Monday, August 7, 2017

IDAA 2017 Snowbird UTAH - CME - Crucial Conversations with your patient: pain and cannabis - Dr. Mark Weiner

I really enjoyed Dr. Mark Weiner’s  presentation because it clearly delineated “cannabinoid research and treatment’ from the whole area of “medical marijuana”.  Marijuana is a 100 compounds in one with a wide diversity of response and much marketing these days of the ‘anecdotal evidence’ without consideration of the overall  science.   I’ve been prescribing for some years ‘medical marijuana’ and pharmaceutical “nabilone”  and the excellent ‘SATIVEX ”(Bayer)  buccal spray with considerable discrimination and concern.  It’s never a first line choice.  I have seen a lot more negative results than positives. Admittedly the occasional positive result is, like any success, a joy.
There is however a religious devotion especially among  the heavily addicted devotees to the ‘herbal’ treatments with a whole lot of religious claims of “panacea”.  There is  little consideration of cannabinoids as just another ‘medication’ to doctors like myself.
I’ve seen people respond to marijuana like I have to other treatments but it’s not a panacea.  There are also serious side effects.   It certainly was widely available and passed over in favour of the most successful modern treatments that have been associated with cures of epidemics, increased longevity and amazing cures of once deadly diseases.
I was commonly recommending marijuana for my patients with HIV and Aids when they developed anorexia. It was an excellent ‘adjunctive treatment’ but it wasn’t curative. Today being diagnosed with HIV is similar to being diagnosed with Diabetes. The life expectancy is shortened by perhaps 10 years.  When I first worked with HIV it was a deadly disease with few survivals and large death toll despite the ubiquity of marijuana.  Today the pharmaceutical companies and medical researchers have produced retrovirus medications in combinations that have caused the extraordinary successes in treatment of new cases. The latest of these treatments, Truvada, is truly a god send but I know some of the nutbars in the ‘medical marijuana cult’ would tell people not to take it because it is produced by their ‘devil god’ "Big Pharma”.  I can honestly say as a simple clinician it’s increasingly difficult to do my job with all the argumentative stoners with their overnight Google MD’s.  Now that Big Tobacco is backing Big Marijuana with Big Smoke Money at the public health level we know whatever tax benefits we see for politicians will be off loaded in increased suffering for patients and health care costs.
I have a head injury patient whose response to marijuana was truly remarkable. I had tried a wide variety of medications for his various symptoms before the trial of marijuana which had a profoundly beneficial response. Unfortunately clinically the majority of my head injured patients have been made worse by marijuana as it disrupts mood stability and motivation and interferes with memory and learning in these other cases.  I read the heavily funded marketing literature on marijuana and it reminds me of when Cocaine was said to be a ‘cure-all’ without addiction. Then Belushi died.
As a clinician, typical of my colleagues. I don’t care what works. I just want to see my patients get better and we welcome treatments. The paranoia associated with the ‘us and them’ crowds of ‘health food’ ‘pusher’s’ is difficult to tolerate.  Today’s marijauania is 30% THC compared to the 3 % THC of the highest grade marijuana of my college days. The dangers to developing brains of this high dosage compound and the longevity issue of using a potentially toxic substance over long periods is worth consideration.
I enjoyed Dr. Mark Weiner’s discussion  of  the effects of cannabinoids on the heart especially in elderly patients causing me to be better equipped to discuss the pros and cons of medical marijuana in the increasing numbers of retired patients who ask me about it’s use in various chronic diseases.
Some patients commonly in clinical practice try to pidgeon hole the doctor into an “either you are for or against marijuana’ categorizatio.  As a psychiatrist I’m well aware of this   ‘black and white thinking” and profiling  so common in paranoid disorders and drug abuse.”  I enjoyed how Dr. Mark Weiner side stepped this issue simply by presenting the clinical evidence. This is what we know. This is what we can say about the cost/benefit of this treatment for individuals.. It’s really no different than what we say when a person wants cosmetic surgery or some other medical treatment which isn’t ‘first line’ and might even be classified as ‘experimental’.  He was clear in presenting the ‘evidence’ and maintaining his comments in this realm. It was refreshing. I learned from his example.
(I reflected that a patient had told me that my dog who had his eye removed recently for glaucoma could have been saved with the cannabinoid oil this patient promotes.  Its been shown to be of some benefit in human glaucoma.  So feeling guilty that my dog had lost his sight in one eye I was willing to consider anything to help him keep his sight in the other eye.  His veterinarian ophthalmologist, Dr. King, hadn’t recommended cannabinoid but another medication which has been working very well in keeping the pressure down in his remaining eye.  I reviewed the veterinary research literature that evening and found that in fact marijuana had been researched and was contraindicated in dogs. Veterinary medicine is fascinating because a drug that can save a cat’s life can kill a dog.  They’ve been researching cannabinoids just as we have.  My patient is a religious nut about marijuana.   I definitely have prayed for my dog’s eyesight.  I have trusted  Dr. King whose treatment is working just fine.  I had a delightful dinner with Dr. Larry Cooper a San Diego Opthalmologist who was kind enough to share some stories of his successful surgical and medical cures of eye disease, being especially thankful for the gifts of modern medicine which have resulted in him being able to save a person’s sight or life.  I really don’t think he as a compassionate clinician would withhold any treatment but I expect that if I smoked a joint I could even imagine this wonderful mensch of a doctor could indeed be an evil operative of Big Pharma and Big Surgery. )
I enjoyed the lecture because it dealt with the science of today. Dr. Mark Weiner is simply one of the leading authorities and yet also broad minded. He does emphasize what the research says about cannabinoids and questions what is in a marijuana plant in general.  He’s a scientist and not a snake oil proponent. It was an interesting lecture from this perspective.  What we know. What we don’t know. What research says. What research doesn’t say.  I enjoyed that.  Great ideas.  I will make a point to follow him in future and consider adjusting my practice to take account of the insights that he provided.
 This is not a reflection of the overall lecture which was much more extensive. I’ve just selected certain slides and some ideas that were of interest to me. I wouldn’t want anyone to see this writing in any other light than this. I certainly will be attending more of his lectures if I can and would strongly recommend him as a presenter, communicator and scholar.

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