Cannabis

Morning everyone!

Welcome to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health. Today we’re going to talk about Cannabis.

I’m particularly excited about this topic because we recently opened a Performance Medicine office in Bristol, Virginia where it’s legal to prescribe marijuana in cases where it’s really needed.

To get started, let’s go over a few key terms.

Cannabis: In this Note I’m going to use the term cannabis and marijuana interchangeably. Even though marijuana has been around for centuries as a treatment for many medical ailments, people think of it as something “bad”.

Hemp: Hemp is the umbrella name for the two major things we will talk about today:

CBD (equate cannabidiol with the CBD side of this)
Marijuana (equate marijuana with the THC part of this)

Note: I have never used marijuana personally, but I have seen it benefit a lot of patients. If I am 80 years old and can’t sleep, anxious, and hurting, I’m definitely going to take medical marijuana. It’s a great tool for a lot of patients.

Background History

It’s estimated that 50% of people between the ages of 30-50 already use cannabis.

The history leading up to that statement is interesting. Up until the early 19th century, cannabis was well-thought of. It was medicine. But things started to change around 1900 with the influx of Mexican immigrants into the United States, many of whom smoked marijuana. The existing prejudice against Mexicans led to racist hysteria over the effects of the drug (i.e. violence and crime). The same situation was being played out with African-Americans with the onset of jazz in the 1920s and 30s. While musicians such as Louis Armstrong, who enjoyed smoking cannabis as a way to heighten their creativity, were adding an amazing art form to our culture, politicians and policy makers were demonizing and criminalizing cannabis.

In a nutshell, that is how marijuana became illegal in the US. It was a racist issue and still is in many ways. In fact, it’s still not federally approved for any use. Thankfully, states have power and can decide to use it for medical or even recreational purposes. So far 34 states have approved it for medical purposes, and 17 of those also for recreational use.

CBD and THC

There are lots of misunderstandings about cannabis in general. What’s the difference? CBD is not psychoactive. THC is. You can get CBD anywhere. It’s unregulated and like the wild west, you truly don’t know what you’re getting unless you get it from a reputable place.

Here’s how CBD came to be well known. There was a little girl named Charlotte who around three years old was diagnosed with Dravet syndrome (a genetic disorder that causes a catastrophic form of epilepsy). At this young age, Charlotte had seizures every hour of every day. After many neurological consultations and numerous medicines, nothing could help her. She was dying.

Her dad moved the family to Colorado, collaborated with some pharmacists, and came up with a substance called CBD Oil. This cured Charlotte’s seizures on the first day. They actually made this into a pharmaceutical called Epidiolex. It’s a prescription medication, but the problem is that it costs around $34,000 per year to take the drug.

Note: It’s interesting how pharmaceutical stuff works in our country.

For CBD to be legal it has to have less than .3% THC in it. It doesn’t have any psychoactive properties, but it has many uses. It seems the best combination is probably going to be a higher dose CBD and very low dose THC. They work best together, which is what you get when you get the whole plant.

Both CBD and THC have their own unique properties. They both work for anxiety and pain. CBD works well at both low and high doses for anxiety. THC works well in low doses for anxiety, but at higher doses can cause anxiety.

Cannabis is a very useful but complex drug. That’s why I think legalizing marijuana for medical purposes is going to be a good thing for patients.

Note: I’m against young kids using Cannabis for a number of reasons. A young person’s brain is not fully developed until the age of 25. Their prefrontal cortex, responsible for decision making, is not fully developed. I sometimes call Cannabis the great demotivator. If you start smoking marijuana before the age of 25 you’re likely to be less productive. This of course is a generalization, but it’s what I’ve seen.

The Endocannabinoid System

There are over 100 different types of Cannabinoids. In the 1990’s scientists discovered the endocannabinoid system in our own bodies. We have CBD 1 receptors in the brain. We have CBD 2 receptors in the rest of our body. They work as cell signalers. They regulate a lot of different body functions, the main one being to maintain homeostasis (balance in the body).

The endocannabinoid system modulates everything:

Pain
Mood
Appetite
Stress
Sleep
Metabolism
Immune function
Reproductive functions in males and females

You make your own endocannabinoids in your body. The most important one is called anandamide.

CBD and THC Forms

CBD, which has very little THC, has three forms:

Isolate: No THC in it.
Broad Spectrum: Has all the plant components except THC.
Full Spectrum: This form seems to work best. It has all of the Cannabis plant, including a small amount of THC (remember to be legal it has to have less than .3%).

THC has several different strains:

Sativa: Think of this one as more of a cognitive enhancer and mood elevator.
Indica: This strain helps you relax. It has a mellowing effect and helps with sleep.

In general, you want the Cannabis plant itself (both CBD and THC).

There’s a group of drugs called nabiximols. The most common is a spray that comes in a 1:1 ratio of CBD to THC. This is not legal in the United States, but it’s been helpful to patients in many other countries. It works great for spasticity in MS patients particularly. Hopefully they will legalize this in the United States.

Note: all of this seems to be pushing towards the eventual legalization of marijuana.

Properties Of Cannabis

Cannabis in general has a lot of good properties:

Anti inflammatory
Antispasmodic
Anti proliferative (think about Cancer)
Neuroprotective – there are indications it may help patients with Alzheimer’s, ALS and Parkinson’s
Good analgesic
Good for insomnia
Great anti epileptic
Good for anxiety
Probably good for autism and ADHD (have to balance it in use with younger people)
Great for immune systems
Fibromyalgia
PMS and Endometriosis
Weight Loss because it increases your brown fat which burns off other visceral fat
Increases your dopamine reward center so you don’t eat for pleasure

How To Ingest Cannabis

Edibles – Probably the least desirable form for THC. Takes so long to kick in and is so variable it’s hard to say how much to take.

Sublingual – This is how most people take CBD Oil.

Vape – This is probably the best way to ingest THC. You don’t want the vape oils. You want to vape the whole plant. You can get the oils adulterated with a lot of flavors. What happened with the kids who were dying of vaping was that there was added Vitamin E oils to these vape pens and that was gumming up their lungs. It actually killed a lot of teenagers.

The jury is still out on these compounds. Turning it over to qualified medical personnel is going to be a good thing.

There are synthetic drugs that we have prescribed for years, and the most famous one is Marinol. This is used for chemo nausea, wasting syndrome in HIV patients, and senior patients who have no appetite as an appetite enhancer. Marinol is a highly regulated and controlled substance that is very expensive.

There are so many uses! This whole industry is fascinating to me. We are continuing to learn how to prescribe to appropriate patients for medical purposes.

All to say, there is more to come. I think cannabis can go a long way towards helping our opioid crisis and alcohol addictions. It’s definitely much safer. There’s so many medical reasons we should have this on our formulary as doctors.