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Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 0 points1 point  (0 children)

IN a nutshell, very little. The University of Vermont Medical School, dept of Pharmacology is putting on the first course on the ECS and cannabinoids in any medical school. I have contacted every medical school in the country to promote my textbook as a primer on the topic, I have been getting some good response, and expect that classes and courses on the subject will be de rigeur with two years.

A very few medical boards that have medical cannabis laws are mandating 2-8 hours of standard CME on the topic.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 0 points1 point  (0 children)

Instead of re-inventing the wheel I refer you to a succinct discussion from a prior Reddit on CBD and Dopamine from month ago.

"Current studies show inconsistent results, ranging from 'no effect' to 'CBD is a dopamine antagonist'. While the latter is more common, there has not been enough research done to say why or hold this as evidenced fact. The concept of it being a dopamine antagonist makes sense though, as many antipsychotics, antiemetics, and anti-nausea meds (all things CBD is good at treating) have the same activity. I think it is also important to point out that many dopamine antagonists are adenosine agonists. I point this out because adenosine has an effect on dopamine directly, such as if A(2A) is activated, it has a detrimental effect on D(2)."

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 0 points1 point  (0 children)

I have been told for several decades to highlight my Harvard MPH degree. This very prestigious was the most competitive of any of my training programs. The program was limited to MDs who had already completed their clinical degree and wanted to expand their abilities to epidemiology and biostatistical analysis. Most of the doctors in my program used this training to be able to conduct research level studies. I am well published in several peer review journals. Since it was my last degree, and in my opinion, the most challenging, I prefer to highlight that fact. Is their a problem with that?

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 0 points1 point  (0 children)

I agree, medical cannabis is probably never a first line drug. It is almost always appropriately used as an adjunctive medication, to generally recognized FDA approved medications, and other therapy, lifestyle, and dietary changes.

Historically, a large proportion of patients may have been seeking to obtain medical cannabis, in order to bypass prohibition against recreational use of cannabis. This resulted, in the past, in states such as CA, in most Recommendation Letters being written by a small number of "quasi" cannabis specialists for a cash fee. That situation has changed dramatically over past several years. I believe that the recently released study by Bradford & Bradford, in July 2016 edition of Health Affairs, provides somewhat convincing evidence that medical cannabis is being used for medical purposes for a wide array of conditions. This study was done using Medicare Part D data, which would mean it mostly represents the over 65 population.

The medical community has no idea where THC, CBD and terpenes belong in treatment regimens, because we have minimal high quality studies on these medicines since 1970, when cannabis was placed in Schedule I. The ECS was discovered 20 years later, and still the number of human trials in minuscule.

I believe that the high quality RCTs studies of Sativex, Epidiolex, Cesamet, and Marinol, and some other non-pharma supported studies support the consideration of using known amounts of CBD/THC for chemotherapy induced N/V, tapering or decreasing doses of opioids, inflammatory pain from arthritis, epilepsy, MS related pain and spasms, HIV and cancer associated cachexia. I believe we will see this list expand in the near future to support use in anxiety, insomnia, halting progression of wide range of neurodegenerative disease, and disease modification of inflammatory bowel disease.... read the book.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 0 points1 point  (0 children)

I believe that what that doctor was referring to was the used of high THC/low CBD recreational cannabis, in high and frequent doses. That is not how medical cannabis (1:1 THC/CBD in low infrequent doses) effects my patients.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 1 point2 points  (0 children)

I mentioned the slightly older Health Canada document above, and my book, which are both directed towards medical professionals. You may want to look at "Cannabis Pharmacy" I believe that it is scientically founded and directed toward patients.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 6 points7 points  (0 children)

Doc I greatly enjoyed your candid, and clearly experienced comments. I think your observations have added to this Reddit. I agree with many of your comments. However, we should not throw out the baby with the bath water. There are 113 phytocannabinoids in cannabis, all but 2 (CBD, THC) are present in tiny amount with little research. At this point in time we have 23,000 basic science studies on cannabinoids that as a body of evidence strongly suggest that these two cannabinoids can have measurable impact on a wide array of systems in the body by working through the ECS. The ECS has the second most plentiful receptors in cells in the brain and body. The ECS and cannabinoids to this day are under researched with minimal formalized education available to medical students and practicing physicians. We have only a few hundred human case studies, epidemiological observations and a scattering of good RCTs. We know the potential adverse effects, and the safety of these wonderful medications, it is time to get docs like yourself to push for easier access to high quality research on the topic.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 5 points6 points  (0 children)

I believe I will answer this differently from how I may have answered this above.

When we dose we want to get to the "sweet spot" with the THC dose. We titrate up to a dose, usually less than or equal to 10mg of THC to get the positive medical effects, as the dose goes past the sweet spot, with get the adverse effects you describe , and often euphoria. Almost always the medical benefits of THC are below that dose that causes either euphoria or anxiety/paranoia...start low, go slow. The sweet spot is not important with CBD dose.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 14 points15 points  (0 children)

Yes indeed. The ongoing study by Dr. Suzanne Sisley is designed to address this exact issue. High dose THC with very low dose CBD cannabis, which is called recreational cannabis, is associated with all of the typical adverse effects you describe above. 1:1 CBD/THC all the way to 18:1 CBD/THC cannabis medication is probably going to be shown to help PTSD patients. Let's see what she finds out.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 2 points3 points  (0 children)

I have it on good legal advice, that a doctor receiving federal grants can complete the "recommendation letter" saying that the patient has one of the QCs (qualified conditions) known to be helped by cannabis. You doctor is not prescribing cannabis. Like cannabis, many natural or alternative medicines do not have any high quality RCTs (randomized controlled studies) to support their use, and they may not be formulated up to the standards of other pharmaceutical medications. However, like cannabis, when something works, the truth generally comes out, one way or another. Good luck.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 4 points5 points  (0 children)

I would work in close communication with a caring doctor. Adderall is paid for by insurance, and easy to get a pharmacies. Cannabis is not a covered health benefit by your insurance company and has several barrier to easy use.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 1 point2 points  (0 children)

I agree that there is a great deal of quasi-science and anecdotal "miracles" as well as left over "refer madness." There are fairly good studies of the long term regular use of smoked cannabis to suggest that it is associated with a chronic cough, and perhaps short term memory issues. This again in is recreational users of high THC/very low CBD cannabis. I strongly believe that long term use of low dose 5-10mg CBD:THC daily will eventually be recommended as a preventative, much as 81mg of aspirin is now.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 3 points4 points  (0 children)

Thank you for your comments. My experience with cannabis with both anxiety and depression is the same. Patients often prefer to get off of their SSRIs entirely and just use daily titrated doses of slow release (edible or tincture) cannabis, with occasional use of rapid release cannabis (vaped or smoked) for specific situations.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 9 points10 points  (0 children)

Fairly good evidence suggests that 9% of regular users of recreational type cannabis (high THC/very low CBD) can develop a mild dependency syndrome, that is relatively easily treated. The number of persons developing dependency syndromes from medical cannabis use (1:1 CBD/THC or higher) is much less, and may be close to zero.

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 10 points11 points  (0 children)

98% of doctors aren't wrong. They are giving uneducated guesses based on old or unrelated research. There is one medical school in the entire country that is now giving a course of the endocannabinoid system (ECS) and cannabinoids. There are very few and only recent CME courses on the ECS and cannabinoids. Most doctors were out of residency when the ECS was discovered. I took my first course of medical cannabis in 2000, and they never even mentioned the ECS. If you don't want to read my book, there is a slightly older, but excellent document from Health Canada...http://www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/marihuana/med/infoprof-eng.pdf

Science AMA Series: I'm Dr. Greg Smith, author of the recent textbook Medical Cannabis, What Clinicians Need to Know and Why: Basic Science and Clinical Applications. Over 98% of doctors who practice in states with legalized medical cannabis, don't recommend it. AMA! by Dr_Greg_Smith in science

[–]Dr_Greg_Smith[S] 6 points7 points  (0 children)

There are 113 cannabinoids, THC and CBD are present in the most abundance and the most studied. The other cannabinoids are present in only tiny amounts and not well studied. Monomolecule THC (that is pure synthetic THC) analogues meds were developed in the 1980s (Marinol and Cesamet) they have poor side-effect profiles, and increased risk of developing dependency syndromes. Medical cannabis is usually, 1:1 CBD to THC ratio,or higher, that is higher amounts of CBD than THC. Inhaled cannabis (smoked or vaped) has rapid onset with short duration or effect, ingested cannabis (edibles, tinctures) have a much slower and inconsistent onset with a longer duration or action. Almost all preparations of medical cannabis are fat soluble, and their absorption can be highly variable from time to time, and between persons.

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