DC medical cannabis license, what they see is that this is Department of Alcoholic Beverages, not a Department of Health, Department of Alcoholic Beverages. who in the right mind came up with this stupidity is just sort of. So, you know, and then you have. So. So you have. You have some states that are thinking about this. Right. And you have some states where it's a mess.

Yeah.

And how do we get to some kind of standardization? I don't know. All I can say or all I can do is to say we gotta teach our own colleagues first. I think to me. It's so important topic.

So speaking of teaching our colleagues and figuring out how to educate people, do you want to know my secret for living a long and happy and healthy life? Well, all I have to do is check out my weekly newsletter, Mark's Picks, where I share my favorite tips for health, longevity, well-being, and lots more. Check it out and the link below. In terms of the forms and the types, I mean, how do people know what to pick? I mean, not everybody has a doctor that's informed like you.

Right.

And so how do you know when you go in, you can maybe look at the route of administration, but there's all these different varieties. They're like, they're just, it's overwhelming. It's like, it's like flavors of bubblegum, you know?

Right. Well, so I think you have to learn a little bit first, like before you go to the, tell us what.

Would be the take homes for people? Like, what are the things that people should know before they go to the dispensary?

Right. I think the first take home should be, know what condition are you going to use it for and get a basic sense for that condition, what are the experts would recommend. So if you get my book and you look up your condition in my book, you can see what I would recommend. There's tons of other great books. I'm not, it's not the only one and lots of experts in some ways. There are lots of experts who actually know a lot more than me. Yeah. But start at least from some basics because otherwise if you go and you rely just on Butt Tender, it's probably not the smartest thing. I hope in the future in 10 years I can say, oh no, just go and there's gonna be an educator in the dispenser who's gonna tell you, exactly what you need.

Yeah, yeah, yeah.

And there are some dispensers that are starting to do that. So sometimes if I'm totally strapped for time and I know a few dispensers in my area that do that well, I would send the patient there. Unfortunately, even with those situations, often we have issues because, you know, you have a sensitive patient and they will just start so much higher. So, but then after you get some core basics and you started trying, you have to be persistent often. just starting with one product is not going to work very well. You have to try two or three until you find your own personal kind of and not only one product. Often people need between two to three.

That's two or three products. And why would you need two or three products?

Well, let's talk about pain for a second. That's an easy example. Let's say you have some kind of a chronic pain, let's say fibromyalgia. If you get a product that's more that has terpenes that are more activating. and you take that past five o'clock at night, you're going to stay up till midnight or past. So you don't want to do that. You want to take that early in the day. But the opposite is true too. If you take a calming, more sedating strain in the morning, you're not going to be able to function very well if you're sleepy all day. So here's a simple example. If your pain needs to be controlled more than with once a day, which often the case, you want to take something activating in the morning, something sedating at night. that's one simple, simple statement. But often you also can use different routes of administration. For example, edibles can be great if you wake up late at night, late in the morning and can't sleep. Let's say you're insomnia girl at 3 a.m. you just wake up and then you up and you can't go back to sleep. The edibles will work great. But if you have both, they won't.

Make you too sleepy.

Well, you have to dose appropriately, right? You have to titrate to dosing. So that's the principle, start low, go slow. You'll start with a very low dose, and I usually start with sublingual forms. So they kind of, there's this idea of therapeutic widening of the window. So if you start subtherapeutically for a couple of days, three to five days, and then you start increasing, you're running much, much lower risk of side effects. If you start and you very quickly titrate up, let's say, each next dose adds 20-30%, which is commonly done for pain, you may actually end up overdosing quickly.

And then be groggy in the morning.

And be groggy in the morning. But if you do this carefully and you get to a point where it's working, so you could actually use sublingual right at bedtime or a few minutes before because it will kick in quick. And then you can also take an edible that will kick in a lot later. So some people can do that. Often it's not even needed. You can just take the oral a little bit earlier. But it takes time to figure all these combinations and you need to either have a very knowledgeable provider who will be sort of like an advisor and say look, okay, well this is what happened, this is why it didn't work or this is why I had side effect. Or you have to try it on your own if you have no access. So the book is written both to help people who are complete novices but also people who've already tried something because it outlines some of those pitfalls. sort of what happens if you overdose and you're afraid of going back to it. How are you going to do that? You know, and that's, that's why still a lot of people take inhaled, because the predictability of the effect is better. You know, you, you, you take a drug and you know how it's going to make you feel, especially if you found the strain that works for you. I have nothing against it. It just often, for medical reasoning, that may not be the best approach. But often, if the patient comes to me and says, Look, I've been smoking my whole life. This is what I do. This is how it works for my pain. I often don't say anything because I find it not often easy to transition person from smokeable product to something else. I would tell them what I think and then give it up to them to say if they want to try. I had a number of people who switched over the years.

What would be the best sort of sleep recommendations? There's a lot of people who have insomnia, 70 million people with sleep disorders in this country and sleep issues. It's a lot of people. I'm just wondering what your starting recommendations are for people and where they could begin to think about using it.

Right. So, find a sublingual product like an oil, a drops or we'll call FICO, full extra cannabis oil. I don't like alcohol because alcohol can burn the mouth. There are some tinctures that alcohol-based, I tend to like oils more whether it's olive oil or MCT oil oil. So find the product oil like that. A lot of the products that are specifically designed for sleep, they're going to have a couple of simple features. Not only the Indica is again outdated, but that's the kind of original term. So you're looking at Indica products, right? But now that we're going away from it, you can look for a couple other things. You can look for this molecule called CBM. CBM as NC.

CBM, yeah.

Instead of CBD. so products that have high CBN in mix with THC sometimes are really effective. And often the products would have the terpenes that are coming inhibiting, like limonene is one, but there are others. And the products would often say that on a label, like a sleep or tranquility or whatever, you know, and frankly those products often designed specifically for sleep. The good news is that a lot of the times, butt tenders would know that. So if you come in, they would know that. And even though there are a lot of edibles for sleep too, they're edibles specifically designed to have the same sedating impact, I always tell people, start with sublingual, you're running less risk of the next morning grogginess. You don't know your particular THC need. It's actually very interesting. THC need for insomnia varies quite a bit. I would say somewhere between three milligrams is probably the lowest all the way to maybe 10, 15, 20 milligrams. And most people fall somewhere between five to 10 milligrams, what I've been seeing. But again, my population on average is a little older and sicker and more frail and more sensitive. So I may be seeing a bit of a lower spectrum in my clinic. So I understand they're probably people who work with other groups of patients where the dosing may need to be higher. So for pain, for pain, which in-.

Start with sublingual for sleep.

Start with sublingual.

Maybe an edible.

Maybe an edible.

And it takes about an hour to set in?

Edible will take at least an hour, maybe a little bit less. Sublingual can take 20-30 minutes. Sublingual tend to work a little bit faster. So plan accordingly. If you need to fall asleep at 11 and you take it right at 11, you may with either form, stay up for a little bit longer than you want. So you may want to time it a little bit ahead of time. Again, that's why people like smokeable, right? Because it hits right in. And there's no lack of time.

Yeah, you're very quick. It's very quick. Right.

And again, as I said, in the literature out there, I often speak about non-inhaled forms simply because they're safer, but it doesn't mean that if you have a problem that you feel needs to be addressed urgently, I think some amount of inhaled products is totally fine. If it's limited and done in a smart way. And again, yes, so the lower temperature of inhaled product the better. So the vape, if you get a quality vape, it's probably safer than burning a flower. If you can vape the flower, now there's devices that are literally, like, I'm not kidding, iPhone controlled or computer controlled where you can, we can pick precise temperature and the dosing. So, that's the next iteration. Yeah, there's this some devices where you can tell the vape you want to take 10 milligrams. And, you know, if you know the cartridge concentration, it will calculate it precisely. So, when you inhale, it'll dose it right for that dose. So, that's a future. It's already here, actually, it's not even in the future.

Is it commercially available?

Yeah, they're commercially available. You can buy them. One system that I'm aware of called PAX PAX, so they are doing that already. Of course, it's not cheap, you can imagine. So, you know, it's not a typical pen vape can be $10, $20. Those things can be hundreds of dollars, if not more. So, they're not cheap. And they're controlled by your phone. They can be controlled by your phone. Well, most of the time it is phone because it's most convenient. because you want to set up a certain parameters on the device to be precisely delivered.

Amazing. Now, there's been some noise about COVID and cannabis, especially for long haulers. What do we know? What do we not know? I mean, it can't be that there's that much reason for it now.

So the big noise was, I think, about a year ago when somebody, and there was a researcher in Canada that made a splash saying that cannabinoids could be used as anti-COVID. I honestly think that was just a hype. The study, I looked at that study, it was very, very preclinical and, you know, we know that THC has a very potent antiviral effect, so there's nothing surprising there. But translating that to the human, I think it went from, it was a preclinical study to the Facebook saying cannabis cures COVID everywhere. And I was like, Oh my God. You know, well now it's fascinating you're brought up long COVID. I actually feel strongly that in the last year, I feel like a third, if not half of everything I do is gearing that direction simply because we have an influx of patients. And there cannabis can be a godsend for a lot of symptoms. A lot of people still have horrendous insomnia and fascinatingly, they have really bad cognitive problems like the attention lock, Brain fog, actually I have seen some patients do really well with a very low doses of THC and CBD. I don't necessarily going to use it on everybody, it's sort of, it's still evolving as to who should we pick for that. A lot of people have, they lose a lot of weight and then they have this kind of general fatigability and they're not eating well and they don't have an appetite. Definitely cannabis can be occasionally helpful for that. I would say there's actually, I didn't mention that as one of the most evidence-based approach. Everybody know that you smoke and next thing you know, you really want to eat. Turns out the evidence for that is very mixed. It's not as clear as you would think. There are definitely people who benefit from it. When you look at the studies, the studies have never been conclusive in contrast to pain or things like nausea. So I still use it. I think that newer molecules like CBG, for example, have tremendous promise for that. But again, we need a lot more data to be conclusive, but definitely can use it. So. So it can be a very supportive additional tool for everything we do. But of course, you know, more than anybody that a lot of these patients with long COVID, they have chronic inflammatory response, they have a mitochondrial suppressive suppression. and kind of this general low energy states where you really want to boost the cellular function first. I don't necessarily think of cannabis being their first line. In fact, I'd be cautious if somebody's going to start smoking for some of the relief of their symptoms. Actually, energy can be drained.

Yeah, no, we've done it. It's true. I mean, we've done a bunch of podcasts on long COVID and I think there's more to learn for sure, but it's exactly. for those who are listening and want to know about what to do about that, which now seems to be between 10 and 30% of people who get COVID, which has been millions and millions of people.

And now it seems like the Delta is also going to give us long-term post-COVID kids at somewhere between 5 to 10% of kids. Yeah, I mean, I think people are.

Worried about COVID but I'm more worried about long-haul COVID because most people don't die when they get COVID. But you think of 30% of 200 million people, We're talking 60 million people.

We have more than 1,000 patients at GW on the wait list. In just one clinic. Just on wait list because we can't get them in quick enough. It's a complex process.

Yeah, I think it's really a problem. But from a functional medicine perspective, it's a lot of people can do it. I think, you know, symptom management through medical marijuana can be part of it, but it's not really the only thing.

Exactly.

So, Misha, when, when people are listening to this, they're like, okay, well, I've got some of these conditions. I have sleep issues, I have pain, I have digestive problems, I have Ms, I have whatever it is that we've been talking about. How do they go about finding a good dispensary, a doctor who can guide them? Like, where do people start?

It's a little overwhelming. It is overwhelming. So there are some really good online resources. I think Leafly is one. Weedmaps is another. So a lot of these websites will have a list of practitioners in the area. If you're in a state where it's.

Legal, can you give the websites for both of those?

Sure. Leafly, spelling, you asked a Russian guy to spell something. I have to look it up. I think it's L-E-A-L-F-L-Y. Yeah, I think that's right. And it is an app also.

We'll put it in the show notes too. Yeah.

L-E-A-F-L-Y. That one, most of the states would have a list of the doctors who are formally authorized to recommend. So if you're in a state where it's legal, the first step, go to the actual state website that's responsible for medical cannabis, and there will be a website. And it'll explain to you typically the process of how to do it. If you can't figure it out, there are websites, other websites that will help you. Like, I really like one called normal N-O-R-R. Okay, I gotta spell that too. Interestingly, most of my spelling efficacy is when I type things, because I remember what my hands are doing. N-O-R-M-L. So it's a national organization for the reform of marijuana laws. So they have a list for each state how you apply, like what is the process, what are the pitfalls? Because you got to get a card first. So once you get a card, hopefully you have a way to access who are the physicians because to get a card you have to get a medical recommendation. So you went to a physician or a healthcare practitioner who is approved for this state like nurse practitioner or naturopathic doctor, etc. hopefully they're knowledgeable. Now, what if they are not knowledgeable? Well, then your next level is either you're going to find someone who actually understands something, and it doesn't have to be a doctor. There's a lot of people who call themselves now. Cana coaches. Some of them are great. In fact, in the beginning, 10 years ago, one of my sort of most informative colleagues was one such person. I mean, basically Beth self-learned the topic because she was basically almost dead from all kinds of medical problems. She was taking 30 pills. Her bills were in thousands of dollars a month. And she said, screw all this, went to Colorado, learned all this stuff, got herself all off all the pills and said, look, I got a teacher. So some people, they have just, you know, through their life knowledge, they became so interested and engaged, then that becomes their whole world. So people like that end up usually being the masters. I would say, and if you can't find one of those, great. If you can't, you're gonna have to rely on your butt tender. So then the road can be split. If you get a good one, you're in luck. You may hit a jackpot right away and you'll be fine and it will work. And if it's not, then something happens, you have to kind of go back and again look for a provider or a source of information that's gonna work. So I know it's not a satisfactory answer, but the reason is we have to teach our colleagues. So I kind of the way I took it on myself, you know, I'm not a researcher. I there are experts in this field who are way deeper than me, but I'm in university, right? I'm a full-time faculty. So we said, look, we got to do something. And instead of creating yet another attempt at forming academic program that's very expensive, we said, look, we got to establish some kind of a cohesive process where we will create a set of competencies. So the way medical education happens this way, you have to prove to the larger administrative body of medicine, education, medical education, that this topic has a set of competencies that can be followed as a standard. If you have a couple of schools here and there and few students can learn, that's fine. But the next step really have to be Every medical student coming out of medical schools must know this topic. And they not just need to know, oh, there are potheads and there are none, and there's some little bit of evidence. No, they have to know how to recommend it. They have to know basics of laws in states where they practice. They have to understand basic clinical application, basics of toxicity, and how to actually practically recommend it. And if we create set of competencies, and then try to go to American College of Graduate Medical Education and say, look, you've got to approve this, then that's the next step. So that's actually what we're doing. We got a grant from industry to organize this. So we already started a process. It'll probably take, you know, some months to get this, but we're hopeful that we'll go and try to publish this in a decent journal and then try to push this. But it has to start something like that because we have to start pushing the future of cannabis to be away from the industry or not away from industry, you can't do it, but also towards more academia and more standardization. Otherwise, we're going to, industry is going to standardize it, not necessarily the way we want to see it.

Yeah, I mean, I think you have a very good point there, Misha, because people are using it recreationally, they're using it for mild symptoms like you, you know, get a Tylenol all over the counter or something like that. But there are more focused medical indications and there are more and more going to be discovered as we're doing the research. And as you found patients with psoriasis or MS or things you wouldn't necessarily think about. And so, you know, as a physician, I like to know what I'm doing. I like to know the dose. I like to know the source. I like to know where it's coming. I like the standardization. I mean, whether it's a, whether it's a drug or a supplement, I'm very, very picky about supplements I recommend because I want to make sure that the raw ingredients were sourced from the right place. I'm not sure I want them coming from China. If they come in, I want the herbs to be tested. I want the purity, the potency, the active ingredients, the concentrations, the bioavailability. I'm sort of obsessive about it. And in the same way, I feel like, you know, with medical marijuana, you don't know what you're getting. Like, you got, it's like, it's kind of a free-for-all it's not medicalized. So it's, and that's, I'm not saying they should, should be only medical. But that there should be a medical, like just there are professional grade brands of supplements, or you can buy it at Costco. Let's talk about that.

I think that's actually a critical point. And it's one of the passing the level of initial knowledge, so going away from who knows what to a point, you know, how do you assure quality here? That's probably the second most important problem right now. It's lesser, believe it or not, shockingly it's much lesser of a problem in medical cannabis area compared to the CBD and the hemp. Because there, there's zero control. So unless it's a trusted company, you have no clue what is happening. Just what I mentioned, are you going to trust your Walgreens to produce quality CBD? I don't know, I'm not saying anything, but I probably wouldn't, right? So I would have my own list of brands that I would trust that I would go to. With medical cannabis, each state that passed the law is required to regulate it. And most of the states actually did a reasonable job to say, okay, we're going to control the production, we're going to assure there's some kind of attempt at quality assessment and quality measures. So if you're getting medical cannabis, you can be assured you're probably getting nothing from China. locally grown, that's actually legal requirement because of the states.

I mean, is it organic? Are you sure about pesticides and stuff?

Right, so you have to still worry about certain things, but you have to worry less compared to what's going on with hemp. The other problem with CBD and hemp is think of it this way. In order to get CBD in concentrated amount from hemp, you're going to have to grow way more plants than cannabis. And so, God forbid you have a mold in there. you brought up this mold problem, you're going to concentrate that toxin down. And we already have seen issues where there was a serious illnesses with people consuming mold at cannabinoid products, whether it's a hemp or cannabis. So you really don't want to hyper-concentrate extracts if there's any possible toxin, right? Because you're going to concentrate the toxin. And then we already have seen, we actually, there's a belief there's been some deaths related to mold or other toxins in the concentrated product. So definitely, I think there has to be more regulatory mechanisms in the future. I think when the whole nation moves away from, you know, this mix of mishmash of states to descheduling or rescheduling cannabis, we're gonna have some kind of national process. And I'm very hopeful. I think it's, if you look at most of the decent industry partners, they doing their best. I mean, a lot of the times it's hydroponically grown. So hydroponically, definitely, generally speaking, will probably be safer contaminants wise. We talked about the cannabis is weed, right? I mean, there's reason why we're calling it. It grows really quickly. It's a very robust plant. It mutates quickly. If you have a right conditions, it's relatively easy to cultivate. and I mean it is an art. I mean the cultivation of cannabis is a profound art, but it's a lot easier than some other plants and it's a lot easier than a lot of most of the, I would say medicinal plants. So I think because of that making the future of, you know, boutique cultivation or quality cultivation, forget just boutique, I think is quite bright and I feel strongly we're going to have some maturation of the industry where bad partners over time are just going to evaporate and we're going to be left with some reasonable quality that everybody can have access to.

So, Misha, as we wrap up, I wonder if you have any parting thoughts about what you'd like to share with the audience about your take homes around medical marijuana?

I think there are two big take homes. So, one is I see cannabis as this amazing example of integration of plant medicine into our health. It's sort of like rediscovering. We've had it for thousands of years. We forgot about it. We made it illegal for whatever. And then now it's kind of coming back roaring because we're realizing the potential here. So I think following this field is important, but I also want to say critical. It's not the only tool. It just needs to be effectively integrated and used correctly in the mix of everything else. we do. It's sort of a great example of the why integrative medicine or functional medicine is a future. Because we have so many other tools and when you learn how to effectively use them, that's where the magic occurs. So don't get overhyped. Don't think that CBD, THC is going to cure everything under the sun. No. Go into the resources that are balanced and deliver the knowledge in a evidence-based approach with some kind of neutrality in it. So there's not a lot of commercial interests. Unfortunately, again, most of the data or information out there is coming from commercial sources because trying to make more money. And I think that's, that will change. It will change. So future is bright. Use responsibly, find the, the way to understand it, and you have to do it yourself. You can't just rely on some doctor tell you what you're going to take. You have to learn the basics here, at least for now.

If you love that last video, you should check out the next one for sure on getting the root cause of all disease.

Getting quality, sufficient sleep on a regular.

Basis is without question the foundation of mental and probably physical health as well. No, we already knew.