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S1E9 - The Doctors

 How is cannabis prescribed?  Do American prescribers practice differently than on the Canadian side of the border?  Kirk goes South to talk to Dr. Karen O'Brien a Naturopathic doctor in Arizona. Trevor stays North to talk to internist Dr. Blair Hrabarchuk.  Listen as they explore medicinal cannabis on both sides of the 49th parallel.

Tuesday, 31 July 2018 21:26

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Episode Transcript

Dr. O'Brian:  My name is Dr. Karin O'Brien. I'm a Naturopathic physician. And my job mostly other than doing some private practice and primary care is certified people for medical marijuana courts in Arizona in Arizona.

Kirk: OK. you are a naturopathic physician.

Dr. O'Brian: I am a naturopathic doctor. NMD or a ND we have two disications. You have naturopathic doctors in Canada.

Kirk: So as a Naturopathic doctor, you can Prescribe medical marijuana.

Dr. O'Brian: Yes I can prescribe Schedule 1 so I could do marono syntheitic d. I'm legal to certify people for marijuana or when I can prescribe Percocet and I can prescribe most things except Schedule 2 in 5 or whatever.

Kirk: OK. So you work within the primary care system in Arizona. You work in hospitals or just for clinic.

Dr. O'Brian: Most of us don't have hospital privileges but I do my own primary care. OK so we work out of scope in Arizona as one of the protesting United States for how we work so we have DE numbers prescriptive authority except for coumadin chemo and a few Ritalin. Some of the bipolar meds.

Kirk: So as a medical professional. Can you tell me your opinion of cannabis and how you see it benefiting patients.

Dr. O'Brian: Wow that's a huge topic.  OK well I guess I see it in a spectrum of ways. Anything from the most benign which I personally used myself which is the CBD. As anti-anxiety I've seen people these patients get off their Xanax with CBT right. I've seen them get off the Flexeril and muscle spasms meds with CBD. Anything up to severe pain control for people with cancer with a combined combined approach of CBD as well as strong THC like Rick Simpson Oil or the concentrates. so I've seen that help MS people with Chronic spasms Parkinson's people with the tremors. In general it's one of the best pain meds I can think of because combined the way nature made the plant it has so many effects. You know if it's got the big punch of the THC which is a very good for relaxation and pain and sleep because a lot of people's pain psyco cannot be stopped because they can never get good sleep

Kirk: Using THC for sleep not CBD.

Dr. O'Brian: No THC. Okay well THC the; It's a one two punch and you gotta understand CBD is like a strong but mellow kind of punch. THC is a big knock him kind of punch. So if someone is got severe insomnia a little THC Indica typically will get them down. OK CBD I use personally for sleep because they calming me they are a deep slow calm strong medicine but they are not as potent as the THC. So CBD. So I encourage people personally to stop using if they can't if they want to be functional and they don't want to be under the influence of THC while they driving and working, I encourage them to use CBD during the day and then if they have a severe pain issue they pain exacerbates at night or they have insomnia. To do something with THC at night like a full spectrum marijuana at night.

Kirk: So when you when your unprescribed and people medicine you prescribed them strains medicine and you prescribed them so many grams

Dr. O'Brian:  You know so we not really allowed to do that. It's a kind of a weird system here in Arizona. I recommend them. This is what I would suggest and then really there's a big gap between me the certifier and when they go to the dispensary. Right. So when they go to the dispensary they have people who know the strains very well but don't really know medicine very well. Right. So there's a big gap that some patients fall through especially the common patient which is an older patient with bad medical condition who's never smoked any marijuana before and they go to the dispensary they totally overwhelmed with the plethora of ways of taking. And what's the Indica and what's a sativa and what's a hybrid or how much. And so I always try and preface all of my stuff especially for my new patients just telling them it's a very individualized medicine. It's not like synthetic medicine when you have an "X" milligram tablet and everyone takes the same tablet right. You have to experiment with it. Some people's receptors of very different to others receptors so some people really can't tolerate to detoxify the THC very well. So therefore, I they have to figured out that they start with the CBD because I consider the CBD the more benign strong gentle chronic folks, chronic stuff really good.

Kirk: Okay I got it man I've got so many questions for that whole thing. First of all I'd like to have you seen many comment about its individualize. Do you recommend your clients use software or apps that track their usage.

Dr. O'Brian: Yes. Well I don't I just tell them to keep a diary There are Leafly apps and there's another one there's several apps Yeah but I mean basically if I have an older person who's not a big computer was I tell them because the problem we find they run into here they'll go to a dispensary they'll find a strain they like and two weeks later they'll go back out of that straight right. So, I tell them they need to get a repertoire for five different strains that they know will work for them that they can use out of the strain they can get that strain. But my approach is to preface a lot of the medicine with CBD.

Kirk: OK do you write a prescription do you write and application what is it called down here.

Dr. O'Brian: This is the procedure the patient comes into the certification clinic such as we in right now they have to bring an Arizona ID they have to Pay the state 150 dollars. All right. And then they pay for the doctor visit myself to certify and they have to bring medical records.

Kirk: Oh OK so you review the medical records confirm that they have a medical condition

Dr. O'Brian: But in Arizona we can make or confirm a diagnosis. OK. So if they don't have medical records which a lot of people still don't have medical insurance because it's so darn expensive here so I can make a diagnosis of pain or nausea whatever the issue may be. So I have to do a much more in-depth exam because I'm making that diagnosis verses confirming the diagnosis from medical records. So once that's done we do some vital signs we have to do some come obviously some physical exam vital signs. Take a history or confirm them check their medical records and then obviously ask. We do a pain scale what's going on with the pain. Right. And then I give it I don't give a specific recommendation like go and get X amount of grams of that because it's so individualize I just say I would suggest that you try CBD for this during the day and I always recommend which is you know for the law that they're not driving under the influence of THC right or doing heavy machinery or doing dangerous work under the influence within eight hours the state of Arizona says I believe, of ingesting THC.

Kirk: So the state recognizes that medicinal cannabis is allowed but recreational is not.

Dr. O'Brian:  Yes Exactly.

Kirk: Now I'm in traditional health care I'm Registered Nurses bound one of the things I'm doing here by. By doing this podcast I'm actually risking my license because as a nurse I can't be advocating cannabis and I've been told by nursing lawyers that there's no research that cannabis is affective. No proper studies.

Dr. O'Brian: Oh, but there is; I cannot quote you the study but I was at a seminar in October in Tucson run by MD's who are trying to look more holistically and they came up with a study for TBI that proves that cannabis that can CBD is actually improving people from Afghanistan and Iraq with TBI. And that feelings are with you you get a traumatic brain injury. Oh really. Oh yes there is studies out there.

Kirk: So where do we find the studies.

Dr. O'Brian: Oh I don't have it at the tip of my fingers. Google TBI CBD Francoeur and study go pubMed.

Kirk: OK and where do you. Where did you learn to use the THC and CBDs in your practice.

Dr. O'Brian: Well I you know I did regular naturopath medicine. Twenty five years.

Kirk: How long is the education?

Dr. O'Brian: Oh Premed and then four years of naturopathic medical school But so we are licensed in the state of Arizona. Again, discrepancy right. Insurance doesn't cover us. We're not really allowed hospitals access but we have a DA number. I can do a pap smear. I could do a biopsy on the antibiotics thyroid medicine hormons. So we all full spectrum. We just don't get we are not required to do residencies because there's no naturopathic hospitals and hospitals will take us.

Kirk: So how did you discover cannabis as a.

Dr. O'Brian: Well my patients you know I had you know thought it's just I didn't realize the Med medical aspect of I heard it worked with Cancer. And it worked of pain. I just thought people just got grokked out and totally stoned. And then my patients started saying I want a card cause And if you don't give me a card I'll go somewhere else. So I had to start investigating. And I started certifying some of my private patients and then I had an opportunity to start working in the medical marijuana certification clinic specifically.

Kirk: OK. We were you mentored through it, did you did you work with someone.

Dr. O'Brian: A little a little bits another naturopathic had done it From the day that it got legal here for medical marijuana OK. But I have to say I've seen more sick people in the last few years than I have in 25 years of practice. Really. Yes.

Kirks: And using cannabis. And in our research and I have to be very careful how I say this because I'm not promoting cannabis but in my research, I'm seeing some really overwhelming anecdotal evidence that people are going through the Colorado system. It's interesting in Colorado system because it's recreational as well as a medicinal everything. Everything is analyzed. The guy was telling me to go get three plants and they have to analyze everything in their plan all the labeling says. I was looking through your consent form here and there's a couple of things that just came out. You said it earlier. How do you determine what someone's getting into the comment in here. You recognize that cannabis is not always thoroughly was the word you use here. You don't know the components of what's in it. You're not very sure what you're getting is that a drawback in the Arizona system.

Dr. O'Brian:  No. Well I think that's just inherent in plant medicine. OK. Because like I said this 60 CBD in Charlotte's Web. So I'm not specifically applying to this but you know we do have quality assurance measures but you know things can fall through the cracks. You know but I always encourage so. I don't personally have a card so I probably should get one and go into the dispensary and look but I always encouraged my patients make sure nothing is processed with hexane or butane organically grown. So there's no pesticides. So it's just like going to the grocery store you don't know what's on your food. You don't know what pesticide they used. You don't know if that batch of celery is nutritionally superior than the next batch of celery.

Kirk: Sure. And government regulations has proved what they advertise and have been presented. I mean they can call it an organic business and

Dr. O'Brian: I'm forgetting just look at what you're referring to.

Kirk: I just I was reading it as I was waiting for ya. I find this interesting. So, this comment here your patients coming in and obviously working through referral center that are obviously coming in here for referral for cannabis but

Dr. O'Brian: Not referral, certification There is a big difference so that hence that wording. I'm not saying you go get X percentage I'm saying this is what I think may help you based on your symptoms.

Kirk: OK. All right. So they are self-medicating.

Dr. O'Brian: Well this is a big gap. This is what I find in the medical marijuana system that is kind of weird. Yeah. So they see me as a physician and I certify they have a disease or a condition that qualifies them legally for medical marijuana. Off they go I can't help but give them some recommendation of you know especially if they've never tried the medicine before.

Kirk: So where do you refer them to.

Dr. O'Brian:  I am no referrals. I tell them to go to Leafly but we have no affiliation with a dispensary and we don't say go to this dispensary that's dispensary already but there's weed maps and leafly the big ones. But I tell them to go online. But I also encourage them that it's very individualized medicine and you need to experiment for yourself.

Kirk: So recommends smoking vaping ingestion.

Dr. O'Brian:  All up to the patient. and you know it's crazy like asthma patients will tell me their asthma is better if they smoke.

Kirk Yeah I've heard that to actually

Dr. O'Brian:  Say the vape doesn't work and the oral doesn't taking it internally doesn't work. The smoking works the best.

Kirk: I've heard that also it defies everything I know about medicine.

Dr. O'Brian:  Exactly Except that you think you think oh I don't want particulates and smoke and everything and then they say it works the best but it's very individualized so some people the CBD alone will work for them and other people The CBD won't touch the pain unless this THC with it. So it's very I think everyone's receptors are very very different. Some people the slightest bit of THC Wiggs them out they feel toxic. I think their livcer can detox it and other people especially if they've used cannabis for long term have a hard time getting effect not because they love enzymes inducted and they just throwing it out pretty fast.

Kirk: When I was young when I was in Colorado I saw I saw a stranger. Twenty seven percent THC. That's incredible. that is mind blasting. Yeah. So how would that affect your patient if someone who was. What would you use that for.

Dr. O'Brian:  I probably cancer some extreme pain for someone who's terminal with cancer. So so so extreme insomnia or something like that.

Kirk: So you see it's not funny. I've always viewed this whole process has been a learning experience for me from the start because I started this with an understanding of cannabis. So you made a comment earlier in the interview about THC I though THC was a stimulant. How

Dr. O'Brian:  You've got to understand there 99 percent of people and don't quote me on the statistics that say I mean, I don't know the statistics specifically for the majority of people this is I'll tell him. Indica strain in the couch in the couch. So it's a very good muscle relaxant pain reliever and helps you sleep.

Kirk: And that's the THC from indica and in the couch.

Dr. O'Brian:  Sativa is the up yeah. And so you got to be very careful. This is strong medicine you use it very with discinment and judiciously. Right. So there's 1 percent of people I'm guessing but there's a small percentage of people the Indica makes them hyper. OK. And the sativa which most makes some people up will make them sleep OK. You've also got to be very careful I have a patient, he has trouble sleeping. So he took a little Indica. It made him depressed for three days indica is down. OK. Sativa is up. So some of the anxiety issue panic attacks don't give them sativa. They should not take sativa. In fact I would say forget about the THC start with the CBD. Right. So you've got to be very careful. But typically Indica is first used at night for sleep or really relaxing. That's the stereotype of Manyana kind of whatever I'll do it tomorrow just lay on the couch and the lazy kind of person. Right. OK. But some people use sativa to be active who are depressed. They'll use it to get off the depression medication to give them energy did do the day and feel good and be active and they compos mentis and they can work and do whatever

Kirk: So Part of your consultation with them and certification do you discuss this with them provide that kind of teaching.

Dr. O'Brian:  Well I they've got experiments the self I can't guarantee it can recommend what is going to work for them. I know that the safest one I can say for muscle spasm anxiety sleep relaxation inflammation spasm is CBD. So I'm more of a CBD if I recommend anything it's more CBD as a baseline and then use the medical marijuana full plant strains for whatever effect they trying to have. You going to be very careful is very strong medicine. I had a patient accidentally he had A.D.H.D and he didn't listen. And they said eat an eighth of a brownie you need the whole Brownie ended up in the E.R. with a psychosis That's what I tell people. Now if you've ever done recreational marijuana as a teenager throw it out the door now. This is medicine and it's a very very potent medicine the way these plants are now being bred occur. And then once people get a handle you know they can experiment with hybrids so once you get I see people getting more experienced with it they'll say Oh well I found this hybrid Hindu Kush or whatever. And that's where they've bred that indica and the sativa together. Yeah and now it doesn't make them too sleepy or doesn't make them too high like up and it just gives them you know a balance. But there's always the question of you know how you know the question that still out there is what is considered. I hardly ever see I have to just preface this by saying I hardly ever see anyone walking in this clinic who has what I consider high and. You know these are people not stoners. I think those people probably just do it recreationally and they don't bother with the medical program per se.

Kirk:  What do you think about age. The age issue in Canada is a huge issue a huge debate 25 years younger. And of course they really talking about the recreational side and from the medical side. How do you work with children with this?

Dr. O'Brian:  Well you know sometimes we do prescribe it but it's usually for children who have severe seizures and those kind of things. So it's only medical so it's a quite a rigamarole process you have to get a child under 18. A medical card. They have to have two different doctors certify them. They have to have proper medical records. But typically these are Kids who have severe severe especially if they are younger than you know. So it costs the parents of a 500 dollars because they have to have two certifications they have to be registered as a caretaker which means they get to get fingerprinted and be able to go to the dispensary and buy it for them. So it's a huge rigmarole it's not common that we do it when it helps it really does help. So we are very discerning about what people under 18 we would certify. But I mean from a recreational point of view I don't know I've had some patients from the Caribbean who say the woman traditionally use it over there for morning sickness and not not overdoing things have you smoking a big spliff three times four times a day I think that's not going to be good for your fetus. But I think in judicious use a little bit may be beneficial for. It's very political so here in Arizona one of the things we have to come in and inform patients of is if their child Is found with THC in his system they will be reported to Child Protective Services.

Kirk: if you can give us any advice in Canada about introducing cannabis medicinally or recreation. What would be your professional advice for us Canadian

Dr. O'Brian:  well As a doctor and a bit of a purist. I'd have to say having strict legislation and laws and testing that all the marijuana is in the recreational side because in the markets just flooded and all the people who come from Colorado Nevada California tell me that the recreational grade of marijuana is not good. OK. It's hard to find really good marijuana or cannabis but I would make sure that there's no hexane butane and all the prepared marijuana products. So, it's all done carbon dioxide process with no extra added chemicals because I think the jury's still out on some of the vaping. How do you make vape material for it and making sure it's all organically grown with no pesticides. Because if now if people are using it as medicine you want to make sure it's clean no pesticides or chemicals and treat it as a medicine. You know enough got mixed thoughts about you know the recreational cause, I mean I believe it's awesome medicine but I also don't think patients should be paying with they need to pay every year for to get the card renewal.

Dr. Hrabarchuk Interview:

Trevor: We're very happy to have Dr. Blair Hrabarchuk here to talk to us about various aspects of medical cannabis today. Dr. Hrabarchuk how just as an introduction. How did you end up being an internist in Dauphin.

Dr. Hrabarchuk:  Thanks Trevor. I've been here 25 years now. It seems like just yesterday but after I finished my internal medicine in Winnipeg I decided Dauphin was a good place to be. Halfway between Winnipeg and The Pas my hometown and here I am.

Trevor:  Oh that's great. Now we hear all sorts of claims from all sorts of people about what cannabis may or may not be able to treat. From what you've been reading in from your experience what do we think cannabis might be good for some of the things I hear about or are like pain nausea seizures maybe M.S.. Do we do we have sort of a list of what we think cannabis might might be good for.

Dr. Hrabarchuk:  Another good question Trevor. Yes. In fact the most recent data summary data that I could find was from the Journal of the American Medical Association published in 2015. Kind of its like a meta analysis. What that means is it's a conglomeration of trials put together to say to summarize what the what data is out there that to support use in certain situations.  And what may be lacking just as an aside the absence of data does not mean that a particular pharmaceutical for example may not have an effect. We just don't have the data. But what there is good data for is pain management. Both either nociceptive or neurological pain.  Both of them.

Trevor [00:04:30] I'm just gonna to interrupt quickly. Can you give us a quick summary what difference between nociceptive and neurological pain?

Dr. Hrabarchuk: OK. Nociceptive pain is pain like if you smacked your thumb with a hammer for example or if you had a bad knee arthritis or you had a bone fracture that is nociceptive or nociceptive pain versus neurologic pain which can come with shingles for example or trigeminal neuralgia or severe diabetic peripheral neuropathy things like so it's neurologic pain ??????

Trevor [00:05:29] So you're saying for sure it's good to both nociceptive and neurological pain how about things like nausea seizures and we've even got some people claiming things like diabetes have you read anything for or against them.

Dr. Hrabarchuk:  Unfortunately the data is not very good for things like even glaucoma. Some psychiatric disorders. I mean it's there there's anecdotal evidence that it's effective in these areas fibromyalgia restless legs things like that. I have not seen any data on diabetes particularly and if there is it's going to be very preliminary I'm sure. There may be data specifically with regards to that painful diabetic neuropathy. The management of that but what there is reasonable evidence was pain control and reducing spasticity for example in multiple sclerosis.  You had mentioned multiple sclerosis.

Trevor: Yeah we seemed to we seem to have a lot of people in the area with M.S. So that question comes up a lot.

Dr. Hrabarchuk:  I mean it doesn't treat M.S. specifically. OK it doesn't doesn't re-myleniate the neurons in the central nervous system but it helps relieve the discomfort of spasticity in that there's several good papers that have been published on that particular subject. It also some good early evidence in patients who have HIV and trouble gaining weight. It's there's data to support its use there. There is data that it reduces nausea for chemotherapy and certainly the data that it improves sleep disorders there's lot of concern out there about opiates and the overuse of opiates. And there's also data to support cannabis use to reduce the amount of opiate that's necessary to control the condition with pain. So, it has an opioid sparing effect.

Trevor:  So that's great.  And actually that segues nicely into you and I had a conversation off air about overdose and cannabis and you know in your many years experience you've seen lots of overdoses from lots of different things. How many cannabis overdoses have you run into.

Dr. Hrabarchuk: I have never seen a cannabis overdose full stop. I mean I've seen many opiate overdoses many negative effects from overdose of alcohol. Things like that but never I'm not sure that that's possible even.

Dr. Hrabarchuk: Well when when physicians prescribe anything there's always guidelines to follow with regard to prescriptions and it's strongly recommended that prescriptions not be given to patients 24 years and younger. There is evidence that long term cannabis use in patients whose brains are still developing have a higher incidence of psychiatric disorder at a later date. I can't quote you the data immediately but it does exist. And how big that effect is.

Trevor: So in the pharmacy the thing I get asked the most about is cannabis and pain. You know all sorts. Usually it's like the one you talked about before the neurologic pain. So how about you know if physicians are prescribing the medicinal marijuana from one of the licensed producers. And let's say it's for neuropathic pain. Let's say I've got you know some sciatic pain going from my back down my leg. What sort of do you have any clinical pearls what they should be looking at. You know should they be worried about the amount of THC versus CBD in there. What what sort of clinical pearls would you have for for a family physician if they were going to be treating me for my sciatic nerve pain.

Dr. Hrabarchuk: OK well first of all cannabis in whatever form will would not be the primary therapy.

Trevor: So it would just be an add on.

Dr. Hrabarchuk: It would always be an add on.  Unless there were contraindications to other pain modifying treatment. But let's say we went through all of that and several other modalities have failed or are contraindicated and then we would consider cannabis as a potential candidate to treat discomfort.  Now you have two options you could use pharmaceutically produced endocannabinoid agonists such as nabilone or you could go with cannabis itself and when you go with cannabis itself you can either go with an oil or you can go with the actual weed itself if the weed is used we usually recommend that it not be smoked that it be vaporized and the advantage of that is rapid onset of effect although the effect is short lived.

Trevor:  I'm just going to sorry jump in again.  I talk to lots of people about quitting smoking is the the reason we're asking them not to smoke. We're worried about the same sort of cancer effects in the lungs as with tobacco cigarettes or why or secondhand weed smoke or why would the nebuliser the vaporizer better.

Dr. Hrabarchuk: Well the vaporizer is better because no products of combustion are produced. It's strictly vapor that carries the active ingredients with it without actually burning the plant itself.  There is lots of data that that says chronic cannabis smoking does promote the chronic lung diseases that we commonly see with cigarette smoking, chronic bronchitis, and emphysema over a long period of time I'm not aware of any data with lung cancer to answer your question.

Trevor:  OK. No that's great. And sorry so if you weren't using the vaporizer tell us a little bit more about what you might do with the oil.

Dr. Hrabarchuk:  OK so the oil is taken in. In point one ml aliquots and it's onset of action is a bit more delayed probably about 30 minutes and it doesn't have the same peak plasma levels that that you would get with vaporization. So actually you could use a combination of both say for acute management and chronic management overlap.

Trevor: OK and how about the when I look at the different licensed producers they usually talk about their percentage THC versus CBD in their products. Any thoughts about what what what ingredient in there is good for what what or what ratios.

Dr. Hrabarchuk: Yep. The THC tetrahydrocannabinol is the psychoactive ingredient that binds to the CB1 receptor. What's usually recommended is you know if this is an initial prescription at least a 50 50 split between THC and cannabidiol which is the CBD that's what CBD is cannabidiol the cannabidiol actually has effects on release of 5HT 5-hydroxytryptamine which is similar to the effects of an anti-anxiolytic like an SNRI so something that might be prescribed for anxiety for example so it can aid in lowering the anxiety effects that can occur due to the psychoactive nature of THC itself.  But certainly both are involved in pain control the only thing that the CBD does not bind to the the CB1 receptor though that just THC does. And that's that's most of where pain modulation.  So a lot of what we are there's a lot about this time at this point just not we just don't know.

NOTE… the quality of the sound prevents us from providing the rest of the interview.