Unveiling the truth about medical cannabis [PODCAST]

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Join us in this insightful episode as we welcome Peter Grinspoon, an internal medicine physician specializing in medical cannabis. Peter enlightens us on the current landscape of medical cannabis, focusing on its potential benefits for patients. We delve into the challenges doctors face in staying informed about cannabis research and the crucial role of unbiased reporting. Moreover, we explore the need for reform in the medical community’s approach to cannabis, while also discussing the importance of responsible prescribing and identifying patients who may not be suitable candidates. Tune in to this thought-provoking conversation that uncovers the intersection of health care, patient advocacy, and a progressive understanding of medical cannabis.

Peter Grinspoon is an internal medicine physician.

He shares his story and discusses his KevinMD article, “Cannabis is ground zero in the fight for racial justice in America.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Peter Grinspoon. He is an internal medicine physician and a cannabis specialist. His KevinMD article is titled “Cannabis is ground zero in the fight for racial justice in America.” Peter, welcome to the show.

Peter Grinspoon: Thanks for having me.

Kevin Pho: So we’ll talk about your article and book in a little bit. First off, just briefly share your story and journey to where you are today.

Peter Grinspoon: Sure. Well, I have been involved in the cannabis issue my entire life, probably for two reasons. One, my brother Danny, when he was fighting an unsuccessful battle with leukemia, my parents illegally bought him cannabis in the early 1970s, right when Richard Nixon was starting his war on drugs. It made such an incredible difference in my brother. When he didn’t use cannabis, he’d be lying on his bed throwing up, sort of miserably dying, and when he used cannabis, he could eat, hold down food, and, most importantly to me, play with his little brothers. So I knew that cannabis was a medicine, not for everybody, but for some things, starting at a very early age, and that really impacted me as I went through and pursued a career in medicine. I’ve been treating patients with medical cannabis for about 20 years now.

The other thing is my dad was a very famous cannabis scholar as well, Dr. Lester Grinspoon. He actually called for the legalization of cannabis in 1971, when he wrote a book called “Marihuana Reconsidered,” which was reviewed on the front page of the New York Times Book Review and was really a runaway bestseller. He had been involved in the cannabis issue for the last 50 years of his life. He passed away about two years ago. So I’ve literally had a front-row view of the legalization movement, and I’ve been involved in this issue for my entire career, so I have a pretty broad and deep exposure to medical marijuana.

Kevin Pho: All right, let’s set the table here. We’re speaking in May of 2023. What’s the current landscape as it relates to the legalization of cannabis and its use, just in a primary care setting? Because that’s something that I do and I see, and I myself get a lot of questions. So what’s the current landscape facing physicians today regarding cannabis?

Peter Grinspoon: Well, first of all, it’s legal medicinally in 38 states. There are still a couple of states where it’s not legal at all, Nebraska and Idaho. In the other states, CBD is legal, but not cannabis. But 38 states is almost 50; we’re really getting there. And then it’s fully legal for adult recreational use in 23 states, almost half of the states. So probably more than half of Americans live in a state where it’s legal recreationally, and most Americans live in a state where it’s legal medically.

Now, 94 percent of Americans support legal access to medical marijuana. Name anything else that 94 percent of Americans agree on. They don’t even agree that the sky is blue or the Earth is flat. So I think that there’s pretty broad consensus that we’ve been sort of sold a bill of goods about cannabis by the government as part of their war on drugs. They needed to taint drug use for other purposes, and that’s a whole other conversation, but there weren’t enough people with just cocaine and heroin, so they had to include cannabis. They’ve been pumping out nonsense for the last 50 years, and patients have really come around on this issue.

Now, with doctors, about two-thirds of doctors right now are convinced that cannabis is a helpful medication, and that grows every year. It depends a little bit on your vantage point. Almost all the oncologists, for example, believe that cannabis is helpful, because they see it alleviating the nausea, the pain, the suffering, the anorexia, and the insomnia of their patients. On the other end of the spectrum, pediatric addiction psychiatrists see the rare but very tragic cases where cannabis might very much destabilize a young adult or a teenager with psychosis, and they tend to have very negative views about cannabis. So I think a lot of it depends on your vantage point.

For primary care doctors, it makes our lives easier. It gives us an extra plant-based, relatively non-toxic treatment that patients love. It is not without harms, and it doesn’t work for everybody, but generally it helps us treat insomnia, chronic pain, anxiety, some of the most difficult things that we treat on a day-to-day basis. It makes our lives a lot easier. So I think many primary care doctors are going along with it, because they see that it helps patients and it makes their lives a lot easier. That’s sort of a win-win for all parties.

Kevin Pho: So take us into your exam room. What would be some common case studies where you would recommend cannabis to treat patients?

Peter Grinspoon: Right. As we get older and portlier, and the knees, the backs, and the hips start to go, chronic pain afflicts millions of Americans, and the options for chronic pain are very bad. Tylenol does nothing except maybe hurt your liver. Nobody wants to be on an opiate. There are 110,000 opiate overdose deaths, and there’s a lot of pressure on us, which is unfair, not to prescribe opiates, because some people really do need opiates and we need to provide them. Non-steroidals kill 10,000 people a year, your ibuprofen, your naproxen, your diclofenac, from heart attacks. They also kill people with bleeding ulcers, and I see so many people in their 50s, 60s, and 70s whose kidneys are just dying because of the ibuprofen they’ve taken year after year after year.

So for someone who has chronic pain, a low dose of cannabis, mostly CBD, a little bit of THC. You start the patient on a very low dose and work your way up very slowly, so they don’t have a bad experience by taking too much, which can make you anxious. Get them up to speed to where they’re feeling better. The pain doesn’t go away completely, but it doesn’t bother people as much. It’s less intense, and they get more interested in other activities. Chronic pain is a perfect example of a very common condition that cannabis is extremely effective for. Patients like it, and it’s often safer than the alternatives.

Kevin Pho: So you have a patient like that, 50 or 60 years old, chronic joint pain, osteoarthritis, like you said, a little bit portly. Would CBD oil or cannabis be something first-line for you?

Peter Grinspoon: It would certainly be before opiates. You know, I’d try Tylenol, why not? And then the question is, do I want to put them on non-steroidals, or do I want to put them on low-dose cannabinoids? I discuss the pros and the cons of both with the patient. I mean, cannabis isn’t good if you’re a teenager, if you’re pregnant or going to get pregnant. It isn’t good before driving. It isn’t good if there’s a family history or any history of psychosis. Non-steroidals aren’t good if you have kidney problems, so obviously I’d veer towards the cannabinoids if someone has chronic renal insufficiency. So it really depends on the patient.

But the fact is, to have another tool in our tool kit, especially in this area of chronic pain, where there are so few tools that work and that aren’t deadly, is incredibly helpful. So for a subset of patients, in my case a pretty large subset because I’m comfortable using it, it really is the best medication for chronic pain. It’s safer and patients enjoy it, and the only obstacle, really, is that health insurance doesn’t pay for it, which will change when we get federal legalization. But right now it’s been very difficult.

Kevin Pho: So tell me what the first step is. If I’m seeing a patient in the exam room and I want to start some type of cannabis-based product, you mentioned things like CBD oil as a place to start. So tell me where I would start, where I would send a patient to, what dose to use. For those who have little knowledge of this, where does a physician start?

Peter Grinspoon: Well, that is a great question, because physicians really need more practical knowledge so they can have helpful conversations with their patients. What happens is the patients go to a cannabis doctor, and then the primary care doctor doesn’t know about it. The way to keep all of this safe is for doctors to be educated and nonjudgmental, and for doctors and patients to have open, clear communication, so you can deal with drug interactions and stuff like that.

But I would ask the patient, first of all, “Have you ever used cannabis?” If they’re 80 and they’ve never used it, that’s a much longer conversation than if they’re like 60 and they said, “Oh, yeah, we used it in the ’60s. We loved it. I just haven’t used it recently, because of when my kids were young.” Then they’re going to adapt to it pretty easily, without many problems.

But the main way to do it is to start low and go slow. Nobody dies from a cannabis overdose; it’s literally impossible. But if you take too much cannabis, you can get very anxious. It could even cause panic attacks, and you could end up in the emergency room. So the key is to start low and go slow. I usually start with mostly CBD, but CBD and THC work well together. I might recommend a tincture, again with like four to one CBD to THC, and just start with like a milligram of THC at night.

Now, for context, if you take a puff, and many of us have used cannabis, I’ve used it, a puff is like five milligrams. So I start with like a fifth of a puff. There’s no way you can get in trouble with a fifth of a puff. It also won’t do anything to help you, but the point is I want the patient to really start at a very low dose. I say to them, “We’re going to make a mistake in the dose: We’re going to give you too little, not too much. So you’re a little bit bored and disappointed, but you’re not having anxiety and a very bad experience.” Then we can go up to two milligrams after a couple of days, very easy with a tincture under your tongue, then three milligrams, and then by the time you get up to, say, five milligrams, they’re usually feeling the edge of their pain has gone away, and they’re feeling pretty good, but they’re not feeling super impaired. You don’t want them to drive, but aside from that, they’re doing pretty good.

Kevin Pho: So when you talk about these options, I just want to be clear on definitions. What is the difference between CBD and, say, medical marijuana?

Peter Grinspoon: That’s a great question. So marijuana is a very complicated plant, with like 500 different chemicals in it, which is why some types make you want to sit on the couch and relax and, whatever, listen to the Grateful Dead, and other types make you want to get up and go to a party and talk to people or clean your house. Some are very activating, some are very relaxing, some are better for pain, and some are better for nausea. But THC is the primary intoxicating component of cannabis. It’s what gives you the high, what makes you stoned. Some people love it, some people hate it, and some people don’t mind it. I view it as a side effect to try to be minimized and avoided.

Now, CBD is the most commonly used non-intoxicating component of cannabis. CBD has been tried by one in three Americans, and currently one in seven Americans are on some kind of CBD product. People use CBD most commonly for anxiety, chronic pain, and insomnia. It’s very good for performance anxiety, for public speaking; they’ve done some good studies. There’s increasing data that it can help with addiction to heroin, to amphetamines, to cannabis, and to tobacco. A study just came out yesterday that it helps with cravings for tobacco addiction. Finally, CBD is approved for these intractable childhood epilepsy syndromes, like Dravet syndrome. It’s an FDA-approved drug called Epidiolex.

Now, if I could just make a mini TED Talk, the U.S. government federally still continues to consider cannabis a Schedule I drug, which means no medical utility and high abuse liability. That’s completely nuts, because they have several medications from cannabis on the market. Marinol is just THC, and Epidiolex is just CBD. And it doesn’t have high abuse liability; it has low-to-moderate abuse liability. Certainly some people get in trouble with cannabis, but compared to opiates, alcohol, and tobacco, many fewer people get into trouble, and the trouble they get into is much more manageable.

Kevin Pho: OK, so I find a patient that I think CBD oil is a good option for. I say a tincture, one milligram of CBD oil. I send them to a dispensary. So now they walk into a dispensary. What happens next?

Peter Grinspoon: Well, just a slight difference: With CBD, you don’t need a dispensary, because CBD is everywhere. Like I said, it’s at Wegmans, it’s at CVS. CBD you can get anywhere; it’s the THC that’s at the dispensary. But you give them some general recommendations about how to start. You give them a suggestion about what to buy, and then you just have them work their way up very slowly. Start with a little bit, take a little bit more the next night, and a little bit more the next night. I have patients journal, so they can talk about different types of cannabis, what helps, what doesn’t help, what dose helps, and what side effects.

Keep in mind, some people smoke it. Doctors don’t usually recommend smoking. There are other ways to take it inhalationally. You can get a contraption that’s called a dry-herb vaporizer that heats it up to 400 degrees instead of incinerating it at 1,100 degrees, so you can extract the cannabinoids, yet you don’t get the tar, the benzene, the combustion products. Some people really do like to inhale it, like if they’re in chemotherapy and they feel right away that they’re going to vomit. They don’t want to take a tincture or an edible; they need immediate relief.

On the other hand, some people take edibles. They take their gummies, their chocolates, their pills. Now, those are good in the sense that they last for a long time, so if you have chronic pain, they can give you long-lasting relief. The only problem with edibles is that they’re harder to titrate the dose, because they take about an hour to kick in. You just don’t want patients making the rookie mistake where they take a dose, nothing happens, they’re like, “Nothing happens,” and then they take four more 15 minutes later, and they end up way too high. So I educate patients about that a lot.

And then finally, the topicals are amazing, the topicals you can rub on your sore joints. That’s very low-hanging fruit, because you can’t get high, you can’t misuse, and you can’t get addicted to a topical. But I did want to mention that these days it’s a different world. At a dispensary you can get skin patches, you can get an inhaler, and you can get a suppository. There are all kinds of delivery devices for medicinal cannabis. It’s not just a question of smoking a joint; it’s just like any other medicine these days.

Kevin Pho: Now, how would you know what to recommend to patients? You mentioned there are so many different forms, edibles, something topical, suppositories. People who work at dispensaries, do you trust them to choose the best option for your patient when they walk in?

Peter Grinspoon: Well, they can be helpful with some of the nuts and bolts, but the problem is it’s a fine line between giving information about the nuts and bolts, you know, an edible versus a tincture, and giving medical advice. Clearly people at the dispensary shouldn’t be giving medical advice, and that’s something that causes a lot of anxiety on the part of doctors. They have budtenders, as they’re called, the people working at the dispensaries, giving medical advice. The solution to that is to educate doctors, so that doctors can give people very specific suggestions and then people can iterate on that, because it is an iterative process.

It’s not like you have high cholesterol and I give you 10 milligrams of Lipitor, or you have high blood pressure and I give you 10 milligrams of lisinopril. If you came to me as a medical cannabis patient for insomnia, I wouldn’t know how much you’d need. But we always use, for all medications, the lowest effective dose. So again, I’d literally have you start with one milligram and then, the next couple of nights, try two milligrams, and start low and go slow, understanding that it’s not going to work really well at one milligram, but we’re going to safely and gently get you up to speed.

So it’s just a different process that doctors have to get used to. It’s like a paradigm shift. It’s a little bit less paternalistic, like, “I’m going to tell you exactly what to take,” and more like, “I’m your partner. These are some suggestions. Why don’t you try them out? Journal. Write down what works, write down what doesn’t work, and let me know how it’s going, so we can fine-tune in a couple of weeks.” It’s just a different process. It’s a very rewarding process, but it’s definitely a paradigm shift.

Kevin Pho: So what would be the next step after tinctures of CBD oil? What would be your next step in your algorithm?

Peter Grinspoon: Yes, it works well for a lot of people, and for a lot of people it doesn’t work, like anything else we do. So I will add in a little bit of THC. THC is a little more complicated, because it can be addictive. It’s psychoactive. It causes the high that, again, some people like, some people hate, and some people just find a nuisance. After using CBD, you can’t drive, or you shouldn’t drive, just like you shouldn’t drive after using Benadryl, opiates, gabapentin, or benzodiazepines. So it’s a little more complicated, but I almost always end up adding some CBD, because CBD and THC work very well together synergistically.

In fact, a lot of people believe that whole-plant cannabis works much better than just THC or CBD, because many of the molecules are medicinally effective in very small quantities, and there’s something called the entourage effect, where you have all the different molecules of cannabis working together to alleviate your pain, your anxiety, your insomnia. So a lot of people think full-plant cannabis works a lot better. But when you get a tincture or an edible, a lot of times they just take full-plant cannabis and condense it into a tincture or an edible, so people get the benefit of all the major and minor components of cannabis.

CBD is not addictive. There’s no misuse liability, and it’s very safe. At very high doses, you might want to check liver tests once in a while. The only problem with CBD is that it acts just like grapefruit juice. It can competitively inhibit the P450 liver enzymes; consequently, it can raise the blood level of certain other medications. That’s not a big deal if it’s, whatever, ranitidine, but if it’s a blood thinner, an immunosuppressant, or an anti-epileptic, and you need a narrow therapeutic window, you need to let your doctor know if you’re using CBD, because open communication is the most critical component.

So I would start with CBD, and then if that doesn’t work, I’d add a little THC in, and if that didn’t work, I’d maybe have them get some full cannabis and give it a try. Again, we don’t like people smoking it, but there are all these other preparations, such as the edibles and the tinctures, many different options. If anything, it’s bewildering when you go into a dispensary, because there are so many different options these days. It used to be like, “Do you have access to marijuana, the plant?” But now there are hundreds of different options.

So that’s another reason why the more doctors are educated about this, the better. I spoke to a bunch of doctors, addiction psychiatrists, in a medical dispensary about six months ago, and it was a great experience. They answered all their questions. It destigmatized it; it demystified it. They got to see all the different products, they got to ask questions, and they got to talk to the budtenders, and the budtenders got to ask the doctors questions. So I think if we do things like that, doctors can just see these dispensaries, and it really makes it a lot more real and concrete for them, and they understand a little bit better why the patients are so interested in it and why the patients are clamoring for it.

Kevin Pho: Talk about the costs. What would a typical month’s regimen be of, say, starting with CBD oil?

Peter Grinspoon: Well, it’s expensive; that’s the problem. CBD, these little gummies cost like a dollar each, and you take a couple of gummies a day. So I would say for either CBD or for medical marijuana, it could be $100 to $300 a month, which is not covered by insurance. Again, once we get federal legality of cannabis, which will happen sometime in the next two to 10 years, insurance companies are going to have to pay for it. Maybe they’ll start paying for it when President Biden reschedules cannabis from Schedule I. That’s going to make it a lot easier to do research, and it’s also going to make it easier for the insurance companies to pay.

The insurance companies are making a killing on marijuana. Even when it was legalized in Colorado recreationally, there was an article from the Journal of Health Economics in 2016 that the Medicare Part D costs for all the medications in all the categories that could be treated by medical marijuana, pain, anxiety, insomnia, muscle spasms, all these costs went down. Medicare D in Colorado, with legalization of recreational cannabis, saved about $200 million. I mean, the insurance companies are making a killing, and they will end up having to pay for this. It’s just that they’re hiding behind the federal illegality.

And it’s very tragic, because one patient recently didn’t want to be on their opiates, and not only did we get them off their opiates, we got them off their benzodiazepines, which is very, very common with medicinal cannabis. They came to me after about three months, and they said, “I’m feeling better off the opiates and off the benzos. My memory feels better. I’m more awake and alert. I’m not constipated. But MassHealth costs one dollar for the Valium and one dollar for the Percocet, yet my medical marijuana was costing me $150 a month, as opposed to two dollars, one for the Percocet and one for the Valium.” So they had to go back to the Percocet, because I work in an inner-city clinic, and people just don’t have $150 a month.

But the last thing we want, just like with psychedelics, which is another discussion, the last thing we want is for medical marijuana to be another treatment just for the wealthy, the white, and the well-to-do. So I feel very, very strongly that it’s got to be accessible to everybody, which is why a lot of us are working really hard to pressure the insurance companies into paying for this.

Kevin Pho: And just to reiterate, you mentioned this earlier, what are some red flags, or patients that we definitely should not consider cannabis-based treatments for?

Peter Grinspoon: Well, it’s thought to be harmful to the development of the teenage brain. So unless they’re like my brother Danny and they’re dying of cancer, or, there’s a lot of interest in using mostly CBD with a little bit of THC for kids with autism, and I mean, it’s hard to argue that CBD with this level of THC is more dangerous than the Adderall, the Thorazine, the Haldol, all the stuff we give these poor kids, but generally speaking, teens shouldn’t use it.

I don’t recommend it for pregnant women or breastfeeding women, unless, for example, they have some very severe hyperemesis gravidarum and they’re in the hospital getting IV Haldol and IV lorazepam. It’s hard to argue that that’s safer than a little bit of medicinal cannabis. It can destabilize people with a history or family history of psychosis. I don’t think it, quote unquote, causes schizophrenia, but if you have psychosis, you should not be using any form of cannabis. So we don’t use it in those populations. And then also, we educate people very, very carefully not to consume cannabis before driving.

Kevin Pho: And my final question, Peter: Tell us some of your take-home messages that you want to leave with the KevinMD audience.

Peter Grinspoon: Well, it’s a very complicated topic. People have very strong feelings about cannabis one way or another, and as doctors, we’ve been subjected to so much nonsense about cannabis that it’s hard to know what’s what, and there’s so much conflicting information, which is exactly why I wrote my book, to help clarify all of this. But the take-home message is to listen to patients, and regardless of how you feel about cannabis, you have to create an environment where the patient doesn’t feel judged or stigmatized, or they just won’t tell you about their cannabis use. That’s true for all other drugs, by the way.

So I think anything that we can do as doctors to educate ourselves about cannabis, about the endocannabinoid system, the series of neurotransmitters and receptors by which cannabis works, which they don’t teach in most medical schools yet, and to facilitate a comfortable conversation with patients, we’re helping ourselves, we’re helping our patients. It’s a win for everybody.

Kevin Pho: Peter, thank you so much for sharing your time and insight. Thanks again for being on the show.

Peter Grinspoon: Thank you so much. I really enjoyed our conversation.

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