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.

Joan Bakewell, BBC correspondent, writes on older drinking

Joan Bakewell has written a remarkable column in today's BBC on line. I love reading her. A writer in her 80's she's a breath of air from what some might call a more civilized and refined era. She describes daily drinking with sophistication and yet concern. With all the stress of aging, health concerns, loneliness and 'redundancy' she sees that many of those she knows have 'taken to the drink'. In England there are wards for the compassionate care of elders whose late life alcoholism has become health threatening. She describes doctors and programs that have brought many back from the 'brink'. She says in closing she'll keep the phone numbers handy herself as one never knows 'what age can bring'.
I loved reading Joan Bakewell because there's so much charm and community in the world of 'social drinking' she describes having enjoyed so much with friends. Three units being the maximum for women according to the authorities though she says some times when she is offered a 'topper up' she wonders who are these authorities that are setting limits for the elderly. Perhaps I liked her best because she referred to the young as the 'under 60' group.
Well, in my 60 and under group the concern will be about alcohol and more so, because frankly 'binge drinking' and 'wild behaviour' without the occasion of World Wars, Nazi Death camps or stock market crashes or even the mixed blessing of being Fitzgerald and Hemingway in a "Moveable Feast", our 'culture of narcissism" has been blatantly errant in regards to the 'authorities' and our drinking and marijuana smoking populations are more grim, angry, and entitled. Besides our problems won't just be alcohol but marijuana, crack cocaine, crystal methamphetamine, ecstacy, LSD, mushrooms and heroin. As my group has aged we have moved from wine to wine and reefer and beyond.
This last month the city of LA closed its 'medical marijuana' dispensaries because of the perceived harm this had had on the community as a whole with increased mental illness, unemployment, crime and violence. Marijuania thought to be a 'peace' drug with the white jazz musician set has long been the drug of violence of Africa and Asia. So often a drug is associated with it's context that we forget that Robert Graves long ago wrote of the "mushroom cults' of the medieval era, the main stay drug of the 'berzerks'. Looking at the west coast hippies lying face down in cow shit and mushrooms makes it hard to imagine crazed thousands of medieval warriors hacking at each other hallucinating on mushrooms. Yet that's the truth of history.
Now looking to the future we must ask ourselves how will we individually and as a society deal with an aging population with increasing loneliness and time on their hands, initially disposable income and a veritable potpourri of addictive substances and the maddeningly throngs of drug pushers that go on to be white washed Wall Street entrepreneurs almost daily. I will forever love Steppenwolf's "Goddam the Pusherman" song. When I see the homeless of the downtown Eastside Vancouver it's almost guaranteed that a rich drug dealer's own fine West Vancouver house has been paid for by the impoverishing of these parasites 'victims'. I've already seen my first of aged homeless their 'pensions' gone to the Drug Pusher so I'm perhaps a bit raw about the protection our society gives these 'clever businessmen'.
In my work at a methadone clinic, teen agers come in hooked on heroin prostituting themselves for more but so do the 50 and 60 year olds. It may have made pleasing film footage to see the youth dancing naked at Woodstock but I'm not looking forward to a second coming of this behaviour at the RV park since I'm of an age myself when I'm only the life of the party if the party ends before 10 pm. I don't want my sleep disturbed by a geriatric crack addict with a new drum set and a bottle of viagra to boot.
I liked therefore that Joan Blakewell spoke highly of the British program and medical community that had programs and hospital beds specifically set up for the elderly with addiction. Here we are still struggling to get any resources for the addicts except 'medical marijuana' and I fear that short sighted politicians in Canada will next be offering us "medical crack" as their great 'solution' to what is such a devastation for individual and community life.


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Marijuana Debate - Canadian Society of Addiction Medicine 2011

Addiction Medicine Specialist, Dr. Paul Sobey refereed the marijuana debate between Canadian family physician and marijuana researcher Dr. Mark Ware and Prof. Jag Khalsa.from the National Institute of Drug Abuse.  Good humored laid back Indo American Prof Khalsa should have been the pro marijuana debater if steretypes were true. Dr. Mark Ware in comparison was such a clean cut and measured speaker by comparison. They were both extremely learned and the debate and discussion was one of the best I've heard.
Dr. Sobey did a masterful job of asking questions comparing efficacy of prescription pharmaceutical cannabinoid products, such as cesamet and nabilone,  with smoked marijuana products. Specifically Dr. Ware's research showed that smoked marijuana to date was superior in treatment of neuropathic pain associated with HIV.  Clearly there was benefit from cannabinoids for treatment of spasticity, nausea associated with chemotherapy, neuropathic pain and improving appetite in HIV patient. Other than rare examples the benefit of marijuana or cannabiniods over alternatives was negligible but physicians were generally glad to have as many alternatives as possible in their tool boxes.  . To date there had been no abuse of pharmaceutical cannabinoids noted by Dr. Ware's recent research or Dr. Khalsa's investigation.  There was a lot of 'off label' use of cannabiniods in areas where research had already excluded the benefit.  Such an example was migraines whereas there was need for more research in it's use in multiple sclerosis.
There was clear evidence agreed on by both that 'smoked marijuana' was associated with Chronic Lung Disease. Further there was overwhelming evidence that it caused psychosis and had profoundly negative mental health consequences for many.  The cost/benefit was significantly altered when the drug was now associated with causing or contributing to the development of schizophrenia in adolescents.  Further it was clearly associated with accidents, specifically motor vehicle accidents and fatalities.
Both researchers said that marijuana should not be used by adolescents.  Brain development continues rapidly to age 25 and Dr. Ware was very specific in making clear that he wanted to see more research and perhaps more use of smoked marijuana in chronically medically ill patients of older age. He was very upset that adolescents were quoting him saying it didn't appear to be associated with causing throat cancer as a justification for their using it recreationally.
Both researchers felt there was a strong need for more study of marijuana.  Prof. Khalsa was very pointed in saying that NIDA had not been against marijuana and that there were countless studies done on cannabinoids in the US. The position of NIDA was specifically against 'smoking' as there was no evidence that smoking of any kind was anything but harmful.
Dr. Ware made the telling comment that when the government introduced so called 'medical marijuana' with some 22,000 now smoking marijuana after 5 years in Canada there was no solid research component as part of this politically powered federal legislation.  Obviously any good marijuania program especially one government funded should incorporate an ongoing research component. The University of California was doing just this in the US.
With typical good humor Prof Khalsa responded to Dr. Ware's cry for more research money for the study of smoking marijuana saying that much medical research is done by private funding. There was certainly financially invested interests in the marijuana debate who had not been willing to date to back up their claims of the benefits of marijuana with research funding.  The marijuana industry certainly was making a killing but not as open to research as Dr. Ware was proposing especially in light of increasing evidence of the long term negative consequences for some and the real dangers for children, adolescents and pregnant women.
Dr. Ware's excellent scientific knowledge and reasoned  approach were a pleasant change to the usual paranoid marijuana devotee who bludgeons the medical doctor with phrases like 'organic' and 'herbal'  insisting penicillin is dangerous and marijuana is life's cure.  I
ndeed listening to both these learned men in an excellent discussion was a breath of fresh air given how smokey the discussion has been in past years.
Despite this being Vancouver, and the discussion immensely entertaining, no one lit up a joint during or after the debate.