Healing Insomnia, Reducing Pain, And Other Benefits Of Medicinal Cannabis

Coming up on this episode of the Doctor's Pharmacy.

How come we co-evolved on this earth with a plant that allows us to have this fascinating interaction with it? Almost every cell in our body has the receptors. It may be the oldest documented medical tool we have on earth.

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D-R-H-Y-M-A-N. And you'll see the discount code in your cart. hi, this is Lauren Vician, one of the producers of the Doctor's Pharmacy podcast. When used the right way, there are many proven benefits to medicinal cannabis, including soothing pain, improving sleep, healing skin problems, and reducing nausea. In fact, cannabis may be one of the oldest documented herbal medicines on Earth. In today's episode, we feature three conversations from the Doctor's Pharmacy on the many benefits of cannabis, and we take a look at how the body's built-in endocannabinoid healing system works in tandem with this plant medicine. Dr. Hyman speaks with Dr. Misha Cogan on what the data currently shows us on medicinal cannabis and the top symptoms that has been proven to help, with Josh Axe on the difference between THC and CBD, and with Jamie Wheal on using the body's endocannabinoid system to promote health and well-being.

Let's dive in. 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 them from coming? It helps. No, it actually treats underlying problems and you know it's more complex than just TH-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. 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- And.

You use it topically for the skin condition? And, you use THC as well as CBD for the skin condition?

Yeah, it, 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 kind of a 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 it 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, you know, irritable bowel syndrome, preferably in a form where it goes down, so 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. and 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 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 it.

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 are we talking about?

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. So 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 the what's happening in our bodies is very hard to figure out. I mean, 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 had cannabis. That wasn't the only thing the patients were using. Don't get me wrong.

It's always other.

So was it 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 anti-cancer 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 grail with a G, like in Georgia. So even even molecule like that one has some clear anti-cancer properties. So 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 sort of 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.

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 and what the benefits of this 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.

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, 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 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? So 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. Like we literally make our own cannabis constantly in our body and then there are a set of receptors. The more commonly known ones are CB1 and CB2. So this, 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 in a lock. So your key is the, is our endogenous cannabis molecules or let's say anandamide and the the lock of the CB1 and CB2 receptors. 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 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 your 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 what's gonna happen. I'm not caught up. Right. So why that happens, nobody knows. The second mystery, that's what I really wanna 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 plant's been used for thousands of years. In fact, it may be the 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 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 then over the centuries, it was used in different ways and then it finally kind of ended 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 the 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 that bind to those receptors. Is there a similar set of molecules in the body that naturally occur that'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. they're long list of those. Anandamide, right? That's probably the, it's one of the most common, it's one of the best understudied. 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 gonna be limited. If you combine that impact with what terpenes can do, suddenly you have a 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 it.

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, Linoleic. 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 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 spasticity. So those are the three original big ones that were in 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%. 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 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. years. 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 Grateful Dead? Well, I wish.

Not quite yet. That's a whole separate. You just opened the can of worms that if we go there, it's not going to 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 and 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 1? Unfortunately, in a lot of situations, cannabis problems come only to two things: the price and logistics and nothing else, and not the efficacy.

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In terms of the efficacy, you know, a lot of people are reluctant to use it in practice. There's 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 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.

Yeah.

So, but for THC.

Yeah, but, but the evidence. But if you look into, you know, I, 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 Bruce can actually ease it up or there's a placebo effect. But next thing you know, now it's getting translated all over the place. Anyway, so bottom line, you got to 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 going to have to travel to a legal state and then cross the lines, which is actually federal. moral crime to bring the cannabis from one state to another. A lot of people don't want to get involved because it feels, you know, 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 a 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. like, you know, high school student. And so, 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 and it shouldn't look like alcoholic beverages. Okay, so I'm gonna say something and 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 their right mind came up with this stupidity is just sort of, so, you know, and then you have, so you have some states that are thinking about this, right? And you have some states where it's a mess.

Tell us what would be the take homes for people, like what are the things that people should know before they.

Go to spend their money?

Well, 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 going to be an educator in the dispenser who's going to tell you exactly what you need.

Yeah, yeah, yeah.

There are some dispensers that are starting to do that. So sometimes if I'm totally strapped for time and I know 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'd 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 we 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 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 once a day, which often the case. You want to take something activating in the morning, something sedating at night. That's one simple statement. But often you also can use different routes of administration. For example, edibles can be great if you wake up late in the morning and can't sleep. Let's say your 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 form. 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 it had side effects. 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 why still a lot of people take inhaled because the predictability of the effect is better. you know, 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 I don't, 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 sort of 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? Because a lot of people have insomnia, 70 million people have sleep disorders in.

This country and sleep issues.

It's a lot of people. I'm just wondering what your sort of starting recommendations are for people and where.

They could kind of begin to think about using it. Right. So find the product, find the 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. 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 for this molecule called CBN, CBN as an NC.

CBN, 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 linoleic 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 into the, they would know that.

Yeah.

And even though there are a lot of edibles for sleep too, you know, they're edibles specifically designed to have the same sedating impact. I always tell people start with sublingual use, running less risk of the next morning grogginess. You don't know your particular THC need. It's actually very interesting. The 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. sicker and more frail and more sensitive. So, I may be seeing a bit of a lower spectrum in my clinic. So, I understand there are probably people who work with other groups of patients where the dosing may need to be higher. So, for pain, for pain, which... Start.

With sublingual for sleep.

Start with 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 lag time.

Yeah, you're very quick, 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, is probably safer than burning a flower. If you can vape the flower, now there's devices that are literally, I'm not kidding, iPhone controlled or computer controlled, where you can pick precise temperature and the dosing. So, that's the next generation. Really? Yeah, there's some devices where you can tell the vape you want to take 10 milligrams. And, you know, if you know the cartridge concentration, it'll calculate it precisely. So, when you inhale, it'll dose it right for that dose. That's a future. It's already here, actually. It's not even a 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 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.

They can be controlled by your iPhone.

They can be controlled by your phone. Well, most of the time it is phone because it's most convenient. You want to set up a certain parameters on the device to be precisely precise at delivery.

Amazing. Now, also 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 research now.

Well, so the big noise was, I think, about a year and 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, there's 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 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 gudsent 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 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 suppression 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, 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 about it. 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.

Well over a billion. Yeah, 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.

So 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, you know, 200 million people, we're talking 60 million people.

We have more than 1000 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 a part of.

It, but it's not really the only thing.

Exactly. So, 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 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 ask a Russian guy to spell something. to look it up. I think it's L-E-A-L-E-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 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 I remember what my hands are doing. NORML, 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. So, 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's approved for this state, like nurse practitioner or naturopathic doctor, etc. So hopefully they're knowledgeable. Now, what if they're 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, kind of 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 old off all the pills and said look I gotta teach. So some people there 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 going to 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. There are experts in this field who are way deeper than me, but I'm in university, right? I'm a full-time faculty. 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 consent 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 then 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 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. You know, 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.

The other thing I wanted to sort of dig into was something you wrote about in your book, which, you know, it's getting a lot of press, which is CBD and endocannabinoid system and how that works and what we should know about that. Because it's one of the plant remedies that you do talk about, which is a little controversial. And people are really scared of it. Oh, my God. If I'm gonna take CBD, I'm gonna get drugs, and I'm gonna get stoned. I can't do it because I, my work doesn't let me smoke pot. Like, what is all the hubbub about it?

And what do we know?

And what, what what is the best application of CBD and what do we use it for?

Well, first off, I do agree, I'm a hemp farmer. I own a thousand acres of certified organic land where we grow organic hemp. That being said, you know, there are different ways to grow the plant to where it has larger levels of different compounds. So, too many compounds in hemp, also known as cannabis, and you're gonna have THC and CBD. THC as a compound has hallucinogenic effects. That's what's going to get somebody high. CBD is a very, very different compound. CBD is just calming. It's, and actually it comes from the bud of a flower of the hemp plant. And it's more similar to chamomile or hops or even lavender. It's more similar in compounds there. So you have these two compounds in a plant Chinese medicine. It's known as a Yin tonic. So it's going to help if you're in a sympathetic state, you're in a fight or flight response. so many so many so many of us are today, it's gonna help bring you down from that. In fact, I would say CBD is maybe the most effective herbal I've ever used at getting people out of that fight or flight state, which is why I do think it is so powerful for people to use. If you if you really need to get better sleep, CBD is the best herb I've used. If you want to improve and help reduce inflammation in joints, it's a really good one for that. I also think it's good for digestion, if it's stress related and some other things, but sleep, inflammation, biggest benefits of CBD. THC though, I do wanna give this warning. I do think doing a medicinal blend of those two, a lot of doctors will prescribe that and I think that can be good to replace opioid drugs and if somebody has major chronic pain, but I really think chronic pain is about the only category out there to where THC should be used for a longer period of time. Because here's the thing, according to Chinese medicine, and I've seen this with people, there is a big side effect with THC and that it's a drainer adrenal glands. Your adrenals in Chinese medicine was also known that it's what gives you motivation, it gives you energy saying, Hey, I want to go out and do things. I want to be active. You'll notice when people overdo, you know, that labeled them potheads for overdoing THC cannabis, it zaps their motivation. And actually in Chinese medicine, it's known to deplete their Jing, which is essentially their sperm cow and their libido as well. So anyways, all that being said, I'm not at the biggest fan of using THC in most cases, but CBD is a non, you know, it's, it's a, they're, they're really just benefits there and none of the side effects.

A couple of of big metronomes to our entire physiological systems, as you well know, the endocannabinoid system, which most folks aren't even aware of. In fact, I think there was a study maybe about 10 years ago that said that 90% of US physicians weren't even conversant in it as a system or its impact. But I mean, there's been phenomenal studies in Israel on that since the 1960s. Raphael Mechoulam is the pioneer physician. He actually did it with NIH grants from the US for that whole time. And it's the system into which cannabis interacts, but it's not because of cannabis. That's the lucky- no, it's not because of cannabis. The body already had that going for it. Yeah, right, right. The body, I mean, sea sponges from 500 million years ago have an endocannabinoid system. So the fact is, is that it governs everything from bone growth to stem cells to brain health. the Israeli military studied it for TBIs, right? For traumatic brain injuries and being able to flood the body in all of those things. There's studies at Cornell Medical Center on the impact on mood and fundamentally anandamide is what they call the bliss molecule, which is endogenous to human brains. And that is what the endocannabinoid system produces.

Yeah, we call it endocannabinoid receptors, opioid receptors. They're actually metabolizing and interacting with molecules that our body already has.

Absolutely. And in fact, there's an interesting genetic variant where Nigerians have an unusually higher amount of anandamide. And there's a couple of other cultures around the world that do. And typically it reflects in less anxiety, greater fear extinction from adverse events, and overall a generally higher set point. So that's amazing and has all these profound impacts that virtually none of us are aware of, but it governs huge swaths of our physiology and resilience. And then the vagus nerve, which is becoming increasingly more known through Stephen Porges' work and Vessel Vanderkolk and others, but it's largely unknown. And it goes from our brain stem all the way down to our root. And again, is this huge metronome governing all kinds of internal regulation. And you can and you can improve it by goggling, by singing, by humming, by massaging your throat. There's pacemaker interventions, there's more kind of high tech pharmacological stuff, but like just those alone, just fascia, endocannabinoid system, and vagal nerve tone, you don't have to become an athlete, you don't have to become a yogi, there's nothing extreme about it. It's just learning how to adjust the knobs and levers of our bodies and brains greater health, greater resilience and overall higher well-being. And the practices that help you do.

These things are in the book, right?

Yeah, absolutely. Particularly easy ones like respiration. Here's just ways to become more in charge of your respiratory awareness. And I'm sure that many of your listeners are probably familiar with Breathwork. They might have heard of folks like Wim Hof or other- We've had a number of those folks on the podcast. Progressing the conversation James Nestor wrote that great book, Breathe. But I think people often these days still fixate on a specific version of breathing, often a hyperventilatory state shifting one, assume that's what breathwork kind of is versus, hey, the goal is to be conversant across the entire range of rate, rhythm, and depth for desired outcome, and then we can kind of just be in our own skins.

And then breathwork, you know, I was a yoga teacher before as a doctor, they called Pranayama, which is all these different techniques for modulating your breath and.

Changing your biology through breathing. Yeah, I mean, and Alistair Crowley, right, the sort of infamous Western sex magician who wrote dozens of books and never said anything straight. It was always hidden in riddles and verses and all this kind of stuff. The one thing he says out loud on the page is Pranayama, Pranayama, Pranayama.

Pranayama, Pranayama alone is everything.

Yeah.

Yeah.

It's so powerful. So you have breathing, you have being in your body, you have sexuality, and then you have substances in music.

Yeah.

So you can kind of consider those depending on how you want to make the argument. Right. Ron Siegel at UCLA has talked about the urge for animals to seek non-ordinary states or intoxication is not only older, not only ubiquitous across human cultures. it's not only ubiquitous across primates or even mammals, it even goes to birds.

Really?

Who seek non-ordinary states of consciousness. What do you mean?

They're tripping parakeets? Yes, yes, absolutely. And fundamentally, he was saying that it's, you know, other than, you know, air, food, and sex, you can make a case it's our fourth biological drive. So you can either see it as an amplifier. Oliver Sacks, the famous neuroscientist, said, you know, say what you will about drugs, but they offer transcendence on demand. They actually work in a predictable way, which is part of the reason why the psychedelic renaissance is generating so many radical insights into theories of mind and consciousness is because you can predictably give somebody a molecule, a compound, park them in an fMRI machine, or whatever other measurement you're going to be doing, and you will get a repeatable result versus getting it to certain llama to be chanting or meditating or something harder to pin down or more esoteric. So substances and specifically state shifting, and my inquiry in the book tended to focus on those compounds which were both available and accessible. They weren't either strictly controlled or wildly esoteric. So they were available over the counter, off the shelf by prescription, schedule three, four compounds, those kind of things, but also from functional, what do they do? Compounds that typically, some of the most interesting compounds to provide that kind of peak state experience, that kind of death rebirth experience, are those that drop your neural EEG down into delta wave states.

Yeah, which is what you get from meditation.

Well, very esoteric meditation. I mean, into the Vajrayana traditions, a lot of meditations are sort of alpha to theta. I mean, A, there's no singular meditation. They're all very different, produce different things, as you well know. And their neuroelectric signatures vary comparably. So deep delta, waking, like delta sleep, delta is typically only accessible to most of us in deep and dreamless sleep. Waking delta is a very rare, pretty esoteric state because it's down to damn near brain dead. so four hertz and less. And that has super intriguing correlates with near-death experiences. So Carl Djerassi at Stanford has done all that work on optogenetics and the ability to source different states via tweaking things, obviously, in mice and that kind of stuff. But in human patients, they had epileptic patients and they gave them the compound ketamine, which is a dissociative anesthetic, which induces delta wave states, found, and then correlated that with a sense of egolessness or ego death, and correlated that with antidepressive effects. And so what they realized is that they isolated the region of the brain that was coming in at right around 3 hertz was the sort of signature that they were picking up when patients were under the influence ketamine and reporting a sort of selflessness or an out of body experience. Then what was really interesting is that they then went back in and electrically stimulated that same three hertz signal in that same region without the drug, without ketamine, and patients were still reported the same out of body experience. And then as a result of that work, another group started researching nitrous oxide. for its potential as- Laughing gas. Yes, exactly what folks use at dentists, what doulas and midwives use to ease childbirth, that compound, because they were like, oh, maybe there is an analog for nitrous oxide as an antidepressive also, and it has actually proven out as well. And then the anesthesiology team at MIT did research on nitrous oxide and were shocked to find that it actually doesn't, not only does it induce delta wave sleep, or state for three to 12 minutes after a 50-50 oxygen-nitrous oxide gas blend infusion. So, sort of wearing a mask and breathing it. But for three to 12 minutes, you get double the amplitude delta wave oscillations in the brain before the brain then normalizes out. So, you get all of these experiences and you realize, oh, delta wave activity is arguably the signature of of a sort of quote-unquote near-death experience, AKA what has been, as you were saying in the wisdom traditions, a death rebirth initiation protocol. So you're like, okay, so those are potentially super interesting because always it's not just that, this is like that old movie Flatliners, with all the med students go into the basement and take turns paddling each other and there's always the cautionary tale of don't play Right. But we are close to getting to do that in more controlled and more responsible ways now. And the interior content of those experiences are often quite profound and provide as much access to the healing, to the anti-depressive, anti-anxiety effects as the physiological experience itself.

And they can help heal traumas?

Well, I mean, there's strong evidence to suggest that, and I just don't think we are anywhere near teasing this apart. And you and I talked about this a lunch of isolating factors. What of even more broadly, all of the research into the psychedelic renaissance, whether it's ayahuasca, MDMA, ibogaine, psilocybin, the compounds that are under a fairly intensive comprehensive study, it's hard at this stage to really separate out what pure neurochemistry resulting in decrease in depressive symptoms, anxiety, et cetera, whatever they're studying, versus what is the interior content, the ineffability, the mysterious nature, the profundity, whatever it is.

Once you see God, how can you turn back and not see it?

Yeah.

And I don't know if we'll ever truly unravel which tail is wagging which dog on that.

So, in the service of this conversation, there are some substances you talked about that are accessible and legal, whether it's ketamine or nitrous oxide, in many states cannabis, as doorways to help us access these altered states, which you say are non-ordinary states of consciousness that humans and primates and other animals seek, which is interesting to me. And I think we're all looking for that, whether it's we pray or whether we dance or whether we listen to music or whether we, you know, we take substances or addictions, they're all attempts to change our state, right? Because somehow disconnected from something that makes us feel whole and complete. But these are sort of, in a way, more adaptive and more therapeutic strategies than often we've used. And you've sort of codified them in a way that is very interesting. And you actually created a research project to look at these things in a more objective way. And I'd love for you to talk about this research project because essentially you took people and put them through a three-month program and measured objective scientific metrics to look at the changes in their state and the change in their biology and the change in their psychology. And you discovered some pretty interesting things. So I'd love you to sort of share about this concept of hedonic engineering which is sort of what the larger frame of this conversation is not about hedonism. It's about how do you activate these altered states which help us then be more connected to ourselves, be more connected to our partners, be more connected to the social fabric in which we live. And how did you sort of create these experiences for people?

What were the elements of them and.

What were the findings of this study?

Yeah, I mean, it was really interesting because as I was doing this research, I basically just started started just keeping my eyes and ears open for any published research that was indicating any interaction with the body and the brain at the air and, you know, in the Realms of neuroanatomy, neuroelectricity, neurochemistry. So what was going on and where was it going on? What parts of the brain was, was it being informed by cardiac state or coherence or condition, endocrine system, any sort of just how, you know, does any intervention positively inform or help boost the metrics of well-being and all the way into non-ordinary states?

I hope you enjoyed today's episode. One of the best ways you can support this podcast is by leaving us a rating and review below. Until next time, thanks for tuning in.

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