Transcripts For CSPAN2 A 20240703

Care physician, educator and cannabis specialist at Massachusetts General Hospital and instructor at Harvard Medical School and a Certified Health and wellness coach. He is also the author of free refills. A doctor confronts his addiction will be joined in conversation tonight by Marion Mcnabb mcnabb is the president of the Cannabis Center for excellence, inc. , a Nonprofit Organization that conducts Citizen Science focused studies and programs in. The areas of community engagement, medical cannabis, adult use, cannabis and social justice in the cannabis industry. Dr. Grinspoon presenting his new book, seeing through the smoke. This book is an unflinching examination at the grossly misunderstand drug that data driven medical science and a critical Historical Perspective to reveal the truth behind cannabis by focusing on the critical purported harms driving pregnancy addictiveness, memory, and by focusing on the most cited medical benefits relieving chronic pain, sleep anxiety, autism and cancer. Seeing through the smoke will help patients, doctors, health experts, regulators and politicians move toward, move beyond biased perceptions and arrive a shared reality towards cannabis. Were so pleased to host this event at Harvard Bookstore tonight. Please join me in welcoming dr. Grinspoon and Marion Mcnabb Marion Mcnabb. Thank you so much, dan, for that very kind. This. Is good. Good, everybody. Its a distinct its my distinct honor and pleasure to be here tonight with my dear friend and colleague, dr. Peter grinspoon, who has just published second book seeing through the smoke. A cannabis specialist untangles truth about marijuana. Thank you all for being here tonight. And thank you to peter for writing this book so that we could all be here. My name is dr. Marion mcnabb. Im the president of the Cannabis Center of excellence. 5013 Nonprofit Organization based out of east boston. Been working in the cannabis industry here in massachusetts since 2017. And ive had the honor of knowing dr. Grinspoon for several now collaborating with him on Cannabis Research studies together the Cannabis Center of excellence. Im excited to be here tonight with my dear friend and colleague as we dive deep into. One of the many topics of his book, one that is near and dear to both of our hearts cannabis and the role it can play in addressing the opioid epidemic. Shortly we will hear from peter, who will read us an excerpt of the and we will follow with time for some q a from the audience. To weve already heard peters background, but ill give my version of it. Dr. Peter grinspoon is a primary care physician, educator and cannabis specialist who is a dear and a Certified Health and wellness coach. Thank you. He is also a tedx speaker and commonly lectures on the topics of cannabis, psychedelics, addiction opioids and physician health. Peter speaks with authority and lived experience and makes us contribute actions authentic and realistic. For tonights discussion focused on chapter 15 of peters book titled cannabis instead of. Bigger isnt always better. This is such a powerful chapter in your book, peter, as it really hit on some practice call and evidence based interventions that can be considered for how cannabis can possibly play a role in helping us address current Opioid Crisis that we are facing. To give discussion a bit of context, im going to share a few Key Statistics with you all. And last year alone, 108,000 people in the United States lost their lives to opioid overdoses and. Overdose deaths have reached an all time high here in massachusetts. In 2014, message ucits declared the Opioid Crisis a Public Health emergency in the state. And massachusetts is now one of the top ten states with the rates of opioid Overdose Deaths in the country. Massachusetts City Residents are suffering from an exponential increase in opioid related. Overdose deaths and people seeking substance abuse. Substance use treatment due to the use of prescription opioids and heroin. In fact, if you take the number one bus from right here to, nubian square, youll go mass and caps, which is an intersection of massachusetts avenue and milan cass boulevard. It is an epicenter of substance use, homelessness and illness. We are in urgent need of solutions and coordination to address this crisis. And 2021. There were over 2290 overdose fatalities in massachusetts, many of which in boston, and the highest overdose death rate in massachusetts is among american indians. Followed by black and latinx men. The risks associated opioid overdoses continue to increase as the drug supply changes. And we see increasing levels of fentanyl a highly, highly potent synthetic opioid present. Now there are subgroups of those suffering with addiction that are more vulnerable to overdoses, including those that are homeless and that are veterans. Were lucky to have governor maura healey as our here in massachusetts as led the nation in exposing the wrongdoing of the billionaire Sackler Family through suing Purdue Pharma and court for cause of the opioid epidemic. In 2020, she announced the resolution of claims against the nations three largest drug distributors that is now providing hundreds of millions of dollars to address the Opioid Crisis across the state and nation. We are in need of Urgent Solutions to address this Opioid Crisis and the role that cannabis can play is only compelling. Its a practical, nonlethal and legal tool, and our Public Health and clinical toolkit that we could be employing and Harm Reduction capacity with the commonwealth of massachusetts currently issuing 500 million in opioid resettlement funding throughout the state. Perhaps its an opportunity to think about new approaches medical cannabis. In my opinion, the following the approaches that grinspoon will now share in his chapter 15 of his book are compelling enough in my mind that they would make a significant impact. All right, thats enough talking for for now. Ill hand it over to peter. For right here. Testing. He. Thanks for coming. Thank you so much to Harvard Bookstore for hosting us. Thank to marian for bravely deciding to join me up here. You to my mom. Raise your hand. Betsy grinspoon. Was actually married to my dad, lester grinspoon, for 66 years, and my dad was a critically important in the legalization. I write about this, but in a totally different part of the book and just very briefly, my involvement in the cannabis issue has been a lifelong number one. My danny was a pioneering Cannabis Patient in the 1970s. My parents, my actually bought him medical in the early 1970s, right. Richard nixon was starting his war on drugs. You know, they could have lost career. My dad, a psychiatrist, mom, a teacher. But the fact is, cannabis really helped. My brother danny, he was on chemotherapy. He was at the jimmy fund building. And when use cannabis, he could really hold down food and play with his little brothers. Made a huge difference, especially for the last year of his life. And, you know, theres very little thats as impactful as witnessing the alleviation of suffering in a Family Member. So i eventually went through a career in medicine and i knew that medical cannabis was medicine, maybe, among other things, i was just a kid, but i certainly knew was a medicine. And that helped sort of insulate me from a lot of the nonsense they teach you in medical school. Weve got a very long way to go get physicians up to speed, not just a medical cannabis, but a cannabis in general. Number two, as i alluded to, my father was a very legendary cannabis advocate, psychiatrist at Harvard Medical School as well. He wrote a book in 1971 called marijuana reconsidered, that at a time when 12 of americans supported full legalization of cannabis and when Richard Nixon was literally starting his war on drugs, my dad called for legalization, he said. There were harms. Cannabis certainly can affect teenagers, could affect pregnant women, but the harms of criminalizing were far, far worse than the harms of using cannabis. It should be illegal. So again, 12 of americans supported fully with my dad rules book, which was reviewed in the front page of the New York Times book review, which i think is the main reason harvard didnt fire him on the spot because they were not happy with his work. And then the support for legalization went up about a point for each of the 50 years he worked on it until he passed away two years ago. So now its about 67 and 94 of americans are in favor of legal access to medical cannabis. Name anything else that 94 of americans agree on . They dont even agree. The earth is round, sky is blue. So who would have thought cannabis unites and who would have thought that growing up, as i did with a front row to the Legalization Movement so part of this book is about the Legalization Movement, about how it came about and the people that brought it about. Part of it is about the war on cannabis users and what weve done to people there have been 20 million arrests for nonviolent cannabis offenses over the last 50 years is actually horrible. I, i could go on and on about what having a criminal record does to your education, to your job prospects, to your. And then i, i do have a chapter called do no harm about and about how doctors were flat out on wrong side of the war on drugs and need to do a lot better not just on cannabis but on all the drugs. I mean, enough of the stigma, the judgment, the criticizing this stuff is is actually killing people. And then i go through all the harms of cannabis, the major ones, you know, driving cognition, teenage pregnancy, see addiction. And i about what are the real harms what is the science say and what are the imagined harms. And keep in mind, like deciphering the science is very difficult because the Us Government has only funded until very recently studies the harms of cannabis and they literally would not fund a researcher or studies into the benefits of cannabis. So we have this research, but its really one sided. I mean, if youre looking in one direction. First of all, youre not to see the other direction. And then the doctors are like, well, theres no data. What we have in theyre looking for data. And there is a lot of data. So and number two, its just very hard to understand these studies because theyre studies. But they were with an agenda. The agenda to vilify cannabis because you couldnt really create a big enough moral panic and with just cocaine and heroin to wage a whole war on drugs, you had to include cannabis. And you only could include cannabis if. You demonized it and vilified it. So i go through all these harms with the most recent science and then i go through the benefits. Can they help with pain can it help with insomnia . Can it help with can it help with autism . A lot of people are giving it to the kids for autism and its its really amazing how both sides get it wrong. The pro people think it cures everything and they whenever a study comes out about the harms, they just say, oh, thats just Us Government propaganda, which is really, really dangerous. I mean, if you use drug, you need to know the harms. We, many of us know the harms of alcohol and we still to drink. But were making an informed decision. But you cant make an informed decision unless you have Accurate Information about the harms and the benefits. Whats he going to do to me and how is it going to help . So i go through all the benefits and then i have a chapter on cbd which is a kind of a funny chapter because so many people are on cbd. And then finally i have a chapter on personal lifestyle uses. How are the ways in which you can enhance your lifestyle . How is it that people have been using it for 5000 years and you know, it helps people appreciate sex and music and religion, spirituality, and helps you mindfully connect to the president. Why is this drug been vilified . It helps people not that again, that it doesnt have horrors, which is what the second parts about. So that is sort of a synopsis of. The book and the chapter usually i read these chapters about like my personal involvement and the sort autobiographical. But you know, doing this summary. Marion, whos a specialist in all of these things and i just think its such a big crisis with the Opioid Crisis. And then just very briefly, on a personal note, im 15 years in recovery from the vicious to prescription opiates. So these statistics could have been me. And thats when my first book was about ice free refills, about how a doctor confronts this addiction, how you get addicted as a doctor, which is not hard because doctors are under so much stress and have so much access and how you recover. But i really wanted talk about cannabis and the Opioid Crisis. So going to do a brief reading then probably, you know, talk a little bit more and then were going to open it up for questions. So to what extent can cannabis help us address the Opioid Crisis . As i write this, we have lost more than 108,000 people in the United States to opiate overdoses within the last 12 months. I mean, that is just a astounding. Number of people to die from opiates. Several states have approved cannabis help address components of this epidemic. Is this sensible generally, there are five ways in which cannabis can alleviate the opiate crisis. Now, four of which im on board with, and one of which i dont agree with yet. So the first way is to offer cannabinoid therapy instead of opiates for patients with new chronic syndromes, all doctors should be equipped to offer this option. Right now, its about 2 of doctors this practice will lead to fewer patient exposure years to opiates and fewer opiates in circulation that could be diverted by Family Member or acquaintance. This is actually how addictions to prescription painkillers start when someone else gets into someones left opiates. Im not at all in favor of under treating pain patients or in cutting off opiates in patients who need them or have been on them with benefit. But it is amazing how many people dont actually need opiates do better on cannabis. The second way to help with the Opioid Crisis is to transition people who have been on chronic opiate treatment from opiate to cannabis. This has to be voluntary. Too many people getting kicked off their opiates that can lead to like severe distress and even an uptick in suicides. And then when you kick them off their prescription by illegal opiates, and thats the deaths are going up, the cracking down on the doctors, people are prescribing it and then people are buying it illegally. So it has to be voluntary as is wholly unethical and dangerous to force people off their opiates. Many people have transitioned from opiates to cannabis on their own and are eager to do this. This is especially true if they have access to a cannabis knowledgeable physician. You know, these are a little bit few and far between, but were working on this. Whos able to help coach them as well as to as well as to give them access safe and legal cannabis. According to a 2019 study, results from previous clinical studies suggesting the cannabis may be an effective analgesic and opiate substitute patients are reporting improved pain health and fewer side effects as a rationale for substituting. Now ive had a lot of success in my clinical practice transitioning patients from opiates to cannabis, though certainly not with everyone whos tried in some cases the pain is just so severe they feel the need to opiates and other people other patients successfully make the transition off of opiates. But have to go back on them because the Health Insurance cover cannabis and they simply cant afford it. Now, this is something were very hard working to change im going to grab some caffeine. I have a sign by my office and my Office Manager gave me this, said, without caffeine, i have no personality whatsoever. So bear with so my patient derek is one success story. When derek first wheeled up to me, he was the recent victim of a drive by shooting. The specialists had patched him up, which was really incredible. What they did, but they he suffered from severe, chronic nerve pain and ptsd. And it started a massive dose of oxycodone. I offered to transition into cannabis which he was open to. We worked together on this and as his opiates came down eventually to none his engagement and interest in the around him increased, he was also doing physical therapy and in time relapsing. So we cant attribute the improvement strictly to cannabis therapy. It certainly seemed like the cannabis was working though it is difficult to imagine that his remarkable renal function have occurred on that gargantuan dose of opiates. He fought his way out of the wheelchair and then off his cane and started a successful Small Business and then went on to study economics. Hes really, really successful. He said to me, if you didnt encourage me to get off the axes, i never would have achieved any of this. The third way to utilize cannabis to lower opiate overdoses is to lower the dosage of opiates. This is because cannabis opiates co work on the same receptor. If you introduce a medical cannabis, a chronic opiate patient, you can lower the dose of opiates by about percent. Fewer opiates floating around, fewer less of an opportunity for the patient to make a mistake and to fatally. According to one study, one low dose thc is introduced an adjunctive therapy we observe better pain control clinically with lower doses of opiates improve pain outcomes and reduced related harms. Now the first way in which cannabis can help us to address the current opiate crisis is by virtue of the fact cannabis can be an unusually helpful for the symptoms of opiate withdrawal. The dozen or so times, unfortunately, that have withdrawn opiates in the process surmounting my addiction. The symptoms went far beyond what the word miserable denotes it was between excruciating and a possible. Thats why people are so desperate to find opiates and to get back on and theyre withdrawing theyre sick. They feel awful and theyre take risks. I mean, anything to feel better. And thats why a lot of them end up taking fentanyl and overdoses. So when i was id feel sweaty freezing, being flushed, anxious, jumpy, depressed. Id have the worst imaginable nausea, muscle and stomach cramps, no cannabis alleviates many of these symptoms similar tenuously. It actually alleviates them. And i can tell you this from the data and from experience far better than pharmaceuticals that we have. This isnt to bash on pharmaceuticals. We just dont have a good pharmaceutical for opiate withdrawal symptoms. And cannabis works really well. So the of using Medicinal Cannabis transformed opiate withdrawal from i want to die to this is awful but i can handle it few if any who have gone through this and this is like hundreds of thousands of people would disagree and it just astounds me that Addiction Specialists havent picked up this valuable treatment decades ago. The the addiction people are very against cannabis and thats Something Else that were working on. They have this like irrational fear of it is. I read a lot about this in the book is financial because then theyre not the ones doing it the patients are doing it themselves or is it just because, you know, theyre still processing the drug war negative, you know, messaging cannabis. But anyways, its a really, really important component of getting people off opiates. I use it as an adjunct, not as a primary treatment for people who are on opiate, who are addicted to opiates. And ill explain why. The final way the might help the opiate crisis is the most disputed, namely the idea of using cannabis itself for opiate substitution, and along the lines of, you know, suboxone or methadone now we use buprenorphine methadone to get people off their opiate addiction because theres really good data that with a suboxone you have a 50 to 80 reduction in overdose and death and we dont have that data yet from cannabis because never were looking for benefits only for harms so ive ive met heard from thousands of patients who have used cannabis to overcome their opiate addiction in precisely this way as an drug you know a big propaganda point on the war on drugs if could just skip the reading for a minute is that you know, cannabis was a gateway. Marijuana is a gateway to harder other drugs and this turned out to be not true at all like simply a propaganda point of the war on drugs. There was an association between cannabis use and these other harder drugs. But first of all, they found it. It was the alcohol and the tobacco were more implicated. But second of all, you cant make causal inference from associational studies. You everybody who turns into becomes addicted heroin drinks, milk as a child right. 100 of people. Aha. But in reality, the drinking milk is a child does not, you know, cause or most people wouldnt try to argue that it causes the opiate addiction. So ironically, hundreds of thousands of people are finding to be a gateway drug. True, a gateway off of addiction, not addiction. So ive met and heard from thousands patients who have used cannabis to overcome their opiate addictions in precisely this way as an exit drug or gateway off, can cannabis be considered a standalone treatment for opioid use disorder . Like we use methadone and buprenorphine mean should people be allowed to try if it works for them . Should he be allowed try or should the system be pitiless stick when its something this dangerous should cannabis clinicians be encouraging this now . I personally dont feel comfortable. Cannabis is a primary for opiate use disorder. My hesitancy has to do with the concept senses of treatment failure. Know if someone comes to me a new medical Cannabis Patient. I see this all the time and want to try cannabis. Theyre migraine. I have a very low threshold for instituting a treatment. If the cannabis doesnt work, the worst Case Scenario is that the patient gets a migraine or a migraine. They already have, doesnt resolve promptly and try Something Else. Lots of medications and do not work for migraines. You know, they be a little bit annoying if theyre doctor you wasted time. But you know, in truth, we things all the time that dont work and theres this is low hanging and theres nothing really lost because nothing bad is going to happen to the patient. If, on the other hand, a patient tries to use cannabis alone to treat opiate addiction instead of and suboxone, which has such great data behind them and it doesnt the consequences may well be overdose and death. We are fortunate that you know we have two medications that reduce overdoses death by 50 . So personally i dont feel it is responsible prescribe the treatment cannabis that hasnt yet been proven to save. We have access to treatments absolutely have been proven to do so that said i havent seen any data showing that the use of cannabis which many people in and of itself or instead of methadone or buprenorphine has caused any overdoses or deaths as far as i know, this is a hypothetical risk that been demonstrated. That said, coming from someone to recovery from a nearfatal opiate addiction. I strongly recommend going with the proven treatment. I mean, i think an analogy would be cancer like a lot. Cannabis advocates think that cannabis cures cancer. Cannabis not cure cancer. It might turn out to cure cancer eventually because really interestingly, different components of cannabis is a very complicated plant with like 500 different components. And many of these components in the lab kill cancer cells. I wouldnt be surprised if in ten years we show the cannabis is an adjunct to many of our chemotherapy. But right now cannabis has been proven in a human to to cure cancer. However it is excellent for the pain, insomnia, the anxiety, chemotherapy, the nausea, vomiting, the lack of appetite. Its great for the cancer symptom. So if you get cancer see an oncologist, but use cannabis for as an adjunct but not as a primary treatment. And i think thats a very good analogy because its exactly the same thing with opiate use disorder. Now, of course again, there are thousands of people who have gotten themselves off of with cannabis. And as with cannabis, these anecdotal stories are going way ahead of the data that we have. And it puts in a quandary. Several states have recommended as a certifying to use cannabis to get people off opiates. The addiction psychiatrist ballistic they literally went berserk like youre going to kill people you shouldnt use cannabis for this. We should use methadone, suboxone. And i sort of agree them, but also at the same time, shouldnt we be studying this i mean, theres theres so much smoke almost certainly going to be fire. So to be determined and that is the end of what i wanted to read, because i know were going to have questions and again, this book was to write because. Well, first of all, everybody baggage. When it comes to candidates, nobody is neutral about it. Its been such a politicized issue. So i ask at the very beginning that people try to their biases to the side when they read it, to really try to be objective. But, you know, again, pro people are so of any study that harms, they think its just propaganda. The anti people still put the American Medical Association and the American Psychiatric Association Still put the words medical marijuana in derogatory quotation marks. I mean you wonder why theres such a huge chasm between the patients and like the psychiatrist asked them about it. Nobody listens them. And what were developing is two separate care systems. People see their doctor and tell them about their problems and get their ssri if its a psychiatrist to get their other medications. And then they go to a separate cannabis physician, get their medical cannabis, and its so when the two dont communicate because the main way to reduce cannabis related harms is to have open and, Transparent Communication among all providers and Family Members so that their medication interactions to someone have a history of mental illness. So im a huge believer in educating doctors about cannabis, about open nonjudgmental, non stigmatize communication between doctors and patients. And at this point im going to wrap it up and leave it for questions. Yeah. So wow, that was good. Very incredible and impactful. Is that not right . Erica, hello hello. Hello. Yeah, that was incredibly impactful. And i have a ton of questions, but its not my time, so im going to open it up for. The audience of any anybody, even have a question . Just raise your hand and you you guys have a great sense of humor on this topic. I appreciate that you do studies money, farmers definition, they say they charge someone for drugs because it takes 1,000,000,000 or whatever. But its also that over two thirds of that comes out of Public Research from the money come from National Institutes of health etc. So theres nothing right now it for the big money which surely the nih can fund studies. Or is it possible . Yeah, theyre starting it. When you go first, you go first. Well, youre the researcher. Yeah, exactly. They are. To in the last couple of years there has been more and more procurements that are coming out. But i would say this is only in the last four or five years now. And i think theres, you know, an understanding. You know, theres a lot of the funding for research and the Us Government funding is actually funding studies in israel for the last when we werent studying them here. But think the tides are turning but the funding is not fully there yet. In 2019, a study was in the in Science Magazine that said this is in 2019 that like the good modern age, 20 times more money was spent investigating harms of cannabis than benefits. But this this is now, you know, in 71, when the National Institute of drug abuse was now theyre going to change the name because but the National Drug abuse was was founded. Robert dupont was the head of it. Now, not only did Robert Dupont, dr. Robert dupont have like this massive drug testing empire. So he was advocating drug testing for everybody. But hes using these quotes, which i have in the book about how cannabis, the downfall of america and, and keep in mind that the us. Funded 80 to 90 of the Worldwide Drug research over the last 50 years. So it didnt just affect us. It affected the whole world and literally at that point, like 100 of it was focused on harms, not our benefits. Now things are starting to lighten up, just like doctors are modifying the precision cannabis due to popular demand. The researchers and the government is as well. So there is the money is being freed up a little bit. But as you say the costs, the numbers ive heard like 203 million to develop a drug and. You know, its really interesting. Big pharma always on the anti side of legalizing and they contributed lavishly to each of the statewide Ballot Initiatives to to defeat cannabis legalization. But at the same time, they were developing their own cannabinoid based medication, like instance pharmaceuticals. These are the guys they in new mexico, arizona, they got in trouble for these fentanyl lollipops and bribing doctors to prescribe them, but they gave tons of money to. The anti movement. Yet they were developing their own cannabinoid and their vision of what would work perfectly was if marijuana cannabis were still illegal yet you had to very expensive cannabinoids from the pharmaceutical companies. So they havent been interested in this at all for a variety of reasons. And then finally, theres a reason that a people can grow it at home, so theres not going to be that much money in it for them studying this as well, unless they come up with something thats so fundamentally, profoundly better than smoked or whatever tincture. You consume cannabis, which i guess would be a big risk. So theres a lot of research on the Endocannabinoid System. The whole system of neurotransmitters and receptors through which all of this works and theres a lot of drug development. And its going to be really interesting to see what they come up with and if any, its better than the cannabis that we humans have been using medicinally for 5000 years. So im sure youll get millions of volunteers around the world, lots of volunteers. And just to build on just a little bit here, theres an exciting opportunity around funding. So theres in massachusetts, theres a Cannabis Research license type and in other states Cannabis Research, you know sort of licenses are popping up in oklahoma and other states and states are funding cannabis. So while the federal level peter eloquently spoke about states are taking different initiatives and there a bill in the state house right now too for Cannabis Research funding from the opioid resettlement. So if folks support that call reps and have them sign on, well take another question question. But right, i have a question. So when you have a patient who transition lands from opioids to, cannabis and for chronic pain and they have of follow up with other doctors and they have a surgery that they need and so theyre admitted to a hospital, but theyre there for a multiple days and they cannot have access to. Cannabis, what advice do you give them . Because they dont have their Pain Medicine and theyre confronted with having to take opioids instead for the duration of that medical stay off the record or on the record . Well, first of all, california had just established that can bring it into the hospitals. The concern in hospitals is that people are really worried about losing federal funding because of federal legal. This wont be an issue once we originally once we eventually legalize on the federal level. But it is a really, really big issue. Weve had meetings in my hospital, mass general hospital. The last thing the security guards want to do is like, you know, yank away with a second. Last thing they want to do is yank away medical cannabis from dying cancer patient. They truly are nice and dont want to do that. The last thing they want to do is look on tik tok or, you know, youtube and see a viral video of yanking away the cannabis from a dying cancer patient. So hospitals are very eager to solve this. What i recommended to my hospital, dont ask, dont tell everybody, it was like, we cant do that. That doesnt solve any of the problems. But honestly, i think what theyre doing is dont ask, dont tell. You educate the patients. They cant, you know, light a spliff in the middle of the hospital is a nonsmoking facility no matter what. But but you know if they you know they should communicate with their doctors but you know, certainly if they brought in some like unmarked candies, nobodys going to notice or nobodys going to care. So its sort of about respect for behavior and just being sort of common sense and being a, you know, a being consider considered adult, you know, the other patients, if you start puffing in your vape. But again, if you have an unmarked candy and you just take a reasonable amount, stop yourself. Cannabis have withdrawal symptoms. And also if its your the pain medication that works best for you, you shouldnt be denied it. So i think people are finessing it, they dont have an answer except california. But again, this is a very short lived problem because with 94 of americans agreeing about legal to Medicinal Cannabis, with 38 states having legal medical marijuana, and now with 23 states having full adult legalization, its only a matter of time to were going to get federal legality legalization. And i would guess like instant three, were going to have access in the hospitals because theyre just worried about getting in trouble and losing their funding. But a lot of people suffer because of that. And its a big problem that a lot of really smart people are working on. But its difficult because, you know, these things have been stigmatized cannabis been stigmatized because of the war on drugs for like the last half century. And also, you know, the federal government has a lot of really a of in transit is intense. Even fighting the drug war the office of National Drug control policy, the dea they naida theyre really theyre not children when it comes to cannabis. So theres a lot of institutional but i think were going to legalize the next like 2 to 10 years depending on who gets elected in. Thats not going to be an issue, but it just causes a lot of unnecessary suffering for the time being. Yeah. And i wonder also also your thoughts around, you know, physician education around this. Its not systematically taught in our hospital and our our medical and our nursing schools. The Endocannabinoid System and so that playing a role in an actual care. Well ironically doctors were when it was criminalized in 1937 one of the leading voices against criminalization was the American Medical Association. They testified to congress. They should be criminalized because in the late hundreds and the early 1900s, doctors were prescribing it all over the place. These little tincture bottles were really easy to find. Then, under withering pressure from the federal bureau of narcotics and harry anslinger, this really racist guy that hated cannabis doctors, sort of flip side, it became very sides and became very anti cannabis. Now theyre switching back, theyre behind patients, but about two thirds of doctors believe the cannabis is a helpful medicine. Ive noticed that it depends on the doctors point. If youre an oncologist like 90 of them support medical cannabis. They see it helping their patients like find me an oncologist is anti medical cannabis is almost impossible to find on the other side if your side if youre the other hand if youre a pediatric psychiatrist and you see rare but very tragic cases like a teen or a young adult use too much cannabis or have a psychotic disorder, use cannabis and become disturbed wise. That is very upsetting so. They tend to be very against cannabis. So different of cannabis among primary care doctors about which are pretty representative. The doctor is about two thirds of doctors support it, but were operating in a vacuum because as marianne alluded to, it doesnt really sense unless you understand the system and the receptor called the Endocannabinoid System. This is a very ancient system in our brains and bodies has been around for 500 million years. Every animal has an Endocannabinoid System and over the last five 10,000 years that weve been using cannabis. This has been bootstrapping onto our Endocannabinoid System because the external cannabinoids are chemically like thc, chemically similar to our natural endocannabinoids. So they are only teaching this as a hangover from the war on drugs in 13 of medical schools. This has to change away, even if you think cannabis is like the devils lettuce, like the satanic weed, you should want to know what the Endocannabinoid System is. You understand the harms like. All doctors need to understand that. So theres a big push to educate doctors. Part of the problem is theres a big fighting over, like what is the truth to doctors . And i mentioned this right at the very beginning, but like nobodys objective about cannabis and we dont even know what objective about cannabis is because theres not a widely accepted truth about cannabis that all authorities, doctors, researchers, scientists agree with. For example, millions of people use cannabis for anxiety, for depression and ptsd. Find a veteran. We have a veterans event on saturday. Find a that doesnt believe from the bottom of their that cannabis helps them with their ptsd and then the American Psychiatric Association Just came out with a position paper saying theres no whatsoever and no reason to believe cannabis helps any psychiatric condition and should not be used in the treatment of anxiety, depression or ptsd. So how do you educate a new doctor when the current dont have any agreement about . This i mean, i think there will be agreement basically because theyre wrong and the cannabis users are. But this is my humble opinion. I dont i dont claim to have a monopoly on truth, but its very difficult to educate a whole profession an issue where there isnt widespread agreement on the very basic facts. Is this a good thing or a bad thing among the profession . How addictive is it . You know, does it a psychotic schizophrenia . I mean, there are so many issues still hammering out that we we not only have to educate doctors have to come up with like a common belief system that at least i mean, i feel theres enough common like obviously it helps of pain, insomnia, anxiety and nausea and weight loss. And obviously pregnant women should be using it. And people with psychosis shouldnt be using it. And teenagers should be using it. I really think there is more Common Ground that could all agree upon than both sides get credit for. And i think from there could you could expand and have a more Common Ground, which is part of why i wrote the book in the first place. But very important but very difficult issue. Yeah, go ahead. Right, right here. No. So all right. I was just going to ask you answered already that what they what do you believe are the key negative medical effects of marijuana . I mean. Oh, absolutely. Are there and and if so, what are they. Well, smoking marijuana has never been associated with lung cancer or copd but at the same time, i dont think smoking a ton of it is healthy. It has combustion products, it has tar, polycyclic aromatic hydrocarbons. So we dont recommend medical cannabis. Doctors dont recommend smoking unless you know someones dying from cancer. Like my brother danny was obviously smoke as much as you want is pretty widely agreed the teenagers shouldnt be using cannabis again. If theyre like my brother danny, theyre dying of cancer. They can smoke cannabis. And you know, you have these emerging indications for medical cannabis. Theres more and more data that it helps with autism. Now, the psychiatrist oh, thc is dangerous for the developing brain, but the same psychiatry is literally these people with adderall, thorazine and held all these heavy duty psycho stimulants and neuroleptic control. The selfinjurious behavior. You have a very uphill battle arguing that thc is more dangerous for the teenage than than adderall, thorazine held on all these this whole all these cocktails. So i think this is being reevaluate weighted. I think its really complicated. But i think teens i think people with a Family History of psychosis, it could really destabilize them. Truly can. And i think pregnant women no evidence this safe in pregnancy. Again if someone has hyperemesis like uncontrolled nausea and vomiting and pregnancy, theyre in hospital, theyre getting iv, haldol, lorazepam, a benzodiazepine like, valium. Its hard to argue that some teenage is going to be more dangerous than that. So its a question of common sense. But i still heard you say what is is there any known medical disadvantages . Oh, yeah, there is. If you smoke it all the time, if you. Yes. Smoking if youre if you smoke it all the time, you can cause a chronic bronchitis. You take it. I mean, the actual marijuana itself. Is it medically dangerous in any that you know well to a teenager it can affect their Brain Development to a woman it could affect the fetus healthy adult. Even nora volkow, the head of the National Institute of drug abuse, recently said and again this is again, i hate to use this again, but she is not a flower child when it comes to cannabis. Shes been complete against cannabis like every single head of night since Robert Dupont in the early 1970s. She recently said that, like modest cannabis use in an adult is not known to be harmful. It needs to be studied. But so i dont think using it modestly in in the safe and reasonable, is it dangerous . And then the other thing is a primary care doctor. What i do are these i dont see is this dangerous. Everything i prescribe is dangerous can die from penicillin. People can die from any Blood Pressure medication give my job is to say is this medication likely to be the least dangerous alternative . So my question is not is it absolutely safe . Its not. But is it safer than whatever else the patient would be using . So the question. Yeah, had a question talking about you mentioned briefly about Insurance Coverage and whatnot. And we about, you know, the Financial Research then, you know i guess im looking for more elucidation on on what your thoughts are about coverage there as well. My professional background is in workers comp, which i feel like most of what they pay for is chronic non acute pain going on and theyve, you know, constantly looking for alternatives yet, you know, as you know with maybe a few states as an exception right there, theres options in a couple of states where the yeah i think workmans comp would work would save so much money if they fully adopted and were able to adapt Medicinal Cannabis. It is less expensive than many of the pharmaceuticals that use they put these people in these like atypical antidepressants like cymbalta help a little bit or maybe grab a pension that mostly makes you sleepy. These are expensive. People could be using medical cannabis less expensive, more effective and less dangerous. The problem is the federal illegality. Number one, how are we going to get a medication to be fda approved if its federally legal . Number two, cannabis is still schedule one in the controlled substance act. All the way back from the early 1970s. Schedule one makes it very hard to research. It makes it very difficult for the fda to approve it as a legitimate schedule. One means no medical benefit. We know thats not true at all. Even the government has appeal against a medication for childhood epilepsy made from cbd and marinol for loss made from thc. So i dont know how theyre still claiming it has no medical benefit and then high abuse liability is such nonsense. It does have abuse, liability. People do get addicted to it. People get in trouble with it, but its not high decided its low to moderate abuse liability. I mean, particularly compared to like on a day to day basis, ill prescribe, you know, valium, klonopin, you know, oxycodone, morphine codeine. Its really hard to argue that these are safer than cannabis and these are not schedule one medications. These are schedule want or schedule five medications. So been a real double standard about cannabis. But until we get out of the whole of federal illegality and the whole of this schedule one classification is going to be very difficult to get insurance. And then the Insurance Companies hide behind that, too. I mean, the insurance are making a killing. There was a study in Health Economics in 2016 that when colorado legalized recreational cannabis, their medicare spending on prescriptions went down 200 million because people on their own for whatever things you could be using for you started using cannabis instead of waiting a month to see their doctor and then getting a muscle relaxant makes them sleepy and they cant function. They just started using cannabis or if they had pain instead of waiting to see the doctor and getting some percocet, they just use the medical cannabis. So the Insurance Companies were saving hundreds of millions of dollars so they certainly can afford and deserve to pay for this. But there are some very legitimate obstacles that theyre conveniently hiding behind to answer the question. Yeah, thank you. We have time for one more. How would you define modest use. Well, depends if youre a medical or recreational. I guess everybody has their own definition, but i dont have a definition of modest use. You know, to some people, its like a puff a week and other people its like, oh, we smoked every 15 minutes, you know people are very people are very different with their use but you know, with any medication and with any drug you want to you none of them are free of harm. Theres no free lunch. Everything that we prescribe has harms. So we try to use the least option and then whatever you try to use the lowest effective dose, you know, recreationally, i guess, depends what your goals are. But for medically, what is the lowest effective use you can use . And if youre using it the lowest way, its hard to argue that thats a a modest dose. And if you need a much higher dose and nobodys going to accuse you of misusing it if youre a veteran with a traumatic brain with like severe pain and you might need a much higher dose, but nobodys going to accuse a person of misusing it. So does tolerance seem to develop absolutely a big problem, tolerance and that makes it very expensive for people and thats another reason we dont want a smoking. Theres smoking all the time. It doesnt last very long. But your tolerance is a big problem and withdrawal to people really do get withdrawal from medical cannabis and thats a real problem for people that smoke very heavily and then for example, theyre in the hospital and. They have to stop abruptly. They can get withdrawal symptoms. They can be you be grumpy, can have trouble eating. You can have trouble sleeping. You can have really weird, vivid when you withdraw from cannabis because cannabis suppresses, your rem sleep is one of the things you do. My chapter insomnia is called to sleep but not to dream because people use cannabis every night to sleep. Sleep well. They dont end up feeling like theyve a drug sleep like you do with ambien or trazodone, but they dont remember dreams very well, which is something that upsets some people. But. All right. We have another question coming. You make too much sense. It wont work. You got it. Yeah. If you get a thousand, 2000, 10,000 veterans who said this helped no politician. Are going to say no. Yeah. Well, think were getting there . Honestly, i think honestly, it hasnt been the politicians, its been the psychiatrists and. That particular issue. And i honestly, the really, really cynical me is like they just like to treat it. They dont want other people treating it. Its a financial thing. It goes down to the Upton Sinclair quote that is difficult to get a man to understand something when his salary depends not understanding it. But thats only im in a cynical mood. I just theyve been sort of propagandized against it. But i honestly think parts of the medical profession are are bigger obstacles to this than than many of the politicians. Yeah. And just to build on that specifically for veterans, i have im Principal Investigator of a study. Right. Actually called i account for veterans. I did a Research Study with veterans in 2019. And you know for veterans they access care for a different system from the va. And so its a lot harder for them even though veterans are finding significant relief in the studies that ive been leading and reducing unwanted use, improved quality of you prove back to work. So, you know hopefully you know when federal happens you know va system will open up but its just an it is very interesting because its different the Health Care Systems that are you know for the general population until a few years ago physicians at the Veterans Administration werent even allowed to discuss the word medical marijuana with their patients i mean, how about what is a more egregious example of the government getting in the way of like privileged doctor patient now that literally the are allowed to discuss it but theyre allowed to recommend it so i guess you could say were heading in the right direction, but again, thats a combination of that. Thats that is the politicians. So maybe it is the politicians and. It could go to marijuana or cannabis withdrawal how they manage that. Okay. Well, first of all, you can avoid it by not using too much, not using it all the time. And you can you know its not all or nothing you could like use a lower dose and and then finally cbd is, you know, cbd is the nonpsychoactive component of cannabis that most people have heard about. One in three americans there have tried cbd and one in seven americans are in some cbd products. Theres some emerging new evidence the cbd can really help with cannabis withdrawal because it doesnt interact directly on the cannabinoid receptors. But it raises amanda side. One of our natural endocannabinoid. So it sort of refurbishes your natural endocannabinoids the you get tolerance is because if you smoke cannabis all the time youre natural cannabis receptors thin out. So then you stop abruptly your natural endocannabinoids, your natural cannabis molecules have much fewer receptor to work on, so you suffer anxiety insomnia, grumpiness poor appetite. So the final thing is there are these new molecules, fatty acid hydrolysis inhibitors that reduce the degradation of our natural endocannabinoid and increase our natural endocannabinoids and these pills can help with cannabis withdrawal. They supplant the external cannabis. Youve been getting your natural cannabinoids, preventing their degradation. So have higher levels so and theres a lot of research into theres not a single fda approved medication for cannabis withdrawal or for cannabis addiction, but there are a lot of medications we use and were Getting Better at treating it. Thank you. Thank you. I think we i think you i think we are time for the event. So i want to thank you all for being here. And thank you, peter. Thank you, marion. Yeah. So i