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.

Marijuana is a messy medicine

Marijuania is a messy drug. It has multiple components, some of which are medicinal while others are definitely toxic.  When it was used as a tisane or tea it was of benefit because of the way heat gently separates the compounds and water allows the medicinal properties to be seaped out of the compound.  The 'potency' of the tea was never such as to cause the altered consciousness states achieved with smoking. The smoking of marijuana increases the non medicinal elements of the compound resulting in altered consciousness states that are really the brain experiencing a 'toxic' experience.  This is why it is called 'intoxication'.
Consider Acetylsalicyclic Acid (ASA).This was another medicinal compound extracted from tree bark and taken as a tea for the treatment of Arthritis.  Subsequently it was purified and Aspirin has been a long proven highly beneficial compound especially in the treatment of arthritis and headaches.  It's only risk really is overdose.  Now consider it's medicinal value by comparison if someone were to suggest that we 'smoke tree bark'.  Smoking tree bark is a very messy business and all the toxic compounds created by the smoke and with the other impurities would essentially counterbalance any good that would come from the one ingredient ASA which has been found medicinal.
Addicts want marijuana readily available and tobacco companies are already signing up to promote it's availability to school children en mass at supermarkets. Right now adolescents in Canada are the highest percentage in the western world of marijuana users despite years of decline in school children use of drugs compared to past decades.  The dangers of smoking including increasing risk of lung cancer are associated with smoking this messy compound.
Sativex an extraction of the medicinal compound found in Marijuana is already available in Canada.  As one of my patients who uses both marijuana and Sativex says, "I can't work if I use marijuana.  The pain is better but I'm too foggy.  The sativex seems to have all the medicinal benefits without clouding my judgement.  On the weekend I use the marijuana tea only because it's cheaper."
He doesn't smoke marijuana. No medical doctor aware of the negative consequences of smoking, especially the mouth, throat, stomach and lung cancers would recommend 'smoking' a messy compound.  The CMPA and a recent article in Medical Post, the National Canadian Medical Magazine, by Colin Leslie, highlight the legal risks for doctors who recommend 'smoke' simply.  Not only could they be liable for cancer but they could also be liable for the decreased performance of athletes as a consequence of lung damage by inhalation of smoke.
Now I actually read a paper funded by BM (Big Marijuania) which purported medicinal benefits to the lung of marijana. This was not smoke and simply not true. Increasingly spurious research is being promulgated on the public about the 'elixir' benefits of marijuana.  Having grown up in the times when the CIA put out Reefer Madness saying marijuana would turn women into prostitutes and men in to rapists I find it highly ironic that  BM now promotes the same sort of 'shit' on behalf of 'their shit!' It's always been amusing to me that we all said "hey man, you want to smoke this shit!" back in the days of innocence, back when cocaine was said to be 'non addictive' before Belushi died.    Given the multi billion dollar industry and the backing of the same folk that brought us all the elixir benefits of tobacco I fear that any 'sanity' will now be able actually moderate the discussion.  Marijuania like cocaine and like alcohol and like tobacco is being marketted as non addictive.  This is a myth. All these intoxicating substances have proven addictive and even lethal for some.
Today I have dozens of patients struggling to get off marijuana because it's simply 'ruined their lives'.  No smoke is safe but this group are particularly vulnerable.  This is in contrast to those who rarely use and aren't prone to addiction.  Justin Troudeau whose mother was addicted to  marijuania  admitted to trying marijuana but though at risk for addiction given his family history is least likely to develop addiction especially given the social supports he has.  Marijuana will worsen and may uncover schizophrenia, but only for those at risk.  The majority of people don't carry the combination of genes that predispose  one in a hundred youth who develop schizophrenia in any society if exposed to a genetic stressor like Marijuana.  More teenagers however  may develop this crippling lifelong illness triggered by their losing that particular Russian Roulette game of genetics and marijuana.
That said, I've just started a book, Reefer Saniety, by Kevin Sabet PHD., Seven Myths about Marijuana.  I enjoyed the forward by Patrick Kennedy, one of the illustrious and brilliant Kennedy family.  Doctors collectively know as scientists do that there is medicinal value in plants and since the ancients we've been extracting and purifying these compounds for their medicinal benefit.
However, it's worth while remembering that while doctors and medical researchers have been seeking to find the safest best compounds for the use with disease the Boys in the Back Room have been using science for wholly different purposes.  Present day marijuana is far from 'natural' , like hemp, the compound it originated from.  Even the marijuana smoked at Wood stock was like 'near beer' compared to the highly toxic purified adulterated Marijuana strains marketed to children today for maximal effect.  The agricultural scientists at Monsanto couldn't have done more to make present day marijuana more unnatural and more potent.  The boys in the back room are the same guys who having done their best with marijuana have moved on to make the best crystal methamphetamine.  It's all basic science.  Nothing new.  The only difference is that one group are interested in producing medicine while the other group are interested in producing oblivion without consideration of the consequences to the vulnerable, young, and mentally ill.
One in six people will have serious problems with marijuana used to toxify their brains, for the purpose of intoxication.  1 in 6 is a medical epidemic ready to explode.  As my Respirologist friend said, "there simply would be no respiratory medicine department without smoke". What he means is that they'd never have had the patients to create a subspecialty. General medicine would have take care of the simple cases of asthma and rare cases of cancer unrelated to the deluge of illness brought on by tobacco.  The tobacco businessmen are the same folk who only a few decades ago advertised. "Smoke cigarettes. They will make the baby smaller and give you an easier delivery."
India has had marijuania grown as a weed forever. It's ubiquitous.  It's not used. It's avoided. The ancient Indians and yogis learned centuries ago that marijuana was not safe.  So the mothers of children didn't encourage them to smoke the substance.  It's like the poisonous juniper blueberries that grow in Canada.  My mother encouraged me to pick and eat blue berries but avoid the juniper blueberries.  Juniper is a poison that has medicinal properties. We use it in medicine.  We don't smoke it and Canadian children are taught the difference between blue berries and juniper berries.
It's not rocket science. It's just science.  With a touch of Saniety, if we consider the premises of Sabet's  "Reefer Saniety".   There really does need to be a balance to the Reefer Madness promoted by Big Marijuana today.