Use Cannabis for Better Health with Dr. Misha Kogan

Foreign. Hi, and welcome back to another episode of the Five Journeys 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.

You also just published a book that I left on my kitchen counter. And I apologize, I can't hold it up and wave it around.

But you just published a book. Maybe I have one.

Maybe I have someone wave it around. Is it on Amazon? Because I know people are going to.

Want to read it. Yeah, it's on Amazon.

All right, so we got to get, we got to start with the basics. I mean, I'm old enough to remember when it wasn't legal. What were you going to say?

Yeah, I want to first actually kind of. You and I had a. Had a conversation before, and we're definitely have a lot of connections. The one thing I'll 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 then let's talk about cannabis.

Yeah, so.

What'S the. Well, let's talk what's simple. What is medical cannabis? What's the difference and what's the difference between that and recreational cannabis?

I guess maybe. Well, if you figure that question out, you'll probably be a lot richer than you think. Well, there's no real true separation. I think the separation is legal. Separation is ethical. Separation is intent. So the intent to use is probably what separates how are you using it, you know, and what you're using it for. This whole idea that somehow higher concentrations or more CBD and that, you know, the higher dose per bottle, per vial somehow means more medical. That's. I, A couple of months ago, I was at New Jersey. New Jersey had a hearing when they were approving recreational cannabis. And so I was asked to speak to the governor there Was and it was pretty hilarious because like they were completely clueless about some really basic stuff. Like well, if you take 10, 5 milligram gummies, guess what, that's 50. And so that could be, you could be quite overdosed with 50. And so. So the recreational versus versus medical is really the intent. I think there's a whole idea that more and more states approving recreational for. I mean, we all know why it has nothing to do with. It's all about the money, right? Because the taxation in some states is up to 30% and more. So if you collect 30%, if you collect 30 cents on a dollar for each dollar generated, you can imagine Colorado is busking in cash from the cannabis industry and everybody wants to follow the suit. So, so that's really the reason.

I don't think we should only be cynical though because the, there is definitely benefit to bringing it out from the sub rosa and putting it in being monitored now, you know, okay, it's organically grown, you're not getting pesticides and chemicals, you know, it's not laced with fentanyl and guess what?

And you don't drink alcohol. And your mortality in a state goes down by 10% from car accidents. Mortality from opiate overdose going down by 30 to 40%. Mortality from alcohol goes down by another. Don't quote me on that one, don't remember. So, yeah, I mean there's clearly exit strategy. The cannabis is probably the best exit drug we have in our society at the moment. I don't know if the psilocybin and ketamine and other things will be next, but on a grand scheme those are tiny fractions compared to how many people use cannabis in the country.

All right, So I mean I for a brief stint of time worked as what we call pot docs and certified people for marijuana. And the most fascinating part to me was the impact of medical marijuana on cancer treatment. Do you have any experience in that? Can we talk about that?

We can talk about it as far as you want to go. We can talk about actual symptoms, which of course that's where the evidence is. And then we can be very provocative and say that the most crazy cases of cures I've ever seen, every single one has cannabis, including cases of stage four. And then now there is no cancer three months later.

Well, why is that? I mean it's definitely has anti cancer properties, but what, that's, what's that about?

So that's another. If you figure that one out, you'll be probably as rich, you'll be as Rich as musk. So we don't really know. We know that in petri dishes cannabis is quite effective for most cancers. It induces apoptosis. So literally it kills the cancer cell. What happens in the human body is a very different story. In animal models it can also be quite effective. The only thing we know in humans is there is a signal, strong signal I would say for brain tumors. Anybody who has a brain cancer probably should be on some cannabis, unless they're taking biologic immune modulators. And then things get much more complicated because cannabis is a potent anti inflammatory drug. And so if you're giving somebody pro inflammatory treatment, you don't want anti inflammatory treatment there. There's some early studies from Israel particularly suggesting harm. So it's not a. If you read cannabis for cancer on Internet you get like thousands hits and a lot of the hits are like oh, I cured my cancer and so can you. Or you get this chiching chung up in smoke saying that I cured two different cancers in the same body. So a lot of this is just a kind of a hype and probably a commercial gain only without real evidence. But the cases are there, the signals are there. I think what's really fascinating is that put those things aside for cancer in terms of palliation. And I have four boards. I have an internal medicine, integrative palliative and geriatrics. And so in palliative medicine we don't have any better tool. The funny part, I just took my palliative research 10 years later and there was no single question on the entire board on cannabis that does tell you the scope of affairs. We have a whole industry here that treats a lot of different cancer symptoms with cannabis highly effectively. And then we have a standard of care and they're completely clueless and they actually advising patients not to do it. Not because then if something works then they can't give them something else and suddenly they find themselves unable to effect manage the patient because the tool's not applicable.

So talk to me about how you recommend get 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 coconut.

Actually believe it or not, there's zero evidence that increases lung cancer. There's suggestion that it decreases lung cancer.

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

Joint, you can look it up. Dr. Tashkin. There's been multiple huge randomized controlled trials, zero evidence of harm. 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 so, you know, there's a lot of fascinating thoughts and, and principles and, and biochemistry and molecular biology 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 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 symptoms and reactions?

Well, I mean it also depends what you're vaping, right? So you have a full 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 flour 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 the 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 and. 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.

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

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. Vape.

What's Delta 8?

I know, I'm like what's Delta 8? 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. 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 A. It's not. It was not true. It's a pre. It's not a precursor. It does occur naturally, implant in a tiny amounts. But it can also be synthesized in a certain way from the plant. So they can be extracted 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.

Check.

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 not, you know, 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 act 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 cannabinole is this kind of a 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. 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 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, and whole bunch of other ones. And so it's a fascinating system that we, and, and all animals have this endogenous cannabinoid system. And then the plants. And Canvas is not the only plant, by the way. The, the most recent fascinating thing is CBD from citrus. I know you guys heard that.

No, no.

Yep. So for the government, for the government workers, you can't have hemp. Right. Because you're going to have traces of thc. If you get tested, it doesn't matter that you never took THC product. You'll get fired because your urine is positive. There's zero tolerance. But if you get it from citrus, there's nothing, nobody can do anything to you because you never took hemp from. Well, you know, you never took CBD from hemp. So even if your urine tests positive, you actually can defend that because you say, look, I got my CBD from hemp, from oranges. And actually, you will not test positive. There's 0thC in the settings like this. So there's several companies doing that.

Interesting. How many, how much. That must be really concentrated, right?

I'm assuming it must be. And I would be really worried about that. I would be very worried about when you take a huge amount of plant and then dramatically concentrate. Right. Because think of it this way. If you started even with organic. Organic material, you may still end up with some traces, tiny traces of contaminants which you concentrating heavily and then ending up with a. With something in there which could be a problem. So. Yeah, interesting.

Yeah. Can we go back to cancer before we leave that completely?

Sure.

What are you. When a p. I mean, so obviously if you're on an immunologic modulating cancer protocol, you would not be a good candidate for thc. But then how about the patient?

I'm not sure. I think it depends on what you're trying to do. If you are on. If you're on a palliative treatment and even with immunologic treatment, but you really have tons of symptoms and you can't manage them. I'd still easily prescribe because I wouldn't. My intent there is to help the patient in the moment. I'm not trying to say. Yeah, and that's where we have tremendous amount of evidence. And actually in 2017, National Academies of Sciences, Engineering and Medicine put a really profound report, in fact, even now, five years later, which in field of cannabis, five years is like a century in medicine because it's like things are moving so quickly. But even still, that report I consider the most profound and the largest evidence that we have for the benefit. And they literally said it's grade A treatment for pain, chronic pain of any kind, including fibromyalgia, for nausea and vomiting during cancer, and for spasticity, particularly in multiple sclerosis. So we have a conclusive evidence. And despite that, most of the societies still don't recommend using cannabis because of the Schedule 1 control substance. Right.

So.

So all right.

I want. I think you and me have a little bit of different thoughts and agendas.

No.

But that never happens. Right?

It never happens.

Shocking.

Never happens.

Honey, what do you want to talk about today?

Good.

That's. That's.

We want to make sure we, you know, take care.

No, well, the thing that. So you. You touched upon this because I have kind of a. Because this is fascinating to me because there's, as you said, there's not only THC and cbd, there's all these other variants of the cannabinoids, and you have 20,000 variants. So. 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.

That's like that's, that's, that's the, that's the million dollar question. And, and we do 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 dispenser, 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 products going to have more calming effects or more of a. 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 prince on the very first time.

Hold on. No, let's just try, let him finish for a second. Hang on.

So 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 FICO full extra 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 1mg 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 in 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 you're 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. So too much vomiting and nausea, you started here for pain, you got here, you keep taking. Now you have hyperesthesia, 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, 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 or 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 say I treated their insomnia very well. Now they're great. But guess what, a month later they run out of that tincture. They go back and no, we don't carry that tincture anymore. Why? Well, because our manufacturer is no longer making it. So 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 they batch to batch is 100% predictability. So you're not going to get a variant from. If you get that, whatever the 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 like 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 that's important. So tinctures, we don't consider edibles. Edibles is something you chew and you eat. Eat. Well, you.

I thought you were referring to a pill that they've. They've standardized. Right. 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 sublingually. When you put it sublingually, we just call it sublingual because by default it bypasses the first pass through the liver. So you're not getting. This is also an important concept. You see how many details here. So when you take the THC and you pass it through the stomach, it's going to get four to five times hyperactivated because the 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 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.

Exactly.

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 you're actually under dosing them with cbd. In order for CBD to work for insomnia, you sometimes have to cross 100 or even 200 milligrams at bedtime. Oh, wow. 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. Exactly. It's not cheap.

That's actually like the whole bottle. So basically down the bottle.

No, I mean, we now use usually 3,000 to 6,000. I mean, nobody's using a thousand anymore. That's like, that's a couple years back.

So what would you do for. What is your kind of start starting point for insomnia? I have a lot. See a lot of Lyme patients that even if I give them pharmaceuticals, don't do very well.

So.

And sleep is so vital. And the nice thing about. Well, actually, let me ask you is the. Does cbd, well, does cannabis affect sleep architecture in a negative way?

That's a great question. So THC does not in every person, but it does. So TSH does. And especially at the doses that are more than 5 milligrams, it can negatively impact architecture. CBD does not. Okay, so that's actually the reason why most of the time you want to at least try to a CBD but really it's more practical. Patient is in the. Since I see patients from all over the world, I mean if they're in a place where they can get legal thc, then what? Right. So how do you, how do you do that? Well then you just go with CBD alone. But other practicality is the cost. I know that they will end up with sending taking 100 to 200 milligrams and that's going to cost them way, way, way more than 1 to 5 to even 10 milligrams of THC. So I look at this because it's going to be long term. They're not gonna be on it for a couple of months. I mean there's probably going to be a long term especially if you're treating chronic Lyme, right. I mean you're not telling them oh you're going to be better in three months. I mean this is going to take a while, a few years, probably at least a year on average. So you have to get them prepared. But, but nowadays I go to after I teach them basic sleep hygiene and some mindfulness I go straight into it because acupuncture is more expensive, can work sure herbs more expensive in the way because you get doses titration. So and you know I'm in the state, a tri state area of Maryland, District of Columbia and Virginia and every state has medical so I can get everybody in my own area where they come to see me face to face. I can get them cannabis. But if they're call from other states usually we start to find out is it legal and then if not then we'll start with CBD and CBN always, always comes up. People always ask me so should I just take straight up cbn? It does work for some people but it's just not as interestingly enough predictable. So usually I say sure you can do some CBN but try to take it with some cbd. There seems to be a better efficacy and then you decide what else they need. If they have a Lyme, right. You want a lot of anti inflammatory effect and they probably have some pain. So if they not sleeping because they're hurting at night, I'd get a lot of cbda cannabidiolic acid because it's a very good. It's like Motrin at bedtime. It's actually more effective than Motrin if you titrate the dose up. Problem with CBDA again cost. You can get Motrin for a couple of pennies literally per tablet and CBDA is going to be way more Expensive. So you also keep running into this practicality. You know, if they have a lot of anxiety and they're just like, they can't cool their brain down. I keep titrating cbd, that seems to be the best. So you also have to start kind of thinking in parallel what else is happening. And then if they also have neuropathic pain, they can't get CB thc. Well, give her cbg. CBG can be very effective for neuropathic pain.

Can you also avoid it in liver, liver dysfunctional patients? You would avoid thc, right?

Not really. I mean, you know, again I'd give them sublingual drops so it doesn't go to the liver if they really like cirrhotic. I don't actually think I have patients like this, but I, I probably wouldn't worry either because in reality it, it's not just. It is metabolized through the liver. So you may just get way more bang for your buck, so to speak. But it's not gonna. The way it's broken down is a non liver related system per se. It's just getting metabolized through the living.

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 know, 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.

We always go back to principles of holism, right. If the body designed in certain way, it's not random. And so the, the, the beauty of cannabinoid exogenous cannabinoid system. We mimicking endogens.

We didn't talk about this actually we haven't talked about our endogenous cannabinoid system. Can you talk about that?

I kind of start mentioning but I didn't go into any detail. So 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 games over kind of. 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 age of 50 to 60. So and it's not an interesting. So some systems in our body continue mix 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 of endocannabinoid system or when you exercise. And 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, it's, it works similar to a lot of other pathways in the body. Like we always think about neurotransmitters, right. Like Ed, you mentioned Gaba and L. Theanine. You're putting. So that's what we call an inhibitory. Cannabis in some way is an inhibitor of a neuro excitation. When you have something that upregulates us rapidly, like distress, 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 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 usually on the level of actual receptors and actual or centrally, but not on the level of how do you feel interact with your own pain, how do you live with the pain. Cannabinoids generally help patients tremendously to simply live better quality of life despite having some kind of 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 two, the big ones anandamide and two eg, but there are dozen others less known, less understood, but not less important necessarily. Yeah.

So I'm, I'm sitting here like thinking, first of all, I've already learned a lot that I'm going to put into practice, which is kind of. Which doesn't happen very often.

So thank you. Pleasure.

And that I'm trying to get a sense of, well, what. Okay, so going back to sleep, I have. Do I just tell. What do I tell the dispense. What do I tell my patient to go look for dispensary or what does the patient. What, what are they looking for? What's the actual prescription? Which is not a prescription.

Well, you, you need to educate them more One thing you can simply tell them, get Dr. Cogan's book, open the chapter on sleep deep and. And follow exact cases because you know, I have cases in each chapter and follow directions. So you can give them resources. First of all, because the you can spend half an hour with the patient telling them precise finding the strain specifically like you're gonna. What we used to call indica, which is like it's really not. Yeah, just don't use those words because they don't mean anything. Everything hybrids pretty much. And even like indica can have stimulatory effect on some people and Sativa can have depressing. It doesn't. It's really all about terpenes in the way how that entourage effect or combination of major cannabinoids with other minor cannabinoids causes the effect on the body. But it's a little different on everybody. So there's still experimentation. Even in the best case scenario, you're going to tell them, okay, go get your calming strain. Couple of milligrams of THC from dispensary. Take it like an hour or 30 minutes before bedtime and titrate it. Absolutely. But you don't actually know. It may be stimulating even at low doses. So for most people it's one, but then for some people it's another. So you have to kind of prepare them that. Okay, if that happens, don't panic. It just, you know, we'll keep with the process. At the end of the day, if they stick with the process, the efficacy is so high that everything else we do, I always tell people, well, you know, the gap assure, great LC and insurer. But you will know this, that the level of efficacy is 30% get response. We feel great. But here I'd say 80 to 90% once you get there, it's getting them there requires a lot of information coaching. And so I actually feel strongly that the future is all about coaches. We docs should not be doing this. We're too extensive. We don't have time to call the patient every week and say, hey, what's going on? Where are you? What's your dose? Have you tried this? Okay, why not? Like what when you tried that? Oh, that happened. Okay, so now we're gonna do this. You know, that's the, the level of feedback. I'm sure somebody's gonna try to automate it. I'm sure there's already works on the apps and things like this where this is going to be built into some kind of a platform where you feed the computer something and It'll. But. But you know, that's also lacking human aspect and maybe.

See, this is where you kiss a lot of print. You kiss a lot of frogs before you meet your prince. I always say that to people. It's gonna. You're gonna kiss a lot of frogs. But tell me something exactly right. Yeah, you kiss a lot of frogs. But I have a question, because I always have a question. So are you recommending that people do tinctures or edible something they're swallowing versus something that's sublingual? Because the sublingual will last like four hours.

Exactly.

So it wears off just when they need to be sleeping.

That's right.

And then. So are you saying do an edible because you can't titrate as easily.

So. So start with sublingual, titrate it to when they falling asleep. Well, and then once you know the rough pills, you transition to the edible. If you're a young person and the situation is horrible, like, you know, somebody's like really not sleeping and you can even start sometimes, just start straight with edible and just tell them, okay, if you overdose and you grind the next day, don't be surprised. We'll cut the dose that down sometimes. What I'll tell them, I'll tell them, go get five milligram gummies, cut them in quarters and start with one quarter, you know, or even less. I mean it really. So that's another option. So you can do the oral, but that depends on what kind of insomnia they have. If they can't fall asleep, tincture is probably going to be more predictable. More, not just more predictable, but more consistent effect. The other problem with edibles, well, it depends on what's in your stomach. If your stomach is relatively full and there's a lot of fat in it, you're going to have one level of absorption or one speed of absorption. If you don't, it'll be a little bit different. If you keep it in a mouth long enough, you're going to have partial sublingual absorption and then partial. So that's another way you can have them chew it, hold it in the mouth for five minutes and then swallow. So they're going to get both. So there are all these intricacies. And that's why I think the coaching. Most people will not learn that unless they're so interested in. So people. We have a lot of enthusiasts who coming in and they're like, oh, I want to know everything. They will buy my book, they'll read the whole thing and then they'll have like 10 gazillion questions because they already like tried stuff on their own. So those are much easier to work with patients. But if you have somebody who's completely clueless and by the way their primary care said, oh, cannabis will kill you or something, something stupid like that. We're still hearing that periodically. Not, not a lot. Thank God that still happens. And so then they going against the grain there and, or like the, the like 90, like my, my favorite story. So where I'd have like 95 year old grandma who has some really advanced Alzheimer's with a lot of psychosis and nothing works. And of course cannabis is amazing in the cases like this. And so the, the kids would bring the mom or parent and the kids and I'd start at some point they're just coming in for geriatric appointment, right to see me. And so I'd say well we're going to start with cannabis. And kids like what, isn't that illegal? And the grandkids in a corner, I told you so, I told you so for years and you didn't listen to me. Now look, you know, so that always gets me.

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 really difficult to.

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 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. So we have a lot of this issue where people will forget to shake the bottle. And like I have this case in the book, which is kind of 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. And 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, like 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.

Because on a plane, crossing. Crossing is.

Crossing is 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.

All right, so we've talked. I want to kind of like go back to. We've talked geriatric, we talked insomnia, we talked cancer. Cancer. What are the other. Well, I'm just. Cancer is like one of these.

Cancer is hard because it's such a big field. And nausea, vomiting in cancer and pain in cancer. I'd say it's so clear and so effective and often just so patients preferred because if they take more pills or if they take especially pain pills, we know so many side effects. Also in studies, often euphoria is considered a side effect. When you have a patient with advanced cancer. I'm yet to hear from single person to say euphoria is a side effect. So you know, it's also depends on the fact that it's just actually improves quality of life for people who suffering a lot with all kinds of chronic conditions.

So what are the other top three to five things that you want to think of for cannabis? Like I know anxiety is probably a huge one there.

Anxiety is huge. Anxiety has some evidence for cbd. But the problem with anxiety, it has a lot of different like causes. And I wouldn't think of cannabis for anxiety as first line because I just, you know, I would try to treat the cause of anxiety. Right. If it's a more psychologically driven stuff, you know, we send them to psychologists or if it's more just, you know, they're wrapped up in their mind and they need to drop into the body, we'll send them to mind, body, teacher or just, you know, MBSR or whatnot. But for, I'd say for the top three, well, definitely pain in all kinds of variations of pain. If it's a chronic pain, think cannabis. For sure.

Sure.

Sleep, any kind of sleep disturbances, think cannabis. Nausea, vomiting, chronic of any kind, think cannabis. So those are definitely top three. The top the following really close spasticity of any kind. It doesn't matter whether it's multiple sclerosis, spasticity or anything else. Like a post stroke, for example, people get a lot of, like they're just. They have a contraction on one side and the body is really hard and spastic. So you know, can be very effective. And then I'll tell you something that you probably never heard of, of and that is typical dermatologic conditions. So eczemas, any kind of rashes, anything that is localized. And of course, if it's a whole body, you wouldn't put it topically. But the topical cannabis is heavily underutilized and I don't understand why. I know this is one area where pharma is hugely investing into topical cbd. I mean there's like a. With half a dozen of companies running to the top, including Pfizer bought, paid $6 billion for like some startup very recently because it's a huge market, like eczemas, psoriasis. I published the case on psoriasis, CBD or thc. It's not exactly clear what ingredient is better, but I've probably cured hundreds if not thousands of different eczema and psoriasis cases just with topically. Just put it locally. There's. If this, if, if their process is not widespread. If it's widespread, it starts to get complicated. But if it's a minor problem, amazing. And then all things gut, whether it's ibs, whether it's Crohn's disease, whether it's ulcerative colitis. Ulcerative colitis. Suppositories. I mean, I've had a few dozen of patients. They don't take any drugs. They just take the rectal suppositories and that's it. And that manages their THC or combination. Combination. Okay. Yeah. Usually it's either one to one, CBD to thc, because those are the easiest to find if they can make their own. I sometimes would put other things like cbda, cbga, because that seems like it's also very effective to. As an anti inflammatory. So think of anything that is within a reach of delivery system. So if it's an easy delivery system and it's an inflammatory conditions, totally worth a try.

We should put it in our daughter's ears. Seriously, she always has ear infections.

You could totally try it. You could totally try it. You could totally try it. And it wouldn't, I mean, because you know, like how much THC is she gonna absorb from the earth?

What?

That'll be fun.

Yeah.

Parenting Moment 101. Do not try this at Home.

So my, my kids use topical CBD. Like my, I have 13 and 15 year old, 13 year old has this condition where the bones grow fast. So he has this aching in the joints and so he was like going professional skateboarding but now he can't do it because. So we start putting him on some CBD topically and he loves it.

And is that a special preparation or you just do a.

No, just commercially available.

We have cbd, we have cream CBD and it's.

Yeah, exactly, that's what you want but you want it as concentrated as possible. So you don't want to use like 100 milligram per jar. It's just, just nothing like probably start with 500 and up. So 10, a thousand, 1200 in the 2oz jar which 2oz are usually standard size. So keep going up as much as possible. Sometimes you have to have THC too. So. So it's not really clear but once you need to THC then of course you have to get a card and like it's a lot more complicated.

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. The balance of CBD to THC or if you're just going to go straight cbd. Sorry, thc.

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

Oh no, I just, I see straight up. If you want to be high, go, 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.

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 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 in infancy even though that infancy is rapidly growing. But it's still infancy.

Yeah, it's interesting.

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 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 so it's a Random House. It's a big publisher, 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 Five Journeys podcast live. Like you 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.

Definitely.

Absolutely.

Sam.