Two Docs Talk: Cannabis

Transcript:

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:16

Hello, I'm Dr. Michael Koren, and today Erich is joining me for our episode of MedEvidence. And I'm really excited Erich this episode, Erich, for a number of reasons. Erich and I have known each other for a long time and Erich has worked with us here in the Clinical Research Center and he's been a family physician in our community for a number of years and we've had cross-referral of patients Me as a cardiologist, you as the family physician so that's been a fun relationship. But Erich has gotten into the concept of understanding the use of cannabinoids or cannabis over the last several years and he's now dedicated his practice to help people by using this mechanism of treatment. So I'm really interested in learning more from you and really taking a deep dive into this so you can educate me and other members of the MedEvidence family about how to use cannabis and what you've learned and how we can share that information to help people in the community.

Dr. Erich Schramm: 1:11

Great, thank you.

Dr. Michael Koren: 1:12

And thank you so much for having me on, and we've collaborated since 2003, since I joined Clinical Research, so we've had a lot of great opportunities to talk about research and you're a fabulous researcher, and actually that's one of the reasons I'm really excited about this conversation, because the reputation for cannabis is that it's not always evidence-based, and you're going to help us understand that. So let's jump in. So let's start with the basic definitions for everybody we hear about CBD, THC, explain what that is to people.

Dr. Erich Schramm: 1:40

Great. So the cannabis plant. It's a very complex plant and has probably about 400 chemical compounds, but the important elements of the plant are , which is your THC, and cannabidiol, which is CBD. Now, a lot of times people say, okay, which part of that plant is the one that has the potential for intoxication? And I'll say, well, that's your THC component. The plant naturally makes one particular type of THC, which is Delta 9, but more recently now it is being able to be produced Delta 8. So it's kind of a very similar molecule, but those are the more potentially psychoactive compounds of it the CBD, the cannabidiol, is not associated with any potential for intoxication but has great potential benefits in terms of anti-inflammatory effect.

Dr. Michael Koren: 2:35

So just to explain, the Delta 8 versus Delta 9, this is not the Navy Seals, but it's actually what we call stereoisomers, and that means that it's the same molecule, but they can be mirror images of one another and I guess it sounds like they have different effects depending upon which of the mirror images it is.

Dr. Erich Schramm: 2:53

Absolutely correct. So it's just a very slight change in the chemical composition. The reason that Delta 8 exists is because it can be manufactured from CBD, and so it can be, as you can acquire CBD over the counter. This is possible to acquire Delta 8 over the counter without having to go through a medical marijuana solution.

Dr. Michael Koren: 3:14

So let's dig into that a little bit more so explain what is available over the counter versus what requires a prescription in the state of Florida. I know it's probably different in different states.

Dr. Erich Schramm: 3:23

Well, fundamentally, if you look at the potency of Delta 8, it's about half as potent as Delta 9 in terms of its potential effects in terms of intoxication. The reason that it exists and became about from CBD is because at one point in 2014, we passed the Farm Bill, which allowed for the CBD industry to be launched, and during that time and over those many years, we had a big glut of CBD on the market, and so those CBD manufacturers were looking for products that they could potentially produce, and Delta 8 was one of those products. So it evolved into that space because it categorically is derived from the hemp plant, which has, by design, much less THC than a traditional medical cannabis plant. So that was the big divider in the products.

Dr. Michael Koren: 4:18

Now, in this area we talk about terpenoids and flavonoids, so tell us a little bit what that means.

Dr. Erich Schramm: 4:24

Exactly so. A big one, important part of the composition and the effect of the plant relates to terpenes. Terpenes are found in all plants it's the oils that give it its scent and taste, and in medical marijuana it's important because the different terpenes are important in driving different functions. Different effects whether it's sedation or whether it's antidepressant effects or whether it's an anti-inflammatory effect can have profound effect on things like seizures, and so it has an important part in guiding the effects of the plant. It isn't just that we have traditionally what we thought of as a sativa plant, which is a little bit more of a considered cannabis sativa, more activating strain versus, say, an indica plant, which is historically more sedating and can be used for relaxation. So it's true that those plant types can affect certain effects, but at the end of the day, terpenes have a huge impact on how patients experience the cannabis.

Dr. Michael Koren: 5:32

So it's almost like wine making you have different types of grapes and the effects at the end of the day are somewhat similar, but a little bit different.

Dr. Erich Schramm: 5:40

Exactly. So here is an interesting one. You can go online and exactly you can decide what particular strains suits you, whether it's a dessert strain, or whether you know it's a gas strain, or they have all these different types of strains for different types of effects.

Dr. Michael Koren: 5:57

Does sativa go better with meat and go better with fish or vegetables? Yeah, I would. That would be a great pair. I would think that would be a great pair.

Dr. Erich Schramm: 6:05

Yes, so yeah, but the flavonoids, t hey give the color and they provide also, i t's very interesting because they can have anti-inflammatory effects. They tend to have anti-anxiety effects, and the purpose of all those compounds is basically they protect the plant against insects and so it's their self-defense mechanism.

Dr. Michael Koren: 6:25

All right, so let's talk about why it works, why it affects our brains, and this gets into some research that you and I have worked on in the past. I remember a number of years ago there was a product on the market called Ramonobons. Do you remember that? Yeah, and so that was a product that actually blocked a CBD receptor, and we all know that when you stimulate CBD receptors, you stimulate your appetite, right, and the concept behind this drug was to block that receptor and reduce your appetite, right, and it did in fact work to reduce appetite and, as I recall, people actually lost weight when they took Rimonabant. But it was actually taken off the market in many jurisdictions and I think probably all jurisdictions at this point, because people became depressed when they took this drug. So it gets into the concept that we have receptors that are able to process the chemical signal from cannabis and cause effects in our body.

Dr. Erich Schramm: 7:24

Right and I remember when I first joined in clinical research Rimonabant was, it was about the time that it looked to have great promise. Ultimately, that turned out to be quite disappointing because a number of people that had considered suicide worsening depression committed suicide and it really gave people a newfound respect for what the CBD receptors are doing, particularly in the brain your CB1 receptor, and so it in fact it was a THC variant, so it was THCV, and the question now is and as a synthetic it had had that problem. Now the question is well, if you get that from the naturally derived plant, is it possible that this in the future could be still looked at as a potential therapeutic product for weight loss that doesn't have the significant effects of mind altering or potentially, you know, mood altering disturbances, and that's hopefully they'll might reconsider that as a possibility.

Dr. Michael Koren: 8:22

Yeah, so explain CB1 versus CB2 receptors for everybody, right.

Dr. Erich Schramm: 8:26

So CB1 receptor, the most important place it's found is in your brain, and to have a THC have an effect on that receptor, you know it has to get through the blood-brain barrier and so that allows for, i f people are saying, well, how, is that going to, you know, affect in terms of causing people to get high or intoxicated or what have you, then that's the effect of THC on a CB1 receptor in your brain. Now we have CB2 receptors too that are found in the peripheral nervous system. We have CB2 receptors that regulate a big part of our immune system, which is, which is hugely important, because when people start looking at and say, well, how does you know CBD, you know how does it do so many different things Anti-inflammatory can help your mood, it can do anti-cancer effects and you're going to say, because it's reflecting its effect on different different CB receptors that we have all over our body. So we have CB1 and two receptors in the gut, and so there's recently some development coming along that looks like at a product that may be affecting CB2 receptors in the gut to decrease, you know, acid reflux, irritable bowel and you know, a pharmaceutical company just recently invested over $6 billion to get access to that potential product. So, it's very interesting where, how these receptors show up, understanding at what point that you know certain types of products have the potential for intoxication. I don't like to tell people that they're going to get high. People are like, hey, I talk about the possibility, as a side effect is intoxication, and so understanding where the receptors are and the skin has both CB1 and CB2 receptors, which makes the skin a great potential source as a therapeutic source.

Dr. Michael Koren: 10:14

Yeah, and for our audience. It's important for them to understand that if your body has a receptor, it can respond to that chemical signal. So our bodies are programmed to be able to respond to chemical signals and they're receptors for a lot of different things. You know, for adrenaline, for opioid analogs, and certainly we now know that there are many receptors for cannabinoids.

Dr. Erich Schramm: 10:37

Right and we have our own natural. We have two natural endocannabinoids called anandamide and 2AG, and Ananda is Sanskrit for bliss, and so they figured this out.

Dr. Michael Koren: 10:48

So, it's.

Dr. Erich Schramm: 10:49

We're hardwired for cannabis and to understanding what the why do we have an endocannabinoid system in the first place? And it's balanced right. So this system evolved to provide balance to your whole body, whether it was the physiologic stresses, illness, infection, and so when you look at the potential benefits for cannabis, it spans a whole wide variety of disease states. So that's that counts for the widespread receptor system. It's kind of the master, you know I call it. It's the like at the airport, it's the control tower. It's running everything and regulating everything downstream.

Dr. Michael Koren: 11:27

So, Erich, thank you for those wonderful explanations. I think I'm ready to pass Cannabis 101.

Dr. Erich Schramm: 11:32

Oh man, you are right on top of that, Mike. I love it Okay.

Dr. Michael Koren: 11:35

I'm ready for the exam. So let's take a quick break and then we'll reconvene and talk about this from a clinical perspective who are the patients and how do you approach them?

Narrator: 11:44

Thanks for joining the MedEvidence podcast. To learn more, head over to MedEvidence. com or subscribe to our podcast on your favorite podcast platform.

Transcript:

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased evidence, proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:17

Hello. I'm Dr. Michael Koren and Erich and I had a fabulous session where we went over Cannabis 101. And I learned a lot.

Dr. Erich Schramm: 0:28

You passed the test. You got them all right.

Dr. Michael Koren: 0:30

That's right. I don't want to say my exact score on the quiz after the test, but I did pass.

Dr. Erich Schramm: 0:34

You might have cheated, I'm not sure, but you got it all right. It was all good.

Dr. Michael Koren: 0:38

So let's now look at this more from a clinical perspective. So you've now dedicated your practice to be focused completely on cannabis, is my understanding. You're not doing family medicine anymore and you're now basically a doctor that helps people use cannabis effectively. So tell us a little bit about your practice and then after that, let's delve into some patients that might benefit from the type of practice that you do.

Dr. Erich Schramm: 1:02

Right. So what inspired me to consider getting into the cannabis realm was so many patients that were looking for alternatives to traditional medications, primarily as in terms of maybe wanting to try to avoid certain side effects or just wanting a more natural approach to their health. And as a family physician, I consider myself to have a holistic approach to health and say, well, it isn't exclusively one side of medicine versus another. I think we can all peacefully coexist. But a lot of that, a lot of my incentive, evolved around being able to help patients outside of the traditional prescription realm and to that end. So this has brought a number of patients that come in looking for relief. Typically, the things that they're looking for treat a lot of sleep conditions. Meditating is very common anxiety, depression, so mood issues tend to be a big chunk of that practice. So it's an advantage to me is that I am no longer confined in terms of traditional medicine practice in which I have time to sit down and really talk with patients initial certification that I'll do an hour with the patient, providing them a lot of information about and a lot of education about the cannabis products and cannabis plans. So that's what has gotten me into this space.

Dr. Michael Koren: 2:31

Beautiful. So let's break it down very fundamentally for people. So I'm a cardiologist and I have a 60-year-old, moderately overweight woman that I'm treating for hypertension has mild coronary disease, but not necessarily symptomatic, and of course, in the course of my discussion with her she mentions that she can't sleep and that's really her biggest problem. So you should just tell her why don't you go out and smoke a couple of doobies and that should care of it.

Dr. Erich Schramm: 3:06

Yeah, yeah, I would refer to it as the smokable form of medical marijuana, and that is a possibility. People can get certified.

Dr. Michael Koren: 3:17

So take this case and tell me why I shouldn't just tell her to smoke a couple of joints and then go to you and I assume a more scientific approach. Okay, so go ahead.

Dr. Erich Schramm: 3:26

Right, and this is a pretty common patient actually. And what I tell a patient? Because that patient may come in and say, look, I don't want to smoke anything, I've never smoked my whole life and I don't want to start now and I say, well, terrific, we can accommodate non-smokable forms of marijuana. And to that end, they'll say, okay, what options there? And I'll say, well, a lot of people like to do edibles like gummies or tinctures, drops. There's a lot of different ways we can get and deliver a medical marijuana product that doesn't require smoking. The other thing is cannabis naive patients. Okay, and that's something that is important, because everybody that I see has a different level of experience, from none to frequent or regular use, and so for a cannabis naive patient, you have to consider that their sensitivity to the THC and those types of products is going to be potentially greater. And so you really have to direct them to not only like, say, a specific type of, say, an indica type strain which is your more evening relaxing, restful sleep, but you're also going to look at things that help to, things like terpenes and CBD that help to buffer some of the effects or the potential effects of THC for that patient, because too much of a good thing for a patient in terms of THC could be excessive THC could be heart rate palpitations, anxiety, bad dreams, so you don't want them to have that experience. So you have to consider products, especially balanced products, which ratio products, which means that they have both CBD and THC in it, because if you just give people a straight THC gummy, then you're going to have less than optimal effects. So I guide those patients to an edible and we could talk a little bit more about the different forms of canvas that are out there but I typically guide them towards an edible at a low dose to start with, and I would put a plug in to say that and I had seen a couple of patients this week who had this issue that I'd recommend also that you can get a good, high-quality CBD product at the dispensaries, because CBD helps to offset the negative effects. Negative potential effects for THC Interesting.

Dr. Michael Koren: 5:40

So you brought up a lot of things, so I'm going to unpack that a little bit in different ways. So you mentioned, for example, people that get palpitations, which, of course, is something I deal with all the time. So second case to throw out at you I have a 50-year-old person, again having sleep problems, but maybe related to sleep apnea, has a lot of palpitations and atypical chest pain, meaning it's chest pain that isn't something that is specifically related to coronary artery disease. I've treated them for coronary disease. We've worked them up. They have mild coronary disease, not zero. So I can't completely rule out coronary disease. But my sense is that more of their issues are related to anxiety and this sense of palpitations that are not specifically associated with a cardiac arrhythmia. So how would you process that person, given what you just told us?

Dr. Erich Schramm: 6:30

Okay, great, and very similar actually to a patient I was talking to earlier this week. And so, as far as palpitations, the heart has CB1 and CB2 receptors, and CB1 receptors are what part of that regulating that heart rate. And so if somebody tells me that two hours after dosing that they're getting rapid heart rate, then I know that's a THC effect. Now the good thing is for a patient with sleep apnea and I see a ton of patients with sleep apnea the great news for cannabis is it does not affect the brainstem breathing center, so you cannot. This is why you cannot kill people on cannabis, because you cannot sedate them to the point where they stop breathing. So cannabis is a great option for people who have sleep apnea because a lot of people, as you know, struggle with being comfortable with it. So to this patient, what I suggested to earlier this week, I would say, okay, back to considering. Okay, if you're going to do your bedtime gummy or a tincture, which tinctures last about half as long as a gummy about four hours. Gummies, edibles go about six to eight hours then I might say we might want to do a tincture. But again, it's important to have CBD in the picture here because it keeps the THC in check, which is good, and it's also has an anti-anxiety effect. So during the daytime for this patient who's going to tell you that they don't want to be impaired and they don't want to risk intoxication, then you would necessarily want to choose and I can talk about ratio products. But this is somebody that I'm going to be looking for a daytime high ratio, CBD, low THC, option 20 or 30 to one where they won't have any potential for intoxication, and then you know I can. Whether they need something a little bit more for stress relief, I can give them that. But in the cannabis world, less THC is better for anxiety. I see a lot of times people's anxieties can be made worse is really. THC is very dose dependent and so understanding how to initiate dosing in these patients is really important.

Dr. Michael Koren: 8:35

Interesting, interesting. So I'm going to give you a third case in getting into a little bit of this balancing concept. So now we have again these are all people that I would potentially see in my practice. So now we have, say, late 40s female who has a very strong family history of coronary disease and has familial hypercholesterolemia. So I'm treating their cholesterol. But we know that even women that have this issue are likely to get some degree of heart disease by the time they're 50. So she's a little bit anxious about that, but she's not symptomatic and we work her up. Fortunately she doesn't have any major cardiac issues, but she does definitely wants to stick with me because we're going to be very aggressive at preventing atherosclerosis through risk factor reduction. But she also is telling me about her irritable bowel syndrome and she also is very weight conscious and we know that weight has an effect on cardiovascular risk factors. So tell me a little bit how you balance all these things.

Dr. Erich Schramm: 9:48

Right, and so it all comes down to understanding what might be the optimal product. And I'm going to go back to talking again about ratio products because it's super important and, in this case, somebody who has having digestive complaints and cannabis is great for that. It's indicated for Crohn's and ulcerative colitis. It has great potential benefit for people with inflammatory bowel disease because of the anti-inflammatory effects and there are certainly understanding and the terpenoids that are involved and maybe helpful for her, and so that may select certain products that favor those kind of terpenoids. But at the end of the day, this would be a patient. How I would treat this patient is with a one-to-one. So I'm going to get a CBD to THC ratio product and the ratio is important because if you're worried about, hey, I don't want this person to get the munchies right, I don't want this person to come back and gain 10 pounds over a year, then I would be looking for a one-to-one ratio daytime product, maybe a hybrid something that or a sativa leaning product, because the other thing that a lot of these people don't have is energy, and so to consider how they can not just help their bowel symptoms, but how they can get through their day better with a little more energy. So a lot of times when I get people in the zone in terms of treatment, their energies are going to be improving. They get out, they start exercising, they get walking. So you're treating the initial problem, the main problem, but you're going to see a lot of benefits occurring in the periphery. So this is what I tell patients all the time. I say, look, I'm going to manage your stress, but we're going to get your sleep better. Or I'm going to help your pain, but you're going to sleep better. Or I'm going to help you with your digestive issues, but you're going to sleep better. Or you're going to have better daytime energy, but it's really going to come down to understanding how to deliver or recommend to them products that help to buffer the potential for weight gain.

Dr. Michael Koren: 11:45

No, those are some compelling situations where it sounds like you're able to help people. So let's get into the pragmatic just very briefly, and then we'll cover this in the next session in more detail. You write a prescription and they go to a dispensary, so what's the next step?

Dr. Erich Schramm: 12:00

Okay, so that's a great point. You cannot prescribe a scheduled one drug. How about that? So when people ask me, I'd say, well, I recommend those products. If I'm talking to a physician, I'll say we recommend those products because you can't legally prescribe a schedule one, and we can talk about that a little bit later. But the process is that patients will be often referred to their doctor, though you don't have to have a referral from your doctor. They'll come in and there's a certification usually takes about an hour. I get the records before they come in and we talk about the conditions that they may qualify. Some are unconditional. The state has 10 unconditional qualifying conditions and then there are other conditional conditions like insomnia, anxiety and certain pain issues that require we call it the same kind or class documentation where the providers put have submit scientific evidence that these are treatable conditions.

Dr. Michael Koren: 12:58

So we're going to take our deep dive into that specific area and in our next session I want you to walk me through the actual experience of somebody that comes into your office and has to go through this process.

Narrator: 13:09

Thanks, for joining the MedEvidence podcast. To learn more, head over to MeEevidence. com or subscribe to our podcast on your favorite podcast platform.

Transcript:

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:17

Hello, I'm Dr. Michael Koren.

Dr. Erich Schramm: 0:19

Hi, I'm Dr Erich Schramm.

Dr. Michael Koren: 0:21

And Erich and I have been having this fabulous conversation about cannabis. In our first session we talked about cannabis 101, just basic terms and understanding why, theoretically, it's effective, and then in our second section we talked about actual patients, where you make a difference. So that's pretty cool, yeah. So now in this session I want to really get into the practicality of it. Like how do you go from me referring a patient to you or a patient learning about your practice and presenting with a medical problem and that person actually walking out with the right product? So let's kind of walk through it step by step. So we gave many examples in the last session of people with anxiety or palpitations or irritable bowel, inflammatory bowel disease, and all those folks could benefit from your services and the products that you'll help them get. So how do they get them? So you make your decision, you know they need a balanced product and then explain exactly where you go from there.

Dr. Erich Schramm: 1:18

Okay, so the guidelines are set forth by the state, which is basically the legislature. So if somebody asked me and say, well, why do things go a certain way in this process? And I'll say the legislature made that determination. And then I remind them that the legislature is not stock full of scientists and physicians, so the way the process is designed is in that context. Now, I still think it's a pretty functional system, but it does the way that its structure is based on what the legislature has put forward. So when a patient determines or decides that they're going to do a certification, then I'll reach out to them and, as a new patient, they'll fill out a new patient.

Dr. Michael Koren: 2:01

So certification makes it legal for the patient to use cannabis in the state of Florida?

Dr. Erich Schramm: 2:20

And then a patient will then either bring the records or they'll sign a medical records release so that I can actually have those records, because you do want to have those records, and then they fill out the medical records from their physician. And then so they'll come in and we sit down and we have a great discussion about well, tell me about any of your previous experience with cannabis, because that can predict what kind of products that they may lean to, because if you have someone who's a seasoned cannabis person, those ratio one to one products may be low potency. But if it's a cannabis naive patient. Those are high potency. You have to understand their background in terms of what they've had in terms of cannabis.

Dr. Michael Koren: 2:58

And are there available products? One to one, two to one, three to one? Is everything out there, or tell me a little bit more about that.

Dr. Erich Schramm: 3:05

Yeah, and so out there in the dispensary world. So once you get certified and we talk about the medical card, a person can walk into any dispensary in the state and get product and there's 22 different businesses as dispensaries in the state, so you can get just about any product in any dispensary. So you, but not every dispensary is created equal. Some tend to gear a little bit more to the recreational users and then some tend to gear towards the medicinal user, so ratio products.

Dr. Michael Koren: 3:33

But the recreational users still need to be certified?

Dr. Erich Schramm: 3:39

Now, in this medical marijuana practice I'm seeing medical patients, and so the typically the first thing the medical patients come into say hey look, don't get me high. I'm looking for relief, so understanding where those dispensaries are and what those products are. So when a patient comes in, of course I want to know what their concerns are, what their problems are, what do they want to get out of that? What would be the ideal situation for them? Oh, you'd like to sleep through the night. Oh you'd like to get through your day without pain. Oh, you like to have less stress. You want a better quality of life. Okay so understanding what they want to get out of that. And then so I submit whatever necessary documentation you have to the state's assigned a seven month period for your certification. Okay, the card. So once I put in orders, say you have now access to your products, the state will send you out emails so you can get registered that you can get your card, which is good for a year. So your certification good for seven months, card good for a year, and once you get your card then you can go off to your dispensary and get your product. And now the state has it so that you can do your certification and you get your card registered on the same day, so people can be in the dispensary that night, and so it's a nice system that they just developed in the last two years.

Dr. Michael Koren: 5:00

So, in terms of your interface with the system, do you send an electronic prescription to the dispensary? Do you give patients a piece of paper? This is my recommendations, or how does that play out?

Dr. Erich Schramm: 5:12

Okay, as far as the process, your driver's license is linked to your medical marijuana certification. So when you punch in and people will put in, you have to submit your driver's license number, your social security number and based on that then it'll identify you through the driver's license database, which allows you that when you'd get your certification even though it may take two weeks to get your card you can use your driver's license on the same day because in the you're creating right. And it isn't that you're providing a certain specific prescription. You're just setting basic parameters in terms of how much edibles or orals or inhalants or flower or topical that you're assigning, and you can determine how that's going to be and then they can go. It's like you're putting money in a bank account and then they can go and draw out of that, depending on what kind of products they do. What I provide for the patient is a detailed written. I have basically different sheets which are the product outlines for all the different dispensaries here. So if I know a patient needs a certain type of product, I'm gonna say underline, highlight, I'll write the dosing recommended on that. So when they leave they have a sheet or two of paper that'll be specific. They go to the dispensary, they show the person the dispensary, because I tell patients I say the dispensary knows their products but they don't know you as a patient and I don't want them to be the person recommending your products.

Dr. Michael Koren: 6:45

So in your written recommendation for the patient you'll say if an oral versus an inhaled product is better, I assume, and give them information about ratios.

Dr. Erich Schramm: 6:57

Right, so what? I try to gauge for that, and so If you inhale cannabis, you get an immediate relief. So patients will utilize this, like people with migraine headaches where there's a compelling need to have immediate, more immediate relief. I saw a patient who is having like spasticity problems and does great having something that's more immediate. But when you inhale cannabis it's going to be good for two or three hours. If you do an edible, the onset for that's about an hour 45 minutes, sometimes two hours, which are going to get eight hours. So, understanding what type of relief you're trying to offer a patient tinctures give you about four hours relief. The oils under the tongue onset at about 30 minutes and then there's topicals, which are another option too. So when a patient goes into the dispensary for, say, a first time, a lot of times there's discounts being offered because those dispensaries know first time patient, hey, they're going to be trying a few things. So it's a great time. And right now I've seen the prices in the dispensaries because the insurance doesn't pay for it has actually come down in the last six months. So there's a great time for new patients coming into the system because they're getting discounts, they get a chance to try these different products. And then I schedule follow up at three or four weeks because you can't just let the patient say here, try this and get all see in seven months. So we get a three or four weeks to understand where those products are sitting. For that patient, make adjustments if they need to go somewhere else to get those products, but that's the way that I set up my practice.

Dr. Michael Koren: 8:26

So one of the concepts in standard medicine is that you like to try one thing at one dose for a period of time and see how the symptoms respond to that, or whatever the parameters you're tracking responds to that. Is that something similar to how you approach things?

Dr. Erich Schramm: 8:42

General guidance. Yes, and I'm conservative because everybody, especially cannabis naive patients, are going to start on the lowest dose, so maybe a quarter dropper or maybe a third of a gummy. So I try to be very specific on how we start a dose. But I will tell that patients as I look, because everybody's different in their sensitivity. They'll say well, if you've tried it at this dose for a few days, you can go into the next higher dose to half dropper or full or half, however that you feel that you're comfortable to utilize it. Here are the potential side effects you might be looking for. But I try to give them some guidance, if anything. When I do follow ups patients if there's one thing that they just could better optimized as their dosing because people are generally hesitant to go to higher doses- but, I try to reassure them. I say, look, you really are not going to get dependent on this, it's not going to be addicting, it's not going to cause mind altering effects. So we try to get them to feel more comfortable. After three or four weeks the patient realizes okay, I'm getting more comfortable with their products and they can start to be more comfortable.

Dr. Michael Koren: 9:43

You may have an increased desire to listen to Pink Floyd. Exactly right, right right right. I'm getting those old headphones out you know, but otherwise you should be pretty safe. So to that point, let's just talk about some of the pragmatic things. Can you drive when you're using cannabis products? What are the recommendations for that?

Dr. Erich Schramm: 10:01

Okay, that's a great question. And so what I tell a patient? I said, look, the whole premise of this practice and these recommendations and products is non-intoxication. Now, if it's a bedtime product and I'm trying to get you to sleep, then that's a different discussion, because your bedtime product, nighttime product, you know, I'd say, think of it like what if you were to go out to dinner and you decide you're going to have four glasses of wine. What do you think you might expect? Sure, sure and same thing. So when you're using a product you know as a potential for intoxication has to be used intelligently. Daytime products, by design, are intended to be non-intoxicating, so you know again. This is why I favor higher ratio products 20 to one, 15 to one, 30 to one as a daytime product.

Dr. Michael Koren: 10:46

CBD to THC Right.

Dr. Erich Schramm: 10:47

Right. So you're really pushing those kind of products and I tell a patient I say if in a doubt you know you can, if you're going to have a concern about the effects for a daytime product, take the product on a day you're not driving anywhere then, you can gauge that and so, but for most patients it really isn't going to become an issue.

Dr. Michael Koren: 11:03

Okay, how do police officers assess this? I don't think they have a blood level test that they do. Yeah, do you blow into something and find out what your cannabis level is?

Dr. Erich Schramm: 11:19

There may be something out there in the works for that, but I'm not aware of it. And, quite honestly, you know my experience is with because I've taken care of a lot of law enforcement patients not cannabis patients necessarily but they have zero interest. Zero interest in pursuing patients with medical cannabis card. Now, if they person is being pulled over for apparently driving under the influence, then yes, you can get arrested or get a ticket for driving under the influence, but they have zero interest in wanting to pursue patients with medical cards, and I think the last federal raid on a cannabis dispensary was in 2009. So the federal government has no interest in going after patients with medical cards.

Dr. Michael Koren: 12:08

So how about, like traveling to different states or different countries? How does that play out?

Dr. Erich Schramm: 12:13

Well, I tell a patient, you know so? The TSA came out and said we are not a drug enforcement agency, but if we come across your products we've got to do something with it. So what I tell a patient? I say, if you're going to go on a domestic flight, put it in your checked bag. Okay don't carry it on. And don't take it out of its original packaging. So if you're going to be driving from state to state, I said just make sure you leave it in your original packaging. Because most places don't again don't want to have anything to do with that. But if you take, you decide that you're going to put your gummies into a Ziploc bag somewhere and try to carry that around that could be a problem, but for the most part I tell them you know you really shouldn't run into any problems with this.

Dr. Michael Koren: 12:56

So you don't advise hanging them in a bag that drops down from your rear view mirror.

Dr. Erich Schramm: 13:03

Correct. That would be a bad idea, right. Theoretically, you really can't be out there using cannabis products in public. That's not the intent of law, so yeah they don't want to see that.

Dr. Michael Koren: 13:12

Okay, so final question for this session how long should patients anticipate needing to wait before seeing the effects of your recommendations?

Dr. Erich Schramm: 13:21

Oh, it should be pretty much right away. You know, the first couple of few weeks is really that initial period to see how sensitive patients are to THC. It comes down to it. But as far as you know, especially for like pain relief, it's pretty quick and, you know, as far as helping to get people to sleep. Likewise, it shouldn't be the case that you know three or four weeks down the road people are questioning whether it's working. If I get that question, then I have to consider that they're just underdosed and say, okay, well, this is why we do follow-up. So then I can say, okay, well, you need to consider how you know you're being dosed with the product.

Dr. Michael Koren: 13:59

Beautiful. Well, you answered all my questions, so we'll end this particular session, but I want to explore with you in the next session future research and what we can expect over the course of the next five years with regard to cannabinoid research, and how the government may change its policies.

Narrator: 14:16

Okay, thanks for joining the MedEvidence Podcast. To learn more, head over to MedEvidence. com or subscribe to our podcast on your favorite podcast platform.

Transcript:

Narrator: 0:01

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased evidence, proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:16

Hello, I'm Dr. Michael Koren.

Dr. Erich Schramm: 0:19

Hi, I'm Dr. Erich Schramm.

Dr. Michael Koren: 0:20

And Eric and I have been having this fabulous conversation about cannabis and we've had three previous sessions where we covered a lot of the nuts and bolts, and so now we want to talk about the future, and I'm a clinical trial guy, I'm a research guy, you're a research guy, and so we always like to let our audience know what's going to happen in the future and also what's the evidence for the information that we're providing them. So we alluded to the fact that the endocannabinoid system has been studied in clinical trials and we've learned a lot, that you have a lot of clinical experience and certainly you have helped a lot of people, and the question is how we take all this information and standardize it. So we know that this works more often than not for this type of patient. So I want to get into that with you. And, of course, part and parcel of that is the government and how they're regulating this, and that probably, at this point, just makes it more difficult to look at this from a scientific standpoint. But it is what it is and I'm very curious to see how that might change in what's on the horizon for this type of research. So why don't you start us off by explaining this concept of why cannabis was illegal previously and why you can use it now, and those concepts about drugs that are scheduled.

Dr. Erich Schramm: 1:44

Right, so first of all, scheduled. One drug is a drug that has no recognized medical use and a high index or potential for abuse and, in that context, an example of that like LSD, heroin, mushrooms, psychedelics, so those are your classic scheduled one drugs. That was the Control Substance Act of 1970, which a lot of people are familiar with. And so what that did? It basically puts those products, those drugs, those compounds into a sort of prohibition and out of that it makes it, from a research perspective very challenging, because it's to be able to do meaningful, quality research on cannabis or any scheduled one, there are a lot, a lot of hoops to have to jump through, and that includes the DEA, the FDA, et cetera, et cetera. And so research, a lot of that research has gone overseas. So there are, when we see the research papers they are forthcoming, a lot of that has moved to be overseas. The government had for a long time, very interesting one single farm in Mississippi where all the investigational marijuana joints were produced.

Dr. Michael Koren: 3:05

Really, then they had a special license by the government?

Dr. Erich Schramm: 3:06

Yes, absolutely. So they carved out and they're still there. It's in Mississippi, so that's the government's version of this and so this gives you an idea of kind of the culture. And so it's certainly been a big has hampered a lot of issues to keep people getting in and doing this research. Not to mention that when people get into doing the scheduled one or scheduled two space because people say, well, hey, isn't all these cannabis places they must be making a killing right? Money, hand over fist and then I'll say, well, the trouble is, if you're going to do business in schedule one and schedule two, you don't get any tax breaks.

Dr. Michael Koren: 3:48

So just explain to people what schedule two is versus schedule one.

Dr. Erich Schramm: 3:51

So as you get less scheduled, then it's more accessible and so less restricted, and schedule two are going to be your. Cocaine would be schedule two. Cocaine is schedule one.

Dr. Michael Koren: 4:00

Well, cocaine is used medically.

Dr. Erich Schramm: 4:02

Well, but historically, most of the common schedule twos are going to be your narcotics and stimulants. In fact, it means like your Adderall derivatives and things like that.

Dr. Michael Koren: 4:12

Because there is a medical indication for cocaine, right. Yeah, bleeding noses, right, things like that, ironically so but the problem.

Dr. Erich Schramm: 4:21

So if you're the high tax burden on companies that do business with schedule one or schedule two, so the cannabis companies aren't necessarily making a killing on this and so, if you can, if they were no longer scheduled one, then it opens up the potential for people who are considering investing.

Dr. Michael Koren: 4:39

It opens up to banking and opens up to, Just for the audience, schedule three. What type of drugs are those?

Dr. Erich Schramm: 4:46

Schedule three is going to be along the lines of ketamine, testosterone, tylenol with coding eubrenorphine, and that was the big news over the summer was that the administration had sent an application to the DEA for rescheduling cannabis from one to three. And would be very possible in the next 12 months that that might occur. Schedule four Xanax sleeping pills.

Dr. Michael Koren: 5:13

Okay. Along those lines and there's a schedule five as well, if I'm not mistaken. Yeah, I'm not sure what those are Okay.

Dr. Erich Schramm: 5:18

Is it just everything else? Anything?

Dr. Michael Koren: 5:20

else those are? Say what drugs that don't need any special consideration? Right, Is that right?

Dr. Erich Schramm: 5:24

Right and I think, a lot of the but the trouble is, I think, with people look at that and say, well, look, you can't kill people on cannabis, so you put it down as a schedule three and you know, and so you know what gives there, you know. So it's just it's. It is not currently likely that cannabis was going to be de-scheduled, in which people would hope that it'd be quote, you know decriminalized and you know, then it would just be, you know, adult use or what have.

Dr. Michael Koren: 5:49

Right Right Now, there are cannabis products that are on the market that are manufactured by pharmaceutical companies, as I understand it, for cancer, pain and things. Any comment about that?

Dr. Erich Schramm: 6:02

Right, you know. So you know. These products have been out there, merinol, and they're all derivatives. They've been around forever but, they're primarily being used for nausea and vomiting or anorexia associated with.

Dr. Michael Koren: 6:14

And they're scheduled to, I assume, similar to narcotics.

Dr. Erich Schramm: 6:18

Not sure how they're scheduled on that. Probably something along those lines.

Dr. Michael Koren: 6:22

Okay, we'll look that up and put it in a show note.

Dr. Erich Schramm: 6:26

So yeah, and and Sativax and some of the other products that are being derived are being developed on the are cannabis based and they're more recently being that.

Dr. Michael Koren: 6:38

But Right, so talk about the research. What, what do you predict? What's going to happen over the next five years?

Dr. Erich Schramm: 6:44

That's a great question, and one of the things that I've looked at is and I mentioned how you know, the big pharmaceutical companies have invested a lot, and they you know, the top five patents in terms of cannabis is amongst the big pharmaceutical companies, and I mentioned Pfizer's purchase of a. They bought Arena Pharmaceutical of 2021. And they're very much interested in their product. So, you know, if the tax burden is lifted and the regulatory burdens are lifted because they're no longer having to be comply with schedule one and schedule two requirements, then this seems that this would be an ideal opportunity for whether it's going to be big pharma or, you know, you know big investors, big investors to come in and and and get into the space. But it seems that it's going to be an opportune time because, as you know, we, we both know that, if you know, it's one thing to do a study anybody can do a study but if you really want to do a good quality study, a large, you know, randomized, placebo, controlled study, you know it takes a lot of resources for that to happen. So that seems like that could definitely be on the horizon, right.

Dr. Michael Koren: 8:01

And and for all of the controversy about big pharma in terms of of high drug prices, you have to give them credit for spending a lot of money to learn things. So we're all fortunate that big pharma is willing to invest a lot of money so that we actually understand evidence, we understand the truth behind the data, and so we use that in our day-to-day decision making for our patients. And the fact that pharmaceutical companies are getting into the space should allow us to know a lot more about how cannabinoids work, how they can be deployed most effectively and safely. So I think we have to at least tip our hat to a big pharma for that.

Dr. Erich Schramm: 8:40

Yeah, no, I think, I think any, I think. Once that space opens up, I think we're all going to get a lot out of that. I think the challenges have been you know, historically in research that you know a compound is developed as, and it has an action at, a single receptor. So we're looking, single compound and a single receptor and you know marijuana really doesn't fit that model. It's multiple components. And so how to navigate products, how to get into that space that accounts for all the different components of that, the terpenes and the different cannabinoids that are out there, not just CBD but CBG, cbn, all the different variations of cannabinoids that are out there. It's a great space in terms of the science because there's so much to learn from that Right.

Dr. Michael Koren: 9:33

That's a really interesting point. So I've had conversations in the past, especially in the old days, when I was a single guy and meeting somebody at a bar and I would ask her if she would want a beer or wine or a hard drink, and she might say, well, I only drink vodka because otherwise I get a headache, and I would always be skeptical about that, saying, well, alcohol is alcohol. If you get a headache from alcohol, it shouldn't really matter what you're drinking. That was the scientific thinking and maybe that's not necessarily true. Maybe there are other components of these things that are more holistic but that could also be studied. So we can certainly do studies where we look at one strain of marijuana versus another strain of marijuana and see whether or not one is better than the other, for whatever the particular diagnosis is. So this gets in the concept of what you're mentioning in terms of a receptor and a chemical receptor versus the interaction of all the different ingredients for products.

Dr. Erich Schramm: 10:29

Right, and that's actually called the entourage effect. So if you read much in the cannabis space, you often hear that talked about the entourage effect. And that is true because the benefit, the efficacy of the plant is much greater from its total rather than just the individual components.

Dr. Michael Koren: 10:48

But ultimately that could be studied as well, based on the study design. Absolutely.

Narrator: 10:51

Yeah.

Dr. Michael Koren: 10:54

So what are your predictions in terms of where your particular niche develops? Is this going to become something that family physicians become more comfortable with, more involved with, or do you think it's going to remain a more established subspecial to?

Dr. Erich Schramm: 11:11

Okay, that's a great question.

Dr. Michael Koren: 11:13

And.

Dr. Erich Schramm: 11:13

I've given that a lot of thought. My answer to that question is going to be that, if it is rescheduled, that there's going to be greater access and that's the reason why they're doing it and then be able to actually prescribe cannabis. Now my experience, having spent a lot of time doing physician outreach and talking to physicians, is that most physicians really don't know very much about the endocannabinoid system, and I graduated med school in 2000,. Didn't learn anything about it, even though in the 1990s they were really understanding a lot of the endocannabinoid system. But I didn't learn it, and so I think it'll take if it ends up scheduled three, then it means that it could be tested on the boards and that will compel then. For we look at our teaching institutions, okay, well, look, now we have to incorporate cannabis as part of that medical education. So I mean and I saw a few other confirmsors doing that went in that MYT watching website or I heard, but that's going to take probably another five years, 10 years, I don't know. So eventually, yes, I think it'll get to a point where patients will be getting prescriptions, but at least, upfront, I perceive it as still being. I mean, I consider myself as a little bit of a specialist, and so there's, I think a lot of physicians that I speak to and work with see it in that fashion. So I think, more immediate, yeah, I think it's going to be looking more like a specialty, but eventually I'd hope that would open up to broader Interesting.

Dr. Michael Koren: 12:39

And my other question is do you predict that the dispensaries will be more regulated in terms of having to disclose exactly what's in their products? So here, for example, one of the standards of the pharmaceutical industry, both over the counter and prescription, is that there is an accurate list of ingredients. So if you buy cold medicine, it could have more or less hand to histamine, more or less ibuprofen or cinnamon, et cetera, but it's a law that requires that this product has this proportion of things and it's sold as that product. Now my understanding is that the dispensaries aren't quite there yet with that. Or am I wrong about that? Or is that regulated, or will it become regulated?

Dr. Erich Schramm: 13:22

In this state, every product that is sold into dispensary has to go through a certificate of analysis. And that is rigorous. So they're testing at least probably for 50 different things, including contaminants, insecticides, and then they test the integrity of the product. So is the product have what it says it has? And is it the THC level? And they do. Are there terpenes present? So when patients ask me about the safety of products, let's say somebody says what about vaping? Is a vape safe? And I'd say, well, if it's coming from a medical dispensary, I'd feel much more comfortable to say, okay, that's a reasonably safe product because it's been tested. But it's things on the street. Same with CBD. I'll say, well, look, if you're getting something on the street or at the gas station, hey, you're on your own because that stuff isn't being tested. So I feel very comfortable with the products that people are getting through this day, the dispensary. That's why, when patients come in because I would, and I joke a little bit with some of my patients and say, let's say, getting back to the old school days, right, and I said, okay, remember when you were a kid or in high school or whatever you know, the strength of the marijuana back in the day in the 60s, 70s and 80s is about a single digit five, seven percent THC. And so I'll tell a patient now I say, look, if you go in and buy a marijuana joint, that percentage is gonna be 18, 25%, especially for my older patients. Let's say, look, this isn't like the good old days. So really it does not take much. And these products, especially related to the purity of the products and the potency of the products, can't be. You don't wanna underestimate that. So I always tell patients let's say, well, look, this is why you gotta really start off with low dose. But yes, the products of this Florida Dispensies are vetted and a lot of this is grown in greenhouses. They go to a lot of great lengths because if one of the products has a problem they're gonna have to pull all the products off the shelf and that cost them a million dollars. So it's rigorous quality control from that standpoint here.

Dr. Michael Koren: 15:37

Erich, I so much appreciate the education. I've learned it an incredible amount and hopefully our listeners and viewers will get the same out of it. And good luck with your cannabis practice and keep it the great work and keep on providing evidence so that we can help our patients.

Dr. Erich Schramm: 15:53

Thank you, mike, for everything you do and allow me the opportunity to be here, and I'm happy to come back anytime you wanna talk any more about this. Good work, my friend, yes.

Narrator: 16:04

Thanks for joining the MedEvidence podcast. To learn more, head over to medevidencecom or subscribe to our podcast and your favorite podcast platform.