Demystifying Cannabis: Strains, Delivery Methods, and Dosing, with Dr. Misha Kogan

You have different cannabinoids, you have different terpenes, flavonoids. And then you also have the point of what we call start low, go slow, deliver it where it needs to go, and stay there. Because when you start at the very low dose, you're not going to expect benefit quickly. Then you're going to start titrating and you get to a point where this is the best spot.

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Hi, and welcome back to another episode of the Feel Freaking Amazing podcast, Live like youe matter. I'm Dr. Wendy Trubo. This is Dr. Ed Levitan. And our guest today is Mikhail Kogan, Dr. Misha Kogan. He is the medical director of the George Washington University center for Integrative Medicine. He's also an associate professor of medicine at George Washington University school of medicine. Dr. Kogan has recommended medical marijuana to thousands of patients and is a frequent lecturer on medical cannabis to professional audiences across the nation. Welcome. We're so psyched to have you here.

Thank you. So wonderful being here.

Great. What were you going to say?

Yeah, I want to first actually kind of say is we're going to talk mostly about cannabis and cannabinoids and. And you are fully trained and working functional medicine physician and have a practice and does a full spectrum of functional medicine.

I just want to kind of put.

That in context for our listeners because.

This is the real deal.

It's not, yes, we're going to be talking about cannabis, but it's. You come from a huge wealth of.

Knowledge, not just cannabis.

So talk to me about how you recommend people getting the medical marijuana, because I always say to people, don't smoke it because then you're going to increase your risk of lung cancer. I usually recommend a tincture or a gummy, but my favorite would be a coconut.

Well, actually, actually, believe it or not, there's zero evidence that increases lung cancer and there's suggestion that it decreases lung cancer.

That the smoking, like smoking a joint, not vape, not vaping, but smoking, smoking a joint.

You can look it up. Dr. Tashkin has been multiple huge randomized control trials, zero evidence of harm. Interesting. So it causes bronchitis, it causes chronic cough And I would never give smoking to geriatric patient because you don't want to increase load of toxins on the body, right? I mean, but, but in terms of cancer, that's another idea, right? I mean you're putting a smoke in, you would expect cancer, but no you don't. And, and so, you know, there's a lot of fascinating thoughts and, and principles and, and biochemistry and molecular biologists that speaks maybe this is real, maybe a future of cannabis as anti cancer drug. And I will tell you it will not be in the pharmacological preparations, it will be in the full extracts. Because at least for now, everything we see is all about full extracts. But, but your point is really good. I think the whole point is how do we deliver it? Right. And what do we deliver it for? Right. So if I want to give somebody a treatment for nausea and they need an immediate relief, right. I'm actually often will give them some inhaled form because especially if, if they're in, if we're in palliative mode, I'm not worried about worsening bronchitis in 10 years, I'm just making them comfortable today.

What about vaping versus smoking in terms of lung, lung symptoms and reactions?

Well, I mean it also depends what you're vaping, right? So you have a dry flower vaping things like it's things like Volcano for example, which is, or, or even simpler devices, but the ones that, where you just take a dry flower and you bake that. And that actually is probably way, way better than smoking because you get a lot lower temperature, you, you get a lot less actual particle particles going in versus vaping the cartridges. So the vaping of the cartridges has its own issue because you get processing chemicals that are end up in there and you will probably. It's actually important to talk a little bit about that. So there was a couple of years ago, right at the onset of COVID or even before, I think a year before we had this condition called evali. So it was basically damage to the lung from bootlegged cartridges. And some of them were tobacco, but some were cannabis. And there was some kind of preservative that killed a bunch of young people. Like about a thousand people died. And that was because it has nothing to do with cannabis. But of course there was an uproar in the medical cannabis community saying what the hell are we doing? So, but that's highlighted the point that you know, anything that's extracted, anything that has chemical processing, when you take that in, you're going to get that now we have this whole issue with Delta 8 and I've seen now three cases of severe toxicity that looks exactly like SARS, like mold, but yet there was no mold. And they were delta 8 toxic because they had heavy metals and some other crazy pollutants that you can't even test with the current strategies on the market like vibrant or nothing. Nothing picks up those toxins. But I mean there's young kids and I have 20 year old with no silver fillings, not eating, vegetarian coming in like mercury that I had a call from the lab, it was that high because he was inhaling it.

So you're saying it's grown. It was grown in some way or processed in some way that there's mercury.

It was processed, yeah. It was a Delta 8 product that he was getting somewhere that had contamination. And there's really good literature on this saying that most of the recreational Delta 8 products are heavily contaminated and some people do vape them.

I know, I'm like what's supposed to eat? I've missed something.

So. So let's actually sort of talk a little bit this about this. Right? So we have the sort of psychoactive ingredients or psychotoxic ingredients that we call them THC. Right. And then THC is a family of THC. Right. There's Delta 9 is what we traditionally get from plant. Like if you just smoke a joint or you vape or you eat gummy or whatever, you getting delta 8. Delta 9, the delta 8 is. It's not, it was not true. It's a pre. It's not a precursor. It does occur naturally in plant in a tiny amounts. But it can also be synthesized in a certain way from the plant. So they can be extract it and it could be formulated in there. So it's a. Supposedly has a similar effect. It's a little gentler effect, a little less effect. And so. But here's the kicker. It's not regulated. So you can buy it, you can go on weeds weed.com and buy it and get it shipped to your house because it's derived from hemp. So it's not derived from cannabis. And of course listeners probably if you don't know, it's important to know there is no hemp. Hemp is our own definition. There's just one plant, Cannabis sativa, nothing else. There's no Rudialis. This is all baloney. There's just one plant and there's about at this point 20,000 plus variants. They're not strains, they're variants. Sometimes we call certain things optivars. They're different terms, but it's one plant, very variable. And so hemp is simply a definition of cannabis sativa having less than 0.3% in the United States, in other countries, like 0.2% of THC. And that's Delta 9 THC, Delta 8 THC can be made from different concentrates. And yes, in the US it can be sold basically legally because Congress hasn't acted on this. So then we have cbd. So the CBD and THC are thought to be major cannabinoids, which is completely wrong, but that's the way we talk about it. So the CBD or cannabiol is this kind of a very, very unique molecule. It doesn't directly affect the receptors and it doesn't necessarily directly changes our own cannabis production, but it modulates how our own cannabis system, which we'll talk in a second, but works internally. So when you take CBD, you modulate not receptors, just like when you take THC, you attach THC to the receptor and CB1 or CB2 and then you have a whole CAS cascade of effects. But the CBD directly does not do that. So it somehow works with our own endogenous cannabis system to make it more efficient and then cause some other additional benefit through non CB1, CB2 receptors. There's TRP receptors and whole bunch of other ones. And so it's a fascinating system that we and all animals have this endogenous cannabinoid system. And so that the beauty of cannabinoid, exogenous. Cannabinoid system. We mimicking endogenous. We make our own cannabis every day of our life from the moment we were born. And actually we make the most somewhere between ages of 12 to 17 and then game's over. Kind of like that. No, it's not. It's just the decline is very slow. But we are losing about half of our endogenous tone. So the amount of cannabinoids produced somewhere around the age of 50 to 60. So and it's not an interesting. So some systems in our body continue makes the stuff right cannabinoids, its own demand. So when you have a stress, when you have pain, when you have some kind of trauma, then there's this massive upregulation within the cannabinoid system. Or when you exercise, remember we always thought that runner's high is the endorphins. That was debunked. It's all cannabis. So our body makes enough cannabis during exercise, it gets upregulated so that you feel Good. And it works similar to a lot of other pathways in the body. Like we always think about neurotransmitters like GABA and L Theanine. You're putting. So that's what we call an inhibitory. So cannabis in some way is an inhibitor of a neuro excitation. So when you have something that upregulates us rapidly, like the stress, trauma, et cetera, Cannabis is first and most important part in the system is to downregulate that very quickly. Because other systems then kick in after as a response. Then that's why it's so effective for pain. It basically blocks the sudden not sensation, but the perception of pain. It also keep blocks peripherally sensation of pain, but not as potent as the perception of pain. That's actually why it's a unique and really potent analgesic. Because there is no other drug in our armamentarium for pain that could affect perception of pain. Opioids don't do that. I mean everything works on a. Usually on the level of actual receptors and actual or centrally, but not on the level of how do you interact with your own pain, how do you live with the pain. And cannabinoids generally help patients tremendously to simply live better quality of life despite having some organ dysfunction that causes pain. We do that regardless whether we put something from outside or not. We do that because we have that system in us. There are different molecules. There's actually a lot of them we know to the big ones, anandamide and 2ag. But there are dozen others less known, less understood, but not less important necessarily.

So as you said, there's not only THC and CBD but there's all these other variants of the cannabinoids and you have 20,000 variants. And every dispensary has their own formulas or it seems like it maybe to the untrained eye me. So how do you actually go on and prescribe something that's clear for cancer, for anxiety, for depression, for like that's it.

That's, that's, that's the, that's the million dollar question and have a question answer to that. I mean that's why I feel strongly. Then it's already becoming a cannabinoid medicine or field of cannabinoid medicine. Because in reality it's that complicated. And you know you have unlimited number of variabilities. If you have a good strong dispensary, you could walk in and have few hundred products and they're going to be separated by the ratio of CBD to thc. They're going to be separated by the particular product's going to have more calming effects or more of the terpenes that are more sedating, like maybe immersing a linalool versus something more activating like a pinene. And so if you're more activating, going to use it more for say cognition or to stimulate cognition or to uplift someone versus if you're depressed, you can try to take that for more. So I mean the complexity is so high that literally at this point we have few professional courses out there that people have to take if they want to be serious about it.

Okay. But for the listeners, you're going to kiss a lot of frogs and you might not find your prints on the very first time.

Hold on.

No, let him finish for a second.

Hang on. So. Well, there is a, there is a kind of an ease way into it, right. So most of the time there's a big categories, right? So if you talking about someone who comes to you with pain, you know they're going to need some THC most likely and you're going to probably, you may give them some cbd, but you have some sense that you may how you want to do it, right. And then, then you also have to think about the route of delivery. So how do you actually going to give it? We started talking about like let's say you're going to vape or you're going to take most of the time when patient comes in and I say 90% of chances, I'll start with sublingual oil drops. Sometimes we call it fecal full extract cannabis oil. So they'll put it right in their mouth most of the time because I can titrate it precisely like I can. Usually my starting dose is 1 milligram of THC equivalent. And then you titrate and they may not even feel anything for two, three days, maybe for five days because I want to get them that chase spot. So another huge. So. So you have all this variance. You have different cannabinoids, you have different terpenes, flavonoids. And then you also have the point of what we call start low, go slow, deliver it where it needs to go and stay there. So you're going to find the spot in J curve. Because when you start at the very low dose, you're not going to expect benefit quickly. Then you're going to start titrating and you get to a point where this is the best spot. If you keep increasing the dose, not only are you going to lose that spot, you're going to start having this problem you're trying to treat. You take too much. If you're treating nausea and now you have a hyperemesis syndrome. Too much vomiting and nausea. They started here for pain. You got here, you keep taking. Now you have hyperemesis, so you have too much pain. Cannabis is actually kind of unique in this. If you take too much of something that's good, you're going to cause the symptoms you're trying to treat. Nobody fully understands why that happens yet. There's seemingly endogenous tone and the tone does both ways, up and down. And depending on what you're trying to do, you have to get the best possible spot and then stay there, which is also not easy because, you know, that's the biggest, the biggest challenge of the industry at the moment is not knowing the ratios. We have an organic process. I mean, we all know how to do that. It's really, how do you keep batch to batch predictability and how do you keep it being a plant, being a plant extract, how do you keep it pharmaceutical grade? And there, there are very few companies that like thinking this way because they're like, okay, well it's botanical, so let's just keep doing. Yeah, that's great. But for the patient, they found something that works great. Like for example, insomnia. It's usually first symptom I treat when patient comes in with multiple conditions because it's 90 to 95% efficacy. I don't have any other tool that's that effective for insomnia. But so let's, let's say I treated their insomnia very well. Now they're great. But guess what? A month later they ran out of that tincture. They go back and oh, no, we don't carry that tincture anymore. Why? Well, because our manufacturer is no longer making it. Try this one. And the whole process has to start over because the concentration may be different, the terpenes may be different, the ratios may be different. And next thing you know, patient's not very happy because they have to redefine the process and that keeps repeating. So there is definitely an attempt by several industry partners. Like the one I know is called Kinesutica, which is they making capsules. That's an RSO Rick Simpson oil capsules. But batch to batch is 100% predictability. So you're not going to get a variant from. If you get that product you got on a day one, three months later, it'll be exactly the same versus when you're buying oils, especially when you're buying flour or when you're buying vapes, there is a change, there's difference from one vegetation. Then the industry is going to solve this. But it's probably going to take a while before we're going to have a really good, predictable steady set of products on the market.

So these are all edibles then you're talking about essentially if they're pill form. No, I thought it was pill form.

So tincture, so that's important. So tinctures, we don't consider edibles. Edibles is something you chew and you eat.

Well, you. I thought you were referring to a pill that they've, they've standardized that. Cannabisuticals.

Correct. So those would be capsules. So they would. They can put the oil in the capsule and then it becomes edible. Because you don't put it sublingual and put it sublingually. We just call it sublingual because by default it bypasses the first pass through the liver. You're not getting. This is also an important concept. You see how many details here. When you take the THC and you pass it through the stomach, it's going to get four to five times hyperactivated because 11 Delta THC, which is metabolite of Delta 9 is, is way more potent than the Delta 9. So it's like four times more potent. So you can take 5mg gummy versus 5mg sublingual drop and have a pretty different effect. And in fact, a lot of the times that's part of the problem. You have a frail older person going to dispensary and somebody will sell a gummy to that person and they'll eat the gummy 5mg and they'll be tripping for 24 hours and being lethargic. It happens quite a lot, unfortunately. And people don't know that. That's one of the common, common initiation mistakes.

I mean, when you're thinking about us, insomnia, you have to take into account how old are you? Because especially if you're going to do an edible which lasts longer, but you're older and you're not metabolizing as well. Here you are. It lasts a lot longer. So, yeah, I used to start people on tinctures just because you could, you could control it a little bit better once it's in your stomach. You got a while.

Well, I mean, my ears perked up when you said insomnia. Because I have people that, no matter what we do, and I've tried CBD with Combination like we use a product that has CBD in it with Gaba, with L Theanine, with Passion Flower, all sorts of cool combination and still nothing.

So chances are, chances are you actually underdosing them with cbd. In order for CBD to work for insomnia, you sometimes have to cross 100 or even 200 milligrams at bedtime. So it's a dose dependent. You can also just simply combine it with cbn. So if you get a ratio of about. Well, the ratio doesn't matter here. If you get 10 to 20 milligrams of CBN then you can get away sometimes with like 25 milligrams of CBD. But CBD alone will work. You just have to keep titrating the dose and not being afraid of it. The problem becomes not the practicalities. I mean, 200 milligrams of CBD at bedtime, it's not cheap.

So it's interesting because when you talk about Advil is very cheap upfront, but it creates a tremendous toll on the back end in terms of you have to detox it. You're stressing the liver if you're not stressing the liver here. And the liver can be free to do detox, which is what we're all about.

Always go back to principles of holism. Right. If the body designed in a certain way, it's not random. Right, right.

I always ask people, you know, do you want to be high or you just want to have resolution of your symptoms?

Right.

Because that'll determine whether you have the balance of CBD to THC or if you're just going to go straight cbd. Sorry, thc.

I don't know. It's a, I think it's a judging question. I don't know. I try.

No, no, I just, I say straight out, if you want to be high, go for more thc. If you're looking not to have your brain impaired in any way or change, then you're going to want to make sure that you have at least 1 to 1 of CBD to THC or a higher ratio so that you don't get high.

Much higher. Yeah, much higher. You probably like 10 to 1 would be where, I mean you could still get high but it's going to be different high and it's not going to be very intense. And if you. Because you know, sometimes really the THC is the key. In fact, often THC is the number one key, it's not the cbd. So we just. The data on CBD is almost non existent. I mean, there's some data on anxiety, but outside of that, and it's a little mind boggling why that is. Because CBD can be obtained from hemp. So in terms of the just sheer research potential, there should be more of it. But still, it's still, the research is an infancy, even though that infancy is rapidly growing, but it's still infants.

Misha, I have a question for you. Do you recommend that people try to find their tinctures in oil versus alcohol? Because I know the alcohol can be difficult to keep in your mouth.

Yeah, yeah, alcohol can be difficult. And you know the other problem with alcohol, it means that it was extracted a little different. So when you the, the actual, when they're doing the original first extraction, it comes up as an oil to begin with. So it's much better. So it's often less processed. But alcohol has some benefits, it has some advantages because it's a bit differently preserved and it's sometimes better diluted or better distributed through the tincture. We have a lot of this issue where people will forget to shake the bottle. I have this case in a book, which is funny. A patient who I knew for a very long time that she went on vacation, didn't take the tincture with her, came back, took her tincture for sleep. Then next thing I know, I get a call from emergency room that they call me and saying we have a patient who claims that she's dead and she would like to talk to you from that other place, being dead. And I'm like, what? What you guys? And then like everybody's dying, laughing there. So, you know, so that can happen. So if you forget to shake the tincture and you get so stoned just because you know that's with the oil, with alcohol, that's less likely. But I agree wholeheartedly.

But you also brought up a really good point. When you go on vacation. A, do not cross state lines with your thc, even if it's legal in the two states. Do not cross state lines. Do not take it on a plane because crossing.

Crossing is illegal.

Crossing us federally is a federal offense, so don't travel with it. And B, if you're going to take a break from it, you've now increased your sensitivity so you have to decrease your dose by at least 50%, if not more. Don't forget to shake, Decrease your dose and don't cross state lines.

Exactly.

I'm assuming that all of our listeners have 8,000 additional questions and want to follow you. How can people reach you?

Gwcim.com. so that's our website, www.gwcim.com. everything is on the website. I have my own website, but the main one, you can find us there. And all the information is there as well as a coaching information for how to get in touch with me and then a coach. And then of course you can just get the book. So if it's just medical marijuana, Dr. Kogan's guide to Cannabis and CBD on Amazon and it's a Random House. It's a big publishers, so it's everywhere. There's also an audible and I'm proud of the person who read it. It's the same person who did Life of PI. So it's. He's got a great voice. It's a very. And the book is written quite simply. So it's not a. It's definitely not a medical book the way it's written. It's like for just a average person to read.

Awesome. This has been fascinating.

Yeah, we can talk for hours.

Yeah, we totally could. So thank you for joining us for another episode of the Feel Freaking Amazing podcast Live like youe Matter. Our guest today is Dr. Misha Kogan and we talked all about cannabis. You should get the book. Get his book. It's a great book. Thanks for joining us.

Thank you so much. I hope I'll see you guys soon sometime in Boston.

So definitely.

Absolutely.

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