The Hotflash inc podcast

76. Dr Mikhail Kogan: Medical marijuana + menopause

June 02, 2023 Ann Marie McQueen Episode 76
The Hotflash inc podcast
76. Dr Mikhail Kogan: Medical marijuana + menopause
Show Notes Transcript

Dr Mikhail Kogan came to medical marijuana via his work as a geriatrician at GW Medical Faculty Associates and as an associate professor of medicine at George Washington University School of Medicine & Health Sciences in the US. 

He co-wrote one of the most comprehensive books on the subject of cannabis in health care, Medical Marijuana, published in 2021. Although he’s not a menopause marijuana specialist (no one really is, yet), he has really helpful insights as to why the research still needs to catch up with what doctors are seeing in patients, coffee is more addictive than cannabis, and what “going low and slow” really means when it comes to experimenting. 

He joined us as part of last year’s Menopause Shift Summit, and if you didn’t catch him there, you can catch him here. 

Highlights:

  • Why cannabis can be a ‘godsend’ for older adults
  • Whatever medical problem we can think of, cannabis has a role 
  • A reminder that cannabis was the most heavily used medicine before the 1930s 
  • A look at our body’s own unique ‘endocannabinoid’ system – what he calls the oldest hormonal system in our body
  • The potential role of reductions in that system in our perimenopause experience
  • The myth that there is no cannabis research – and an overview of what that research shows
  • His prediction about cannabis for Alzheimer’s and Parkinson’s
  • Low-and-slow and the ‘J curve’ and dosing 
  • Why he says the cautionary advice over cannabis from addiction specialists is very different from medicinal applications 
  • Back to myths, he’s also talking about medical marijuana and addiction
  • His top advice for what and how to buy

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I think that it's such a profoundly underutilized, plan that have literally touches beneficially every aspect of our living and our health and menopause is not any different

Ann Marie:

Hi there. I'm Annemarie McQueen, a menopause in midlife journalist. I have 25 years of experience covering science health, and. And I created hot flashing to inform, inspire, and entertain people who go through pairing menopause and menopause, and the people who care about them. This podcast brings you interviews with scientists, doctors, practitioners, entrepreneurs, thought leaders, and more. In the end, our menopause experience is about so much more than ours. Symptoms. I think it's a total and complete mind, body, and soul shift. It's taking radical responsibility for every single part of our lives. It's becoming who we were born to be. It's nothing short of a hero's journey, and I am here walking the path right beside you. We're gonna have fun.

Today I'm speaking with Dr. Mihail Kogan, an integrative geriatrician. He's the co-author of the 2021 Buck Medical Marijuana, Dr. Hogan's Evidence-Based Guide to the Health Benefits of Cannabis and C B D. Dr. Kogan walks people through how they can safely use cannabis and C B D to treat many of their health issues, and that includes the symptoms you're experiencing as part of perimenopause and menopause. Hi, Dr. Kogan. How are you today? Hi. It's so wonderful to be here. This is a very emerging part of this story, and so I really wanted to get you on because you literally wrote the book on this last year. Yeah, I, I did. Here, it's there. It's medical marijuana. It's. Um, okay. First of all, we'll just go basic. Can you tell us a little bit about how you came to be a cannabis? Expert. I, started getting bombarded with patients inquiries and, you know, I'm an integrative medicine physician and a geriatrician and palliative care doc, so I kind of take care of people in their older years and trying to use minimum amount of medications and procedures. And so sort of, I think it's by default that people were seeking me out saying, Hey, you are integrative doc, so you need to know about this. And I'm like, Hmm. Yeah, I probably should. So I started looking into this and as Locke headed in 2012, I met Dr. Donald Abrams, who's kind of a grandfather of the whole field of medical cannabis as a number one research in us, or first researcher in us who, started looking into benefits of cannabis in HIV population. We talking. 30 years ago, so when no one talked about this, so he and I were served on the Board of Integrative Medicine as founding members and, he was sort of giving me. Road forward without me even knowing about it. So I've kind of jumped on vag and learned, and one of my patients, in 2017 I think introduced me to Joan Lehman Smith, who's my co-author in the book. And Joan is a professional writer, so she had some ideas. We originally wanted to write a book about. Medicine for older adults. We went to a few publishers. They said that, I forget that that's not sexy enough, but we heard Dr. K, Dr. Kogan is interested in cannabis. Well, that's sexy enough. I said, I, I'm not a writer, especially let alone cannabis. What the hell? They said, yeah, but here's contract. And we are kind of like, Okay. So it was a sort of the, just the circumstances and, and I think the, I think what I'm proud about the book particularly, it's extremely, patient and pupil's friendly. There's a lot of excellent cannabis book, like cannabis pharmacy and, you know, uh, Bonnie's book. I mean, there's a lot of different great books. The problem that a lot of them are written by physicians, and so their language is too medical and too, detailed. I think Jones really wrote the book for everybody. It, it kind of took, I like to be very humorous. I grew up in Russia. I take everything sarcastically and with a humor. It's a little ra weird time for me to say that, but yet at the same time, that's the way to get over this crap that's going over there. And, um, you know, so I, I, I use a lot of humor in my work and life. And so I think the book kind of took that on. And this topic is also, Lands itself for illa amount of jokes and just generally I think, can take this topic quite lightly, because it's a very serious topic. But in itself, we took this topic for decades too serious on a political level. And so I think it needs to be a little bordered. Down and simplify it for, for masses. And also I think that it's such a profoundly underutilized, plan that have literally touches beneficially every aspect of our living and our health and menopause is not any different. I can tell the listeners pretty much that whatever the medical problem you think about cannabis will have a role in there. And the reason for that is very simple because we are, have, have our own cannabis system inside of us. We're calling this and the cannabinoid system more short, e c s. And it's something that's actually the oldest hormonal system in our body. You know, we always talk about endorphins or or endogenous orbis. We talk about neurotransmitters, things like dopamine. Those are all relatively new development and evolution. But if you look in animal kingdom, the oldest system we have, In brain, it's limbic system, and then the rest of the body is the cannabis system. So how come that our bodies co-evolved with this plant? It's a question upstairs, not to me, but the reality is we have for, for millions of years. Humans and all kinds of animals coevolved with this plant, that produces molecules that are similar to what we produce. Cannabis is not the only plant that does this. There's a lot of plants out there that mimic some of our internal workings. But cannabis is probably, in terms of an cannabinoid system, obviously it's the most, most prevalent mimicker or. Kok, if you wish. Okay. Um, so yeah. And, and another tidbit of information which is outlined in the book very nicely. It's the old medicine we know. It's the first document that oldest medicine that was documented in Chinese medicine, original track books dating more than 5,000 years ago. It was used for dozens of medical problems back then. Um, and even in our own backyard. In United States, cannabis was the most heavily used medicine until 1930s. Uh, every single pharmaceutical company was making it. Every pharmacy carried it, every doctor prescribed it, every patient took it. So entire US was taking cannabis until prohibition error, which was made up crap, uh, eye lift or was similar. Situation in Russia so highly parallel for me that something that has so much benefit was prohibited for a particular reason. Just because they needed a scapegoat on a political level in both countries here and there. And so everything was a lie. The addiction was a lie. The toxicity was a lie. Everything was a lie. And so then subsequent culture grew up with this. Um, And, uh, there is addiction potential, but there's an addiction potential to coffee and to the alcohol and to the cigarettes, and to cucumbers, to anything. I mean, sure it's stronger to cannabis than cucumbers, but. But actually not stronger than to coffee. Okay. Not stronger than coffee. Coffee addiction is thought to be on a certain physiological level is stronger. Withdrawal from caffeine is harder for some patients than withdrawal from long use thc, et cetera. Hydro, which is the. Intoxicated molecule in the plant county. Okay. And where's the research at now? Um, just for the general use. I understand from your book there's less in the US and a lot of it that's coming out of in the, in, uh, the rest of the world. Can you just sort of frame Right, right. It's particularly actually the, the first bulk of research came out of Israel because Israel is the first country as a whole country that legalized medical use. I actually was just there, uh, last week at the pretty large conference, and it's pretty fascinating amount of research. They do a on, on a level of practical applications. One of the problems with. Research in the us, uh, we, um, we can't really conduct federally sponsored trials because, uh, as a schedule one, uh, controlled substance, you can't obtain federal funding to study benefits. You can only study side effects. Israel got over that, so they actually have a federally funded studies in Israel that are, um, You know, way further ahead of us. But nonetheless, there's a lot of real research. I mean, I think unfortunately there is a misunderstanding saying there is no research in cannabis because it's a controlled substance. That's just not true. Uh, we have studies showing that's very profound benefit for chronic pain. We have studies showing now in the last couple of years that it's quite beneficial for sleep. We have studies that CBD is somewhat beneficial for. Occurring different types of anxieties. Uh, we have studies comparing combination of C B D to tc two existing medications showing that they're better for pain than everything we have. So in 2017, talking about like the hard, hard summary of the research, if you will, in 2017, national Academies of Sciences put out a very comprehensive assessment. You with the help of experts, Donald was one of the experts who was invited and they analyzed every existing. Piece of data. There were 20,000 studies and they basically looked at all the data and they said cannabis is the best thing we have out of everything. That for chronic pain, we don't have anything better. No medications, no procedures, no nothing. So it's a grade A recommendation. What grade A means is that if this would be a drug, it would be a best seller instantly. Okay. So, and that data came out in January, 2017. It hasn't shifted anything. It hasn't shifted the world on, on opioid overuse. It hasn't shifted. Shifted the fact that cannabis is still by a lot of chronic pain clinics considered a no no. So, you know, I. Evolution of cannabis is slow to, to definitely to my liking. Uh, but in terms of research, the research is all there for pain there. There's no need to do more research, like as Donald jokes. I don't need to study aspirin to tell me that it's works for pain. Right? It it, it's ironic. It's exactly the same with cannabis. We don't really need studies, what we need studies for to to figure out exactly the dosing. So how should we give it? Who should get it first? At what ratios of THC to C B, D, at what dosing, et cetera, et cetera. There's a lot of. Expert opinion. There's certain recommendations. There is recently a national recommendation. Uh, recommending start with C B D for chronic pain and then when you reach to about 40, 40 to 60 milligrams, it's a day of C B D switched, t h c. I disagree with that recommendation. I don't think that's too sound and I don't think it's based on a lot of research. I think THC for pain is must for most patients. That's been my also clinical experience. Um, but at this point for pain, THC is usually in my second line. First line is usually non-pharmacological, physical therapy, exercise, lifestyle adjustment. Some vitamins like be complex, magnesium for pain, often quite useful, but they usually don't really. Cure the pain. They just kind of help a little. But the cannabis can cure certain types of pain, literally. So neuropathic pain, cannabis has potential after quite a while to be curative, meaning you can start withdrawing it and you have no condition at all. It's gone and you don't have to use anything. That doesn't happen a lot, but it periodically does happen. Um, Other conditions? I would definitely say cannabis has fascinating role to play in the future, is different skin problems, eczema's, psoriasis. We published the case not so long ago, use of cannabis to cure psoriasis. Uh, and there's good amount of up upcoming literature. There's also. Uh, a ton of companies that try to make drugs because it's a quite lucrative, uh, financial area. Definitely for that. There's a lot of interest in cannabis and cancer. The best evidence for that is really just to treat the symptoms of cancer and cancer related treatments such as nausea, vomiting, pain related to cancer. Uh, it's, it's a little bit more well, Not a little bit. It's very controversial to be using cannabis to cure cancer. Yeah. I would say that everyone who've seen enough patients have seen such cases. Myself included. I've seen a list of cases that I can only define as miracle when patient was taking cannabis and cancer just disappeared. Unfortunately, we can't put, uh, We can't clarify how that happens and, and to whom and why. And the trials are quite few in between. We only have conclusive data from brain cancers, uh, with a small trial showing pretty dramatic benefit Beyond that, you know, if you're a listener and you're wondering, I have a cancer, should I use the cannabis, my internal. Guy tell me, absolutely it must for every cancer patient out there. Problem is I can't base that on the research data. I can't simply say, well, this is why you're going to use it. Here's the paper. Like that's how we work in the clinical settings, right? We're not gonna give something to patients just because we think it's gonna work. We give it because there's been an assessment done in a evidence-based format that proves that this tool is effective. Um, so with that disclaimer, the rest of our conversations, we, I'm, I'm gonna probably keep repeating, saying Yeah, no, I think it's this, but probably there's not enough evidence to be conclusive. Um, but I think that's gonna change rapidly because partially there's a huge commercial interest, and so there's more and more. Industry that is sponsoring different trials. We are actually probably gonna start one of such trials, not hopefully too long in the future, looking for chronic pain. Um, so there's, there's just a lot more interest showing up, looking at. Can different extracts and different routes and different preparations of cannabis be actually disease modifying. And you know, my personal interest is Parkinson and Alzheimer's disease and, and at the conference they just went to, we beginning to really, uh, Figure out what is the future of research in this topic is, but it sounds like it's very bright. My prediction is that cannabis will be used as cure for both Parkinson and Alzheimer's within five to 10 years. We're not looking too far out. Okay. Yeah. And, and I'm basing this primarily on, um, Not just basic understanding of what happens in those diseases and the fact that, and the cannabinoid system is heavily dysregulated. We already knew this for about 10 years, but we seemingly now seeing animal studies showing that at the right application cannabis cures, Alzheimer's diseases, at least in in small animals will. That translates to humans. Not everything that's happens in small animals translates to humans, but I have a believer in this actually. So I know it's not necessarily the. Topic of today's the conversation, but I thought this would be nice. Pretty, no, but it, it is interesting cuz we know women I think are well over half of the cases of Alzheimer's and we hear cons consistently that in menopause and perimenopause we're at a greater risk for getting. Dementia and Alzheimer's. So it's comforting to hear that maybe down the road. Well, that, that's definitely the case because when estrogen starts to decreasing, the estrogen is pretty important in a regulatory, uh, in a cognitive function. So that's probably the sum of the link. Mm-hmm. Mm-hmm. So, yeah. Yeah. But as I think I mentioned it already, if you think about. All kinds of medical problems we have, like everything that in, I don't know, Harris Book of Eternal Medicine, pretty much. I can say that almost every medical problem you can think of, cannabis is gonna have a role. It may not have a role now, but that's only because we don't have a full research yet engaged. And I'm not saying this because I'm a pot promoter. No, I'm saying this because the internal system, the end cannabinoid system is dysregulated and over and almost every chronic medical problem. Okay. I'll give you a simple example. Um, I was totally, one of the most important topics for me at this conference turned out to be a study of older adults looking at effective cannabis on high blood pressure, and turned out it's one of the best antihypertensives that we can have. It has a very predictable drop in blood pressure, about five points with all minimum side effects. Um, and I didn't even know, but. This, and I would think that why would hypertension have, if it turns out that it does, and I, I bet that we're gonna see this in in every medical problem, including the everything menopause related. I have no doubt. It's just a matter of how will we get there are covering some of these pieces. That's interesting. So I was gonna say, what's your hunch for why we're suffering? Uh, from your area of expertise, we're suffering with this transition. And I wonder, I guess you're sort of suggesting that this endocannabinoid cannabinoid system is dysregulated and, and sparking some of these problems. Oh, I'm sure. I think I, uh, k Key question is how does it ties altogether? I. You know, how does it tie with serotonergic dysregulation? How does it tie with, uh, you know, estrogen drop? And it does some of it. This, this is sort of not where I would say I'm the real expert. I mean, I, I know, uh, I'll tell you what I do know in a, in a minute, but I think some of this also, the science is. It's just really not there yet. Um, there are a lot of really basic questions we don't have good answers for. I mean, we understand that after age of 14 games over regarding the cannabinoid system because you start having gradual decline in the, in production of, in the most important two and course important cannabinoids and then divide and two h e e, which are t hc, like Tetra, like. But you know, why does it happen this way and other? Is that decline linear? Does it elevates after per after menopause layer? Does that decline accelerates, which we actually think it does. Um, and what is the sign clinical significance of it? Does that mean around the menopause? Bald woman have to start substituting with some exogenous cannabinoids. I mean, it's, it's a fascinating question to which no one has good answer yet, but the, the intuitive ideas is absolutely, I mean, because you would want to figure out, I mean, we've talked, uh, We've been yo-yoing around hormonal replacements forever. And the problem is, it turns out you give hormones, you have side effects. With cannabis, there is no such thing. You give cannabis. There is no side effects in the long run. I mean, if you're stupid, you overdose it and you run a car and a tree. Okay? I mean, that's not what I'm talking about. I'm talking about if you correctly. Provide, uh, optimization of the decrease and then the cannabinoid tone. There are seemingly only benefits with zero side effects. And, you know, we haven't really had history here to look at the. Data for decades and say, well, now we have some conclusive historic data. I think it'll come over time, but, you know, question is to the listeners, what is your personal and the can disregulation? The, the, the one of the kind of a gurus of our field, the, the kind of the lead researcher is Ethan Russo. He always says that, I mean, everybody have an can, cannabinoid, defic, uh, every adult after age of whatever, 25. The question, what is your personal dysregulation and how do you fix it? And most of the time this has to get addressed on experimental level. I mean, and of one, you have to try some things yourself to see how you respond to each possible, you know, exaggerates, cannabinoid, terpenes and all this. So that's another thing. I mean, everybody think that cannabis is THC and C P D. That's a. It's complete misunderstanding. I mean, THC and C B D are not even most important items anymore. You know, they're just like, okay, they're main constituents, main ingredients, but nothing's gonna happen without other critical molecules, terpenes, and minor in the cannabinoids. I mean, now we have. C, b, g, which is thought to be canna, which is actually probably gonna be one of the most important things for the menopause because it's a, it's a mood optimizer, it's an appetite stimulant. I mean, there's, there's certain features of it that are unique, unique from THC and C bd. But you know, there's also acidic form C B D A and T H C A. We try to outline all of this in the book. Um, and the only problem is by the time we finish writing the book, there's so much new data that we're like, should we go back and re um, this is a topic where every book, by the time it comes out, it's already outdated. So I don't, I don't feel bad that somehow we didn't do something. It's just. It's not possible to do everything because No. In this space where it's moving so quickly, particularly so, yeah. Um, you mentioned C B G, you mentioned terpenes. How do women wrap their head around these different things when they're maybe don't even know about T H C or C B D? I'd say get the book and read it, and the reason is very simple. It's so complex that you need pace, time to process the information. I can give the basic lecture in 60 minutes, but it, it, the, the, the amount of information in that lecture is gonna be like so massive that to process it is not gonna be really easy. Um, it, it, it's just, you know, it took, it took us decades to kind of, Get a good sense of certain endogenous processes like the, the cortisol system and then, and the opioid system. It's not any different. It's actually much more complex and much more different and much more sophisticated in how it interacts with the rest of our functioning. But, um, but we do have to learn it because the potential is so massive. And I know that the women past age of 50 are the ones that one of the smartest and best healthcare consumers, because they wanna learn. You know, it's, it's guys like me in their thirties and forties think they're gonna live forever and nothing can touch them. They think they're invincible until stuff starts happening. You know, women is a lot smarter, right? So they're like, yeah, I gotta learn all this. And then I'll teach my husband, usually husbands man coming up to me. In the clinic, usually the ones dragged, but their wives say, you gotta go see this guy because he's gonna help you stay healthy. Not to, you know, just money manage your conditions. So you have to read a lot, you have to learn a lot. You do wanna experiment some, because figuring out what's your personal cannabinoid tone is, is not a, there are some ways to learn it without taking anything, but unfortunately, That's not fully possible unless you're true expert in the topic. And it's fortunately, easy to do. I mean, c b, D is in every state. Uh, CBG is in every state. C BDA A is in every state. C H C A, isum gonna be in every state, anything but c HC can have access pretty much easily. The prices are coming down. Um, routes available. So topical and, and let's actually talk about this because I tend to put more emphasis on topicals, vaginal and rectal suppositories and sublingual drops more than other cannabis experts, I would say, because as a geriatrician I know the value of non. Non-oral route. Mm-hmm. Because often that's the, you don't wanna, you, you want to minimize certain interactions. You want to minimize taste problems. You want to minimize, especially people who, who's not even cognitively aware, how are you gonna give'em something to swallow if there's a risk of them choking on it? Right. So having alternative routes of administration is critical. So we should talk about that sooner later. Yes, I will bring that up. Um, for now, we know that there was a couple of studies, there was one at University of Alberta that came out last year. Uh, there was Veterans Affairs in California talking about women are doing this, like it's between a third to a quarter, who are doing it and where they're finding out about it, friends and family. Um, can you, what. What can it help with? Because it seems like right, it's sleep, it's anxiety, it's muscle aches. What, what can women consider it for? So I would say sleep. It's the number one. And the reasons for that is simple. A, it's about 80, 90% effects. So when you find the right mix, and the book has details on which mix to get and how to start. So I, I don't think I'm gonna go into that. It's gonna be too detailed. Um, but, um, If you pick the right products and you, this is by 80, 90% effective. Um, and, and we don't have any, anything come close to that for pain. Cannabis is probably 50 50. Uh, for things like nausea, it's also maybe 60%, but it's just not for sleep. It's seems to be the universal effective. Why is because actually cannabis is what regulates sleep. Thinking that melatonin regulates. It is quite a bi misguided. I don't want to go there. Melatonin has a lot less role to plate in sleep than it actually people think. It's really the cannabis that initiates and maintains the sleep. It's the endogenous, uh, cannabinoid system. And, um, there are other. Important players, but so definitely sleep and especially sleep around menopause. I had tremendous successes and you need very little, you can even try just C, B, G and um, and the sleep pools, everything with it. You know, if you don't sleep, you know, the next day you're. More in pain and you're more depressed and everything seems to be worse. Right? And if the sleep is disturbed chronically, then you start having chronic medical problems, high blood pressure, and all kinds of things. Yeah. And so that's big one. Okay. Uh, occasional spasms, especially if you are very sensitive person and the topical application's gonna work for you. I would say topical cannabis creams are god stamped for occasional leg spasms. Or actually for any pain, whether it's a neck, a back, anything it topicals don't work well in most patients I would say it's only 20 30% effective. But for those for whom it's effective, it's like the number one treatment. Okay. Because there's no side effects. It's very low cost. It's easy to get, you know? Um, but for the rest of us, you really would want to probably take oral. Um, and then for vaginal pain? For rectal pain or for back pain? Uh, my first line is suppos. Okay. Whether they're vaginal or rectal. Um, that's a big one. Definitely as a lubricant. So, uh, the THC containing lubricants have been used for thousands of years. Seems to be the number one. After ADI act and also just, it enhances not just sex, it actually enhances any touch, pleasure. Um, and, and, and actually it's also decreases pain. So if there is a problem in a woman who, not just with lack of satisfaction, but also pain during intercourse, uh, it's a, it should be the first line treatment because it's so easy to apply and you don't have to apply the suppository. Okay. That may be somewhat. You know of fooding for some people, but you can use it as a cream and there's now pretty much in every dispensary you can buy THC containing lubricants. Wow. And if, even if you can't find that, because you are in a state that doesn't allow it, you actually can make your own. So that's another massive advantage. They're pretty much information on how to make your own cannabis everywhere. You can buy books on Amazon. There's all kinds of, you know, I am personally not. Like I, I don't grow. I, I don't as a, as a manufacturer, I don't understand some of this intricacies, but I do understand that especially for the oil based lubricants, cannabis is gonna be, uh, very easy to make sin. You can get. A base oil base, cannabis oil, what we call often feco, full extra cannabis oil. And then you can mix that with the oil-based lubricant. It's gonna mix really well. And then it's gonna, you can use it for pain, you can use it for dryness, you can use it for just to enhance pleasure. Wow. And, and, and the data on that is, Reasonable. Okay. Uh, now people of course, always smoked pot to get high and then have sex. Well, that too, but you know, that's a bit actually more controversial because it, it's a sweet spot there. Uh, pun intended, you know, if you take a little too much, you actually turn off the sex drive and, and like it's harder to reach the orgasm and, and it seemingly actually increases dissatisfaction risk. Sex. But if you take trust the right amount, it actually dramatically enhances it. And there is studies that looked into this and not just, there's a lot of observational assessments, but there's also been a couple of smaller control trials showing that, that seems to be standing. The trial of testing, oh, this is amazing. So, The genitourinary syndrome of menopause, all of those constellation of symptoms, it can actually Exactly. Yeah. That's, wow, that's something else. Um, well, and then again, it, it goes back to the same fact that there's probably link to the endogenous drop in this cannabis tone. So you're not, in essence why it's potentially so effective is you're not really doing anything to. You simply replacing what's body missing? It's the same issue as you would try to put estrogen back in if it's lacking. Yeah. Problem with estrogen as we know, you take a little too much and then you're gonna have issues. Okay. Um, but, but anyway. Is there any interplay if people were using hormone therapy, that estrogen and progesterone or testosterone? Is there any concern that. Using this in some way would, uh, create any issues? Not at all. I mean, if you take the, if you don't know better and you take any replacement orally, then you're in trouble and you shouldn't be because the hormones should not go through the liver. So it should be no first pest. Certain types of cannabinoids, particularly C B D, can change how liver metabolizes medications. Uh, but clinically we're not really seeing that impact our care much. It's a theoretical fear. Um, there may be some areas where it's sort of applies like seizures and. A few others, but I don't think this would play out here. So I don't think there's any concern. And moreover, I think if you're applying it topically or vaginally, there was really zero concern because that's not gonna go through the liver. Okay. And we do hear about this in perimenopause, what women are always saying they can't drink, uh, like they used to. Uh, livers are right. That's exactly right. Are under, yeah. Our livers are sort of un busy, busy dealing with us. Busy peace is, is right. Yeah, well also, also as we all get older, unfortunately we tend to accumulate toxins and that's another, you know, whether it's a mercury from fish or teeth you have in your mouth or pesticides in your neighbor's backyard, we tend to have slower capacity to get rid of these things. And, and the same goes true for every medication you take for even some supplements, et cetera. So I think as metabolism slows down, some of this starts occurring. More as the nature of getting older. Not necessarily that it's just a menopausal issue, it's just, it's just the issue that some of the organs are not functioning as if 20 years before. Okay. What is your advice for women trying to talk to their doctors about this? Or do you think this is something they should try to handle on their own doc? I don't think very many doctors at this point are gonna know really what they're talking about or want. No. Yeah, absolutely. Right. Uh, we even wrote like a whole chapter there, how do you deal with your doctor? Because frankly, that's exactly the case. I, I say, you know, Doctors still often, and majority stay away from this topic. But I'll tell you, we're not stupid people. We understand that the evidence for everything trumps your personal opinion. Uh, if you're a good doctor, it is. And you know, and as evidence it grows more and more. Doctors say, Hey, you know, that's valuable. I, I give. Regular grand rounds at George Washington University on this topic every couple of years. And first time I gave it when I asked, well, so who's already here at GW prescribing and there were about 300 doctors in the room and only two hands went up. Mine and my former chief of geriatrics, and now when I did this just recently, there was 18. So, you know, it's growing. It's not growing. Crazily exponentially, but it's growing. So your Dr. May actually know about it, or at least your doctor probably heard about and have some relatively neutral opinion. And if you come to this not as, oh my God, how can you not know stupid you, but say, look, I heard about, what is your opinion? By the way, here's the book. And give'em the book and say, you know, it's written by a doctor and you know, maybe you wanna learn a little bit and maybe we can talk about next time. And also, you know, we do read studies that patients bring us. We may look a little, um, upset that, that, uh, that your Google, uh, search produced something and that you think that your Google is better than my medical school experience. But, you know, but we we're listening to this, right? Because I'm ultimately. The truth is not what we think it is. It's always changing. Hmm. Um, so the data will trump all of this. I think the part of the big problem, which this is my personal passion, that's what I'm trying to do now, is that the next wave of doctors is not getting enough education. So I think we have to. Put in a medical school curriculum a requirement for this topic to be mastered at certain level. Mm-hmm. So that every, every graduating medical student in us, when they graduate can say, I know this much. Now we need to determine what this much means. But in reality is no one has done this. So when we're trying to come up with kind of a national standard right now, and. See if that goes in. Um, but uh, I, the bigger problem is not doctors. The bigger problem is dispensaries. Oh, okay. Because you can get a recommendation from your doctor. Your Dr. May even know a little bit until you go get this. But then you go to dispensary cuz the doctor has zero control on what you're gonna buy. Zero. There's no way to control it because the, the government in every state prohibits doctor interfering, inter interacting with dispensaries because that's thought to have illegal ramifications, which arguable, but you know, and I'll tell you how I'm dealing with this in a second, but you know, so you go to dispensary well, and then all bets are off. You may end up with a wonderful but tenderer who knows a lot and can give you a great suggestion. Well, you can end up with 18 year high school student who is clueless. Clueless and will give you crazy like personal opinion like, oh, I smoked some pot last night and sex was great. Why don't you just go home and smoke this half of this bottle? And naive patient will just go paranoid crazy and will never touch it again. Right. So there's a lot of bad advice. Um, Still going on. Do states cope with this differently? Some states requiring that every bit of information coming out of those bartender's mouths is somehow guided by a clinical person. So Connecticut to Maryland now, Chico, uh uh, Michigan, different states beginning to put in a very special way of dealing with this problem, but it's not universal. Some states have zero. Control meaning to get the, the, the variability of this is massive. Um, so that's why I think you have to give, become your own advocate in this. Okay? Like you really have to learn some basics that when you show up to the dispenser and you get crazy advice that you're saying, no, thank you. I don't want what you're telling me. I need this. So you need, you do need to be that detailed to understand what you're actually looking for. A lot of women my age when you talk about this, we've all had that experience from when we were young where we Sure we had a overwhelming experience and maybe quite a few people are walking around now. Like I, I don't know. I remember that time when I, you know, I couldn't talk for hours at a time. So I know in your book you mentioned go low and slow and, um, stop. When you get where you need to go, what sort of, how does that Exactly, yeah. How does that kind of unfold? How should you add to that? Yeah, right. So the, the, the stop where you need to go means that more is not better. So the, the, uh, maximum effect appears in a J curve. So like you start and it's not very working very well or not at all. Then you titrate up, up, up, and then you hit a certain perfect spot. Sweet spot. Where it's gonna work the best. If you've gotta keep mo going up and taking more, the the benefit will disappear quickly. So that's why you have to stop because more is gonna be worse, not better. So it's, it's actually not, uh, it's a pretty unique, there's some other substances that do that, but not that many. Often more will have be stronger impact. Here it'll not. Plus it'll save you money. Because it's just that simple. Um, so that's one. Starting low has to do more with two things. Well, obviously a lot of people are more sensitive than they think or that somebody else's think. And so the recommendation may be take five milligrams of t h G for chronic pain, but somebody may be so sensitive, they only need a quarter of that dose. Mm-hmm. So you don't want to miss. So you don't wanna go straight from over that sweet spot, right? You wanna start under and then get to it. And another benefit, when you doing this, you somehow, when you start for this, what we call a sub-therapeutic dose. So the dose less than, and I know that this less than what can produce benefit. You in, you widening the therapeutic window, you enhancing the benefit. It's not fully understand why it's happening. The thinking is that when you first impact the receptors very slightly, you start fine tuning the whole system to get a better impact. So couple of days of two or three days of a very low dose tends to often increase the benefit after you titrate a dose. That's especially true with pain. It may be less true with sleep. It may be less true with some other conditions, but with, with like nausea. But with pain, it seems to be true. Okay. You want to kind of titrate it up very, very slowly, starting at the sub-therapeutic dose. Okay? Um, And then slow is because again, you don't wanna overshoot, you need to titrate it up to a point where, you know, okay, this is good. Um, if you go too fast, you may either miss the window or you may simply, you know, you may not miss it, but you're gonna think that you, you are not actually gonna get there. You're gonna say, okay, well, I'm feeling better. I'm gonna stop here. Yeah, but I mean, maybe you want to go up, but if you go up twice, then you're definitely gonna miss the sweet spot. So you, you have to really titrate by, some people say 20%, some people say 30%. I mean, the, the titration dose, that's where you really want to have an expert to work with you. If your condition is complex, if your condition is very simple, like, no, no, you have a cramps, or you have. Some le restless leg syndrome, for example, or you have, it's actually not so simple, but if you have condition that relatively self-limiting and, and you know it well, and you know how to work with it, you can definitely try yourself. Okay? Uh, but again, you need to know the basics. You have to be very methodical and slow. Um, there is someone I follow on Instagram, Dr. Daniel a Amen. I don't know if you know him. He's a, he's a psychiatrist. Yeah, sure. He's a really cool guy, but he, he's not a fan. He's not a fan. He says he is done research and it drinks. He's an old school. He's an old school, and, and I'll tell you more than that. He doesn't understand some basic science. I've listened to what he has to say, and he's totally mis misjudging this whole topic of cannabis. Uh, and I see this repeatedly in multiple other, because the people who see addiction first, I have a favorite expression. You go to a butcher, you're not gonna buy a salad. You know, so there is a biased population, uh, you know, he's seeing primarily patients with addictions. Okay? And so when patient is addicted to cannabis, there's seemingly only negative impact. The pro, the problem is that has nothing to do with medical application. Right. It is a recreational use. Everything I was talking is medical. What is the difference is a critical aspect? Well, the difference is very simple. Recreational, everything is about T h C. There's no C, b, D. There is no anti rush effect. It's all about th h c. And so people just get high and almost exclusively it's smoking. Why? Because it's a rapid onset. You get high almost instantly, within few seconds, you know, and you can predictably get high. The problem with other methods of intake, like. Say oral, right? So it's like candy or, or, or chew whatever, chocolate or brownie You gotta get high potentially and maybe even higher than when you smoke. But it all depends on what you ate at the same time. It depends on so many factors. It depends. Did you drink alcohol around the same time? It depends on whether or not you had a fatty meal or carbohydrate high meal. So there's all this factors that playing in. So the, the, there's, it's less consistent. And, and of course the bigger issue with non recreational is that we never give unopposed th hc. It's exceedingly rare for me to give a product or recommend a product that only has T hc because the value of that can be enhanced. So potently by other cannabinoids, by terpenes, by flavonoids that, you know. We don't practice that way. Okay. And so, so what he's seeing with Dr. Hammond seeing is just people recreational, but he's missing a whole boat of medical application completely because just not the patients he's seeing. Just like I'm not seeing any surgical patients in my practice or any kids. So, yeah, we have a, in my area, Dr. Patricia Fry, who's kind of the, the, the outmost cannabis expert in our area, but she's a pediatrician, so she sees tons of kids. So if I have a problem, And I was like, wow, am I seven year old? I, I, you know, I have teenagers in the house. That's it. That's my relationship with pediatrics. But like, I'm a geriatrician. I look at the other spectrum, but, so of course I'll send patients to her. So I think that's another thing we need to all know, understand that. You gotta find the per perfect provider for you. And often those providers are not the utmost experts out there or the most visible people. They're often quiet people in the community and they know way more than me and Dr. Neman. And you know, there's nothing wrong with that. It's simply each one of us have our own niche and our own world to. Okay. Um, see for me, I'm, as a geriatrician, I see a lot of postmenopausal problems and especially things that are really hard to treat, like the, you know, irritable, uh, bladder syndrome, uh, chronic vaginal dryness, frequent u urinary dysfunction, like all of those things that are often so hard to manage. That's where I use cannabis all the time. Because often there is no better tool. I mean, I can, or let me reframe. It's not necessarily the better tool, safer tool. I don't have anything safer than cannabis. The cannabis is pretty much the safest thing than Tylenol, than Motrin, that anything I can offer to my person over 65. Okay. And that's why I think I became so fascinated by it, not necessarily because I think it's like the best tool, most effective. No, there's tools for pretty much everything. If you study hard enough, you'll know the value of it, but it's the safest by far. And, and the more I look at it, the more I realize. We should be screaming and, and recommending it to almost every one, one of our patients in one way or another, because it'll cut suffering and deaths. We probably, I'm guessing that potential of cannabis to save lives is somewhere at about 50 to a hundred thousand lives per year. And applied, right? Wow. Because we killed about quarter of a million of Americans every year with medications, and that's appropriate medications that does not include, uh, recreational drug overdose or opioid overdoses. This is just like, I prescribe Tylenol and the person dies because of liver failure. So I'm talking about those kind of things. So that's about a quarter of a million per year if we universally start using cannabis for every existing condition, we know that at least in, in, with. Opioids with sleeping aids, with tranquilizers, with antidepressants, we see a drop about 30 to 50% persistently, no matter where we look, what condition there is Immediate drop in, in use of those medications. So for opioids and Medicare population, uh, when the cannabis was instituted since it was instituted, we saw about 4 million daily decrease in prescriptions. 4 million per day of narcotics. So that translates in a pretty massive life. Saved. Yeah. Yeah. Um, now why are we not hearing more about. Because that means that the pharma gonna lose trillions, not billions, trillions of dollars, you know, over decades. They don't want to hear this. They wanna first develop their own pharmaceutical cannabis drugs and then substitute, go from what they're selling now to that. And then they say, okay, fine. Now we're ready to implement this. This is how it's gonna happen. But our consumers are my patients. Your followers. They should be voting with the wallets and feed because the reality is data is there. I'm not saying anything that you can't verify, go and look it up. Do you have any sense that there's preventative benefits? That's a little less clear, I would definitely say for urine infections and, and because it's so effective in the vaginal dryness, I'd say Sure. For that. Um, but for other things, it's a little harder to say. I would say that some of the experts, like Dustin Select, would probably say, are you crazy? Of course there's a equipment. See, I, I'm a little more cautious because, um, It's not yet cheap tool. You know, if this would be more like, uh, I don't know, B complex or magnesium cost wise per month, I would immediately say yes, everybody should be, but it's still, we are talking$5,200 a typical monthly bill. That's not cheap change. So I'm hesitant mostly for that reason, but I would say absolutely. You know, there is dry skiing. I mentioned dry, you know, um, so many possible applications. Like now we are really waiting for the eyedrops, cannabis eyedrops because they're gonna help the dry eye syndrome, they're gonna help the glaucoma. They had all kinds of things, right? And they're gonna be probably, you know, long run cheaper than existing drugs for those conditions. Uh, but again, that's a future. Um, but you know, but if you grow your own, so this is where things could be very effective. If you are in a luxury position, you have a backyard or you're in a state where you can do that and you grow your own plants, oh, then you're in a golden because of course then the plant itself is fascinating, right? You can. It, uh, it has a nutritional value. It's full of antioxidants and, and flav and, and flavonoid. So you can harvest other benefits out of it. I mean, you can, you can make tinctures or, or tease out of it, et cetera, but, but I, I don't think I'm an expert enough to say, okay, use it this way. So you're gonna prevent something. I am trying to do that for my patients who I'm worried about cognitive decline. But I'm doing this out of belief, not out of data, which, which is me. When, when that happens, I can't speak to that in front of the recording because I don't feel comfortable. I can't vouch for that. Maybe I'm wrong. And you have to, you have to acknowledge that until clear data comes out, our opinions is just that. Okay. And in terms of misinformation, cause you talked about this in the boat too, just some top things to watch out for when, well, first that it's addictive substance. It's a misunderstanding. We know exactly. It's about 10% addictive. So if you smoke every day, you have about 10% addiction. But even then, it's not true addiction. It's a psychological desire to stay high. It's extremely different from alcohol and or opioids. Those are subject addictive substances. You see, cut cold Turkey, you're gonna get really sick. You could die. With cannabis. Okay, well, you get a little angry. You may not sleep well for a couple of nights, but there's no chance of any real prompt. Um, then there's this whole myth that, that you can overdose and you can die from it. And there's, that's a total nonsense. There's not a single death attribute to use of cannabis in entire human history. It's never been recorded and it never will be. The, in the sixties, they did this fascinating experiment. I, I wish somebody would've recorded that on the video. They tried to kill a monkey with. Cannabis. They stuck the poor thing into cage, plastic cage, and they were sticking cigarettes in it until monkey died. And they were like, oh. Finally, after 800 cigarettes, we killed the poor thing. It turned out, died from as fixation from carbon monoxide poisoning, not from cannabis. We have no idea what the lethal dose of cannabis is. It's, it's, it's impossible. It's, it is improbable to give it. So that's a myth. Complete myth. Um, it's also a myth that's side effect free. There is a proponent that's saying, oh my God, it's the best thing ever. Just take it in a, you know, total nonsense. When you're overdose, you can get really scared, you can get paranoid. There's a lot of dizziness related to it. There's a lot of dry mouth frequency of urination people get, can get kind of sumlin and just like really lethargic for a long time. So it's, it's a side effect for own thing, just like everything else. Um, I think another myth is that somehow everybody have to smoke it like that, that every, every cannabis user smoker, like, like that I get from doctors, they're like, oh, I, I would start conversation about something and, and, and, and they're like, yeah, but we don't like people smoke anything. I'm like, who told you that you should be smoking? Like, why is this in your head? Like, come on, it's 2022. Um, I never recommend smoking products, mostly because again, I'm a geriatrician, right? So why would I give any of my older patients recommendation of inhaling anything hot? I don't care whether there's, there's no risk of lung cancer, by the way. In fact, there's decrease in lung cancer if you smoke pot versus if you do nothing. It's tiny, decreased, but it's there according to studies, but, But the chronic cough and bronchitis will go up in chances. So why would you smoke, right? If you have sublingual topicals, rectal, you know, now we're gonna have the ophthalmic. You know, you, you, we get topicals now as a patches, we have topicals as cream. You know, they're, we're probably gonna have subcutaneous forms soon where you inject something and stays there for a long time. So we have all kinds of ways of administering. So inhaled route. It's still a predominant use out there, but a lot of it has to do with how people like to control their symptoms. If you're in pain, you're not gonna wanna sit there for an hour to wait for the relief. You'd want to be relieved instantly. So, you know, we have to understand that people will do what they will do. There's nothing wrong with that, but as a physician and scientist, I, I'd say inhaled route needs to be discouraged at every level. So don't be scared. Your body's made for this. Exactly. Your body wants this. Anything else? Last words. Um, learned the cost. So, you know, I work with, half of my patients are Medicare, Medicaid, so I'm very post savvy. Um, And for that reason I don't work with very large brands because they weigh overpriced and they're not any better than small boutique brands that tend to cost often a lot less. Um, so I promised you, I'll say how I do this practically, I always try to get CBD from hemp, not because the quality is better, quality is questionably, it's worse, but, but because it's a lot cheaper. And over the years I evolved a few companies. I'm not gonna mention that on the camera. I don't think it's relevant, but you know, so I recommend certain brands because I know they're very top brands, they're high quality and they're a lot cheaper. And they're a lot cheaper than what people can get from dispensaries. So dispensaries are for THC containing products. That's how I think. Uh, and also because they go to dispensary, often things happen beyond my control. It's just happens. So if I tell the patient, otherwise I give them prescription and say, here, you're gonna go on internet and buy this brand. This particular product and you're gonna take it this way. You know, that's how we work as physicians. You know, when prescribed medication, you tell exactly how to take, when to take and what side effects to watch out, right? This is a standard practice of mass. Um, but I would say that, um, Learn to get the brands you like, stick to them. Um, you know, if particular brand is out of production for a period of time, okay, get some substitution. Um, and don't be afraid of like just saying notes to the dispensaries because they often need to sell stuff that's getting close to expiration date. And you, you're your own consumer. Like you gotta really control that and say no. Forget it. I'll wait another month until you get this batch back in, in the stock. It's fine, you know, and stock up. So do have an extra at home, because often what happens, this is a, a second big problem with industry is not only the certain. Push to certain, sell certain things, but often the way it's made, it's in batches. And when the batch run out, sometimes there's a disruption in, uh, raw material supply, especially with covid. And so you may not get what you are used to for a while or when it comes back and stuck, it may actually be a slightly different product and you're gonna have to get used to, again, to modify your dosing up or down slightly. So with that, learn the labels. That's very important point. Read the labels, right? Compare the label to the product you took before, because it may actually have a different amount of active cannabinoids of thc. So you have to, we usually, um, follow the THC dosing for the titration because the THC is what causes the psycho toxicity. Every canna in the sector psychoactive, but the toxicity that would being high only caused by thc. Um, And so learn your dose of THC and then, then you can go from one particular product to another, taking same amount of T hc, even though the rest may be different and an impact may be totally different, but this way you are not gonna overdose. So you're not gonna end up with a situation where you took same amount of th HC and somehow you 10 times higher. Okay, that's just not gonna happen un unless you switch the route of administration. So you, you know, if you're going from smoking to eating it, you may have all kinds of different effect. So I think that's, that's enough. And get the book. It's full of very good information. Sorry. I, my, uh, co-author, I always forget to do this. My co-author always say, ah, you gotta sell the book. And so, yeah. Well, it's full of, I've read it. It's full of advice. It's like a primary. Thank you. It's right. Thank you so much for your time. I really appreciate it.

Ann Marie:

Thank you so much for joining me. If you like this conversation, I hope you'll check out some of my other interviews on the Hot Flashing Podcast, subscribe, give a rating, maybe a review, and come back for more next week. Hot Flash Inc. Was created and is hosted by Annemarie McQueen, produced and edited by Sonya Mac. The information contained in this podcast is intended for informational purposes only, and is not intended for the purpose of diagnosing, treating, curing, or preventing any disease. Before using any products referenced on the podcast, consult with your healthcare provider, read all labels, and he all directions and cautions that accompany the products. Information received through the podcast should not be used in place of a consultation or advice. Care provider. If you suspect you have a medical problem, ie. Menopause or anything else or any healthcare questions, please promptly see your healthcare provider. This podcast, including Annemarie McQueen and any producers or editors disclaim any responsibility from any possible adverse effects from the use of any information. Contains herein opinions of guests on this podcast. Are their own, and the podcast does not endorse or accept responsibility for statements made by guests. This podcast does not make any representations or warranties about a guest's qualifications or credibility. This podcast may contain paid endorsements and advertisements for products or services. Individuals on this podcast may have direct or indirect financial interest in products or services. Referred to here in this podcast is owned by Hot Flash, Inc. Media.