E57 - Cannalogue

 

Dr. Mohan Cooray is a specialist in internal medicine, gastroenterology, hepatology, and advanced endoscopy. After graduating from the University of Toronto’s Life Sciences program with the highest distinction, he was accepted into the prestigious Michael G. DeGroote School of Medicine at McMaster University and was recognized for his achievements with the Outstanding Gastroenterology Resident Award in 2015. Dr. Cooray was quickly recruited for a highly coveted position at the Michael Garron Hospital in Toronto, where he worked with patients undergoing treatment for digestive diseases. Internists are doctor's doctors; they are all about the evidence. And Dr. Cooray did not start out believing cannabis was a reasonable treatment for his patients. What changed his mind so much he helped found a company, Cannalogue, that aims to get cannabis and cannabis education out to medical patients? You gotta listen!
 
Monday, 02 November 2020 02:04

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Episode Transcript

Trevor: Kirk we're back.

Kirk: We're back. How are you, Trevor?

Trevor: I am good. We can cut this out if it sounds boring, but let me tell you about my mic. So, this interview with Dr. Cooray, I was going to at first, I have to admit that it was really embarrassing that I tried to record myself on my Lav Mic and accidentally turned my voice memo on and off right at the beginning of the interview. And so, I didn't really get any voice memo. But it turns out it's better and worse than that.  My Lav Mic hasn't been working like ever because it took forever for me to figure out it is the adapter between my Lav Mic and my phone that was not working.

Kirk: Oh really.

Trevor: Took me two days to figure it out.

Kirk: All the tests you did here the other day.

Trevor: That really helped. So, but it wasn't until I was sort of playing with other mics, including my son's gaming headset, and was moving things around and noticing that whether I turned my son's gaming headset on mute or not on mute nothing happened. And then I tried talking with my phone buried under a pillow, and suddenly I couldn't hear it at all. So it was always recording off my phone and not off the Lav Mic at all. So if people care, you know, we're learning these audio things as we go.

Kirk: Thanks for Covid.

Trevor: Yeah, well, more tools in the toolbox, I guess. S Kirk, I got to talk to Dr. Mohan Cooray.

Kirk: Yes.

Trevor: And I know you and you've been doing some reading about him and his group. What do you think?

Kirk: I really enjoyed his story. What I find interesting about this particular story, first of all, we find quality people talk to us. The caliber of guests that we get sometimes astonishes me. Here's a gentleman. He's an Internist right. And what I like about that is he's a doctor's doctor. Right. Other doctors come to this gentleman for consults as an Internist. A wide body of knowledge, lots of education. He's now a cannabis doctor and he's in.

Trevor: And I'm going to jump in because, as I mentioned, water in there. But I'm sorry, just in case you've never met an Internist. It blew me away when he when I found out he was an Internist interested in cannabis. Because I'm not kidding when I say the Internist I talked to won't believe you the sky is blue unless you have a study showing the sky is blue. They are evidence-based guys and girls.

Kirk: Well, that's what I was going to comment on. And it was interesting to hear how he not justifies just not the word I'm looking for, but how he articulates his understanding of cannabis and how it's been studied. He makes a quote in there about, you know, there have been studies and when you look at the patients and he became canna-positive because his patients came to him and he was open to listening to them. And through his patients, he learned about cannabis and started finding studies that apply to his practice. And I found that a fascinating story.

Trevor: Oh, me, too. And I don't think I wrote down as, quote, "Fundamentally, we have to understand there are limits to evidence-based medicine." Seriously, I don't think I'd ever heard an Internist say things like that. It's not that there isn't evidence. And he talks about the evidence there is, but just an Internist who says, you know, evidence is important, but... You don't usually hear that from them.

Kirk: Well, always. But it always comes down to clinical application, right? This is one of the things that in my practice, I am protected by guidelines that I am to practice with right. Now, guidelines are just those, they are guidelines and if you alter from the guidelines, you better have a really strong evidence-based rationale for doing so. In the northern practices that I have, there are often times where the guideline says X and you look at the environment you go, I got to find a way to apply that guideline that it works for my patient. So, I think, I think in this case, reading, you know, reading about guidelines, I mean, doctors often talk about that they practice their art, right? They practice the science of being a doctor, what is practiced, but always out there making adjustments. So, I appreciated his honest approach. And, you know, it also occurred to me, Trevor, as I was listening to the interview, how canna-positive health professionals always seem to be just very positive people like.

Trevor: Yes, he is kind of what yet another one of those kind of infectious guys. You just kind of want to chat with them because he's got a good outlook on everything.

Kirk: Yeah, yeah. And I and I and I have discovered that in our Cannabis research for this project, Reefer Medness - The Podcast, I'm Kirk, I'm the nurse.

Trevor: I'm Trevor Shewfelt. I'm the pharmacist.

Kirk: Yeah. So I mean, in this whole art of us playing this game of research in cannabis, I'm always stumbling into canna-positive, really positive people. I've also had some interesting things happen to me since last time we talked.

Trevor: All right. What's what what's going on with you?

Kirk: Well, I am now a certified cannabis competent nurse.

Trevor: OK, and what does that mean?

Kirk: Well, through our webinar, we did our webinar with Executive Links a couple of weeks back.  Through that process, I networked with some people from Ontario, some nurses, health professionals who are who are involved with putting on a online learning, learning platform. So, I attended it. It was about a 12-hour online course for me, and it walked me through what cannabis prescribers must understand about cannabis. So, I walk through it now. I'm not a prescriber. I'm not a nurse practitioner, but I am, I do work with cannabis in my practice because my patients come into the clinic under the influence mostly of recreational cannabis. So, I took this course to learn more about what a practitioner should know about cannabis. And I found it very fascinating. And I have stories coming for the future. So, this is a little bit of a poke about future episodes on how to become a cannabis competent practitioner.

Trevor: Excellent. But how about we'll talk a little bit more about that afterwards and how let's get back to Dr. Cooray. Anything else you want to say about them before we we let them go?

Kirk: No. Let's get into a story so our listeners can hear his story. There's about three parts to this, right? There's a story about how he got into Canna-positive. There's a story of the business that he offers to people across Canada. And there's a story about what he offers prescribers on his Webpage. So he's an educator as well. So there's I want our listeners to hear the three stories built into your conversation.

Trevor: Yeah, absolutely. Let's let's go out to Dr. Cooray.

Trevor: We have Dr. Mohan Cooray on the line.

Dr. Cooray: Trevor, thank you so much for the opportunity today and a pleasure to be with the audience. So I am a assistant clinical professor with the Division of Innovation and Education, with the Department of Medicine at McMaster University. The current president / CEO of Catalouge. And I'm also a internal medicine specialist as well as a gastroenterologist. So I know maybe the best way to maybe even introduce a little bit of myself self is that when I started my digestive practice in Toronto about five, six years ago, I was a very skeptical physician that really did not believe in any efficacy or application of cannabinoids in terms of regular traditional medicine and particularly digestive diseases. And it wasn't until my own patients started exploring and wandering themselves that I saw the results firsthand for myself. So, the best way to put it is that I am now a believer, although it took quite a bit of convincing to convert me over.

Trevor: Thank you, and that's a great introduction. And let's probe that a little bit, because all the Internists I've met are really, really evidence based. And if they don't see the study, they won't believe the sky is blue. So, what how what maybe tell me one of the patients that started turning the tide for you and maybe some of the studies that you've read that made you convinced that cannabinoids were useful.

Dr. Cooray: Absolutely. So fundamentally, we have to understand that there are inherent limitations to evidence-based medicine. So, when physicians of all different varieties, primary care specialists are requesting the quality of evidence to be as rigorous as pharmaceutical standards, it's a misinterpretation of evidence that exists, but not necessarily to the same standard. So, it takes a lot of time to be able to rehearse oneself with the evidence, but there's quite a bit of evidence there, but it's just not necessarily on the silver platter that physicians would like. So, for myself, when I started speaking to my patients and a lot of patients, two good examples of patient populations that that really convinced me was one was the Irritable Bowel Syndrome population IBS, and then the other was Inflammatory Bowel Disease such as Crohn's and Colitis. So again, I said exactly as you said, that there wasn't any evidence. We don't know enough. We could always give it a try for, let's say, for example, quality of life or pain modification. But there's insufficient medical grounds to be able to recommend this. So, a lot of my patients that were having difficulties, it could be because of other medications, because a lot of pharmaceutical medications, even NSAIDs, you know opioids come with a lot of side effects. So, it's difficult to be able to treat pain when you don't have enough medications altogether. So, when I saw my patients with IBS or Inflammatory Bowel Disease trying it, I couldn't believe it. And what I saw was that let me just kind of break this down a little bit Trevor, was at first was that relative to quality of life and pain indices, there was a substantial improvement relative to even some of the conventional medications that we prescribe. And then the second part was, was as it actually modifying the behavior of the disease? Now, I can tell you that there were subtle changes that we were seeing, but not enough at a large level to be able to say that it changes the behavior of the disease. But fundamentally, for me, as a physician and as a doctor, I'm looking to be able to help my patients in any way, shape or form. So even if their pain is getting better or their sensation or perception of pain is gone, that to me is a win, particularly when there's little to no side effects compared to traditional medications.

Trevor: Thank you. That is great. Now, we've had a few patients with some Inflammatory Bowel Disease on the program and others who are written into it. So, well, because I'm a pharmacist, we'll go right to suppositories because that is always popular. So how are you and I assume you have different things for different patients. But if you have somebody with Inflammatory Bowel Disease, a Crohn's, a Colitis. Are you using suppository forms of cannabinoids or is a mixed bag?

Dr. Cooray: So that's a great question, Trevor. So, the best way to put this into perspective is that the medical applications, or medical cannabis as a whole in Canada is evolving. The way that we, by convention I think consider cannabis, we think the normally the inhaled or vaporized routes. So, for myself as a gastroenterologist, I would love to have suppositories. I would love to be able to treat my patients that have proctitis or various different anal/rectal disorders with suppositories. But unfortunately, that's not available in the medical marketplace right now in Canada. Hopefully soon it will become available. So, in the first generation of patients that we're getting exposed to medical cannabis, they were taking it through the inhaled route, whether it would be a vaporizer or some other route, that's how they were consuming it. Not again, to my recommendation, but that's how they were doing it. Now, we're actually fortunate to have other modalities and methods to deliver the medication into the body. So, as you know Trevor, I'm sure you're well aware, the audience is well aware that there's oils that you can administer under the tongue or to swallow. We have capsules that are available as well, and that allows patients to have a little bit more consistency in terms of the onset, as well as the delivery of the medication as a whole. And then it allows them to be able to avoid some of the smoking, especially if it's any particular chronic basis. So, for myself, we're always looking at making sure that we're giving the medications in the safest way possible at minimizing all harms. At least now we can say that we have oils and capsules and newer lines that are coming available, but not quite suppositories because there's a tremendous role for. But it's none of the companies, at least here in Canada, have made that a priority yet.

Trevor: Fair enough. We've talked with and it's another gray zone that we dealt with in a different podcast we've talked to with compounding pharmacies. I happen to be one too but, who are our compounding suppositories for patients with Inflammatory Bowel Disease? But it is it's definitely a gray area for where I practice in Manitoba, my college has said thou shall not touch cannabis. The gentleman we're talking to is based out of Ottawa. He the Ontario College of Pharmacy with a little more lenient. So, it was still a lot of hoops, but he managed to compound suppositories for patients and it worked really well. But you're right, at the moment its even compounding is a legally fraught episode.

Dr. Cooray: One of the difficulties that I have Trevor, is that medicine shouldn't have boundaries. Whether, the way that we practice in Ontario should be relatively the same as it as it should be Manitoba, Saskatchewan and elsewhere. Whether we're in Canada or the United Kingdom or the USA. When we have a medicine and we have some demonstration of evidence that it works, there should be no misinterpretation or misinformation that's going because of some degrees of control. So that's where I feel that even for ourselves, that Cannalogue, we are happy to be advocates because it's just, as you said, that you have patients that are in need and wanting to try. But because of the colleges and the regulations, the pharmacists as well as the doctors cannot get their hands on it. So I think this is it's an opportunity for us to maybe revisit the entire system. The medical system here in Canada, because the way that we practice medicine in British Columbia shouldn't be any different than Ontario or Manitoba.

Trevor: Well, I think you've done this before because is an excellent segue into why don't you tell us a little bit more about what Cannalogue is and what it does.

Dr. Cooray: Wonderful. Happy to do so. So Cannalogue is an online marketplace for medical cannabis products for patients all across Canada, where the medical cannabis products are recommended by doctors and the services are approved by Health Canada. The simplest way to explain it Trevor, is think of Cannalogue as the Amazon of medical cannabis. And the most important aspect for me to mention to your audience today is that medical cannabis is only online. So, if one of the audience members is looking for a prescription to access medical cannabis from a physician, we provide that entire service completely free of charge. There is no cost for the assessment for the patient and provided the patient has a reasonable indication for the use of medical cannabis, we will give them access to Cannalogue where they can essentially pick from all some of the best licensed producers in the country, the highest rated medical products. So that way they have a tremendous selection that's available at the convenience of their fingertips for delivery straight to their home.

Trevor: And that sounds like a wonderful service, especially I'm in a more rural part of a flyover part of Canada. So, people around my area don't necessarily have access to physicians who not that they're necessarily against cannabis, but have any familiarity to do it. So, an online portal is a great service. Now, I have to pick your brain a little bit on the money thing because it comes up. Now, six months ago, if you were a physician in Manitoba, you would not be able to bill for talking to a patient on the phone or doing a Skype call. Covid has changed that. And now physicians are able to bill for we'll call it telepresence talking to their patients. I know it was round a little earlier, Ontario, but gets back to how do your physicians get paid for the service? Are they billing their local ministries of health or is there a business relationships with the licensed producers? How's that work?

Dr. Cooray: Great question. So, what we decided to do here in Ontario and also to be able to extend the services and coverage all across Canada is that we initially piloted the telemedicine platform to see just because of the face-to-face encounter, to be to be able to document some of the necessary medical requirements, and what we found was that even the, it's not tremendously difficult. But depending on the technical savviness of the individual, even the telemedicine applications may be a little bit challenging. So, we then migrated to doing telephone assessments. So that way, it's just easier, particularly for the older demographic that are maybe not so comfortable with phones and computers. Just to be able to for the ease of access to be able to talk to a health care provider over the phone to access their medical cannabis prescriptions and the way that we do it and technologies that we actually don't bill OHIP. So, we're located in Ontario. But even if we were to provide services for Manitoba, Saskatchewan, elsewhere, we don't bill any of the prominent provincial insurance plans such as OHIP or others. Because for us, fundamentally, the way that we're approaching this is that we want to provide high quality medical services where the what we refer to, and I'm sure you're well aware, is where the schedule of benefits has certain requirements that are there. So, meaning that I must examine a patient's two systems to be able to be remunerated under the schedule. That's one example for specialists. And that's not feasible over there, over telemedicine, let alone a telephone. So, what we have decided is that in the best interests of patients, particularly to be able to grow the services of the medical applications of cannabinoids, we've decided to forgo billing any insurance plan across Canada for now.

Trevor: OK, and you can add to this or not, but at some point, your providers need to get paid for their services. This isn't just an altruistic operation. How are how are they getting remunerated at the moment?

Dr. Cooray: Great question. So, we're privately funded. So, because we're a privately funded, we don't necessarily have to put all of the monetary requirements and fees, including obviously paying our most important population of physicians and nurse practitioners. So, because we're privately funded, we're able to provide all of the services for the patients free of cost and then no additional expense to the insurance, the insurance programs, or OHIP at least here in Ontario.

Trevor: That is that's great. Thank you very much. I was scrolling through your website. There seems to be a few other interesting things Cannalogue is involved in. There was some compassionate pricing things, but the one that sort of caught my eye was being involved in some studies involving covid-19. Do you want to talk a little bit about those.

Dr. Cooray: Happy to do so? So, one of the, Cannalogue, because of our academic background, research is very much a priority for every single person at Cannalogue, especially for us physicians. And prior to covid-19, we had quite a numerous set of research interests that we were looking to further investigate heading into 2020. But obviously, just as nobody anticipated, covid-19 took the world by storm and there was no higher priority than trying to see if there's any applications of cannabinoids in the setting of a covid-19 infection. So what we actually uncovered Trevor, very, very early on, pretty much, I would say, because we're from the physician and medical community, we were tracking covid-19 back in Wuhan very, very early even into late fall of last year. So because of that, we were able to understand a little bit more about the way that covid-19 behaves in humans, at least to our best understanding. And what we uncovered was that there is a mechanism upon which one of the vital cannabinoid, cannabidiol CBD could potentially be beneficial in the setting of a covid-19 infection. Now, I want to preface this and make sure that the audience is explicitly clear that there is no evidence to suggest this. We are there's nothing for me to say that this will reduce symptoms or have any benefit. That is the purpose of the clinical trial that we are looking to further explore. So and I want to dissect this a little bit down for the audience so that it's clear. So part of this is that most people, when they think of coronavirus, or covid-19, they think about, well, what does CBD or any of the other Phyto cannabinoids do to the actual virus. Which is a very important question in the setting of, let's say, invitro or petri-dish type of experiment. That's a very important question. But the more significant question that we're actually looking at is what is the impact to the host from covid-19? And could cannabidiol CBD potentially reduce the severity of symptoms in the host? And now there's a fairly robust amount of literature that says that the cytokine storm or the inflammatory response to covid-19 is in fact a predictor of the severity of illness altogether. And in fact, males over 50 for many different reasons are the highest risk population. And males over 50 with certain immune markers like an elevated IL6 are the highest risk population to have a fatal outcome. And because of this, what we understand is that CBD and the other Phyto cannabinoids have anti-inflammatory properties. So because of the anti-inflammatory nature, we believe that CBD, although very early and we can prove we have not proven this yet, may in fact reduce the severity of symptoms and covid-19 by just exerting its anti anti-inflammatory properties on the host.

Trevor: That's fascinating. Myself and I think everybody else have become amateur virologists. And I'll plug another podcast TWIV, where they talk about different biology things. And yes, they go into great detail about, you know, it seems to be in week two and the infection may even be on its wean. But the cytokine storm seems to be doing all these weird and wonderful things in the body. Everything from the strange clots to infiltrate in the lungs to Covid toes. Everyone seems to be not contributing so much to the virus, but to the immune system going bananas. So you're saying that you're at least thinking or hoping or studying that the CBD might sort of calm down the immune system enough to calm down the cytokine storm?

Dr. Cooray: That's exactly it. So depending on the individual, each individual based on their genetics, has a different type of risk. Age is risk. Sex is a risk. So, because of that, then the high-risk individuals, if we can hopefully maybe just calm or suppress the inflammatory response to the virus, we anticipate that the outcomes actually could be better in high risk individuals.

Trevor: Wow. That me and everybody else will love to read that paper when it comes to that. That sounds great. So, I will poke one more of that. So how are you getting the CBD into these individuals or are planning to in the study?

Dr. Cooray: So, one of the difficulties in terms of navigating this Trevor, that you identified is that the process for clinical trials in humans that we are looking to try to explore with cannabinoids very much parallels what's happened in the pharmaceutical space. So because of that, the standards upon which we are trying to conduct clinical trials in humans has certain requirements to be able to move forward. So, what we're actually doing right now is that we're in discussion with Health Canada as to how we can navigate this, where we understand that maybe some of the requirements are not necessarily there just because it's a shorter time frame that we have to be able to even apply these principles in the first place. But it doesn't defeat the medicinal properties or the active ingredients will in the body. So, the way that we're looking to execute this is very much more so as an outpatient study rather than a hospital study. But the challenges are that we still have to meet all the rigorous standards from Health Canada. And that is the best way to say it without going into the details is that that's a work in progress that's very difficult to maneuver around. And this is probably why, you know, taking a drug of any variety to go through the phases of a clinical trial are extremely difficult.

Trevor: Well, we wish you the best of luck. And like I said, we're all willing, ready to hear that that paper. So anything else I've missed on how Cannalogue works or more about what our listeners need to know about. If Cannalogue sounds like something that's interesting to them, how they access the service or maybe even let's say I'm a family physician in rural Saskatchewan. I go I've got all these people asking me about cannabis. I don't know what to do next, could Cannalogue help them. How could, between the patients and the physicians, how I Cannalogue help?

Dr. Cooray: Absolutely. So, for I'll maybe answer the physicians and I'll come back to the patients. So, for the physicians, we have a brand new discovery program that just launched last month. So, for physicians that are actually looking to learn to be able to prescribe themselves. We have an entire program that's dedicated for them so they can come to Cannalogue in, they'll see a ribbon banner at the top. They can just follow the instructions to sign up. Now if they're not comfortable prescribing themselves but, they would just like to, if they have a patient that they think might benefit someone with chronic pain, insomnia, anxiety, many different applications altogether, we are more than happy to take referrals and then we can service the patient.  Full service. So that way it doesn't take additional time for the physicians and we can take care of everything on behalf of the physician. So if they're interested in prescribing, they can come to Cannalogue and be part of the discovery program. If they're interested in referring, it's a very simple referral process and they can refer to us directly. On the patient side, I wanted to highlight one important thing Trevor. So particularly because of covid-19, even before covid-19, we were launching the best compassionate program in Canada. The most inclusive program where we have the lowest medical crisis in the country. And because of covid-19, this is a medicine for us and there's no greater of a time to give them medicine than now. Particularly given some of the stressors, mental health issues that are there. So, we have extended our compassionate care program to include eligibility for any anyone that might have been impacted by covid-19. And we have the lowest prices for medical cannabis products in the country. Currently, with prices as low as three dollars and 50 cents a gram, 20 to 50 percent off some of the products. So, I just want to make sure that the audience was aware that if prices is a factor these days, then by all means, we are hoping to remedy that by going below costs at Cannalogue. If anybody has private insurance or an insurance plan of any variety, all of those insurance providers are approved. Cannalogue is an approved provider. So, they can access all of their treatments there. And the last thing I want to mention for the patients is that the problem that we solved when we were looking at the broken system of maybe five, six years ago when I was a skeptical physician, not understanding what's the dose, how to prescribe. And it was a very complicated system. What we discovered or uncovered back then was that when a patient got their prescriptions for medical cannabis, they were locked to one producer. And with the Cannalogue platform, they're never locked anymore. They get access to the best medical producers in the country where they have access to all the different types of medical cannabis products. In terms of oils, capsules, even topical that are coming in, and more lines of products that are coming. So, they're never locked to one licensed producer anymore to have access to all of the products that are recommended by doctors within their fingertips for delivery to their homes. And we've tried to make the entire experience for patients from A to B as simple and easy as possible. So, any patients that have any concerns or questions Trevor, we welcome them. Please, if they can go to www.cannalogue.ca. All the information for patients, are right there.

Trevor: That sounds like a, especially for rural Canada, that is fantastic. Anything that we can do sort of without having to drive a few hours to major cities is great. A little off topic, but I got into a conversation with one of our other physicians. So, our co-host Kirk, you won't hear him now, but he'll be coming in later. He works up north with several physicians. He's in sort of remote rural communities. And one of the ones he said, this is a great guy, but so anti cannabis. And he forwarded Kirk some stuff from the Manitoba College of Physicians and Surgeons listing all the reasons why physicians shouldn't be involved in medical cannabis. I guess the ones that and he actually used the word criminal. "I think those cannabis doctors are criminal." I think you're going a little far. But the big ones, he pointed out from our local college, was to make sure that an authorizing physician must not have any working relationship with any licensed producer and must not be in a premises clinic or other provided by or subsidized by licensed producer, which sounds like they want to make sure there is zero, we'll call it quote unquote, business relationships between physicians and licensed producer. Which seems silly when you consider the number of business relationships there are between pharmaceutical, big pharma and different clinics. Any thoughts on I know you guys are based out of Ontario, so the Manitoba college doesn't directly impact you, but how we might convince the Colleges of Physicians and Surgeons across Canada, like you said, to have more reasonable and consistent regulations across the country for cannabis prescribing doctors.

Dr. Cooray: This is such an important area Trevor. It actually makes me sad to hear what you just said because I left my digestive practice.  I have over 13 years of post-secondary education as well as, you know, numerous years in practice. And I left that to be an advocate for medical cannabis, not just here in Canada, but all across the world. And I think part of this is to understand why would someone like myself that went through a rigorous specialty specialization program, why did we never hear about the human endocannabinoid system? Why did we even never consider cannabinoid cannabinoids ever in any treatment algorithm? Is there some potential bias that could be influencing our present decisions to want to have more and more and more and more evidence that may be beneficial to somebody else, although potentially leaving our patients that are suffering and continue to be subjected to harm or even harmful medications like opioids. The root cause of a lot of this is a demonization of cannabis that was painted from the 1930s onwards. With regards to what I would call propaganda. They decided to end prohibition and there was all this messaging about alcohol and they decided to paint the wrong picture of cannabinoids. And what I personally believe is that this effect has led onto the translation of thought between generations. All the way down to where we are now and among very highly educated and respected individuals in the colleges and physicians across the country. So, the key here is that it's a comparison of apples to apples. Cannabinoids are far safer than opioid. Cannabinoids, in fact less addictive with no if we're talking about CBD with no psychoactive properties compared to alcohol. So I think part of this is the inability of highly educated and specialized individuals that are working in this area to be able to see for themselves what's happening. And they want to condone their existing way or practice because it works for them for whatever way it is. But unfortunately, until they want those requirements, which could take another five or 10 years, people will be becoming addicted to opioids, continuing to be addicted to alcohol, having life threatening ulcers from NSAIDs when there's a safer alternative right there. And that's where I'm happy to speak to all of the tops of all of the colleges, physicians, surgeons, nurses, whoever across Canada, because I think there's a fundamental role for reeducation that needs to be done. And part of my obligation to even the Division of Innovation and McMaster University is to be able to retrain physicians as well as regulatory authorities on the medical applications because they just don't want to learn themselves.

Trevor: Well, that is that that's a pretty much fantastic way to end. But in case I missed anything, was there, was there anything you thought I was going to ask. Wished I was going to ask? Was there any sort of closing thought you had. We will probably put that as your closing thoughts anyways. That was perfect. But anything else I missed?

Dr. Cooray: No Trevor, no I think that's wonderful. I think the maybe the only point that I would maybe direct the audience is that depending on the applications, chronic pain is a one application where there's a benefit that's there. I've seen a lot of benefit in digestive diseases with Irritable Bowel and other digestive problems. Sleep disorders, insomnia is another big area. Stress disorders, anxiety, depression, particularly during covid-19. A lot of people are having stress for many different reasons. Maybe being in the house too much, maybe being with the family too much, or it could be just financial reasons. So this is where cannabinoids, medical cannabis particularly, and CBD, I'm a huge proponent for CBD because it's not addictive. It's not intoxicating. There is no psychoactive elements and it actually has tremendous medical applications. So, if the audience becomes aware of how one could potentially benefit, whether even it's for their arthritis or their fibromyalgia. Point is that there's a tremendous role of medical cannabis in traditional medicine that we just have not yet discovered.

Trevor: Kirk, I really, really enjoyed that conversation with Dr. Mohan Cooray. What a what a fascinating guy. Someone who has done so much education like, you know, thirteen years of formal education and then some residency stuff. And then where did gastroenterology and then of left turn into cannabis.

Kirk: What I found fascinating about this is the business component of what he's offering. So, we both have done a little research. What do you know about doctors prescribing or working with cannabis on a national level?

Trevor: Well, not a lot is the short version. None of the ones we've talked to get their money directly from the patient. So, we know that. They seem to, the ones we've talked to anyways, we'll call it these telepresence ones, whether they're phone or they Skype or they Zoom with the patients. The patient doesn't pay anything up front, but they also don't seem to be billing their local Manitoba Health, Ontario Health and New Brunswick Health. Their money seems to come from somewhere else, I think is the safest thing we can say. And the other part is the how it's actually licensed gets a little, I'm not I don't know is the short version because like doctor, doctors are licensed in different provinces. So, what does that mean about what? Dr. Curreri talked about that a little bit. To do a proper bill OHIP which is Ontario Health, he's supposed to review two systems and I'll let you tell what two systems are to do a proper billing to OHIP. But he's not billing OHIP. He's getting money from somewhere else to talk to a patient. So, I'm not quite sure exactly where the money's from. One of the obvious places that I don't know, but an obvious place would be money from the licensed producer, but I don't know that for sure.

Kirk: Well, I want to work backwards so our listeners sort of understand what we're talking about. I'm a Registered Nurse in the province of Manitoba. I, I can call myself a Registered Nurse anywhere in the Commonwealth because I'm registered in Manitoba. Now, I cannot work in anywhere in the Commonwealth unless I'm registered in that jurisdiction. For example, I was once registered in the College of Nurses of British Columbia. I was once registered with the College of Alberta and now I'm registered with the College of Manitoba. So for me to function as a nurse and to and to earn a living, usually I'm employed by a Manitoba employer. So Regional Health Authority would employ a nurse in Manitoba. And I'm registered in Manitoba. I work for the federal government in the north. So I'm registered in Manitoba. I work in Manitoba. But there are nurses from New Brunswick that come to Manitoba to work in Manitoba. So they're registered with Manitoba government as a nurse. When I went to Ethiopia, I had to register in Ethiopia. Now, the point is, is that to work in a jurisdiction that must be registered, but no matter where I go, I can call myself a Registered Nurse. So there's a subtle difference right. Now you as a pharmacist, your college works a little differently. You're licensed. You're not necessarily considered a registered pharmacist, right? You're a licensed pharmacist.

Trevor: Yes. I think it does get a little it does get a little confusing. I'm a I'm a licensed pharmacist in Manitoba. Other jurisdictions actually have the initials RPH to registered pharmacist. So it gets a little murky.

Kirk: OK.

Trevor: What it means for me is I can work in a pharmacy anywhere in Manitoba. If I was suddenly to move to Saskatchewan, I'd have to take a new test, pay them some money and get licensed in Saskatchewan.

Kirk: Well, now, see, that's interesting. There should be internal free trade, right, of goods and services. And this is where my research on doctors and this is what I wanted to understand about doctors. Doctors must also be licensed in a province in order to practice in that province. And this is where I guess it gets kind of interesting is how does a doctor bill for his service? A doctor is a private entrepreneur, has a proprietorship, has a limited business, and his business then builds the government of Manitoba when he does a does a procedure or an assessment. Now, you talked about systems. Usually in my practice, if I have someone who comes in with a respiratory issue or a cardiac issue, my job is to usually assess systems above and below. So, if you come in with a lung problem, I should I should assess the cardiac lung system and maybe the abdominal system. And so you get an understanding how the body's reacting. So, in I guess in Ontario, they have to assess two systems. So, someone comes in with a cardiac pain. I assume the doctor would have to assess the respiratory and the cardiac if that's for billing. As an employee, I can't bill, because nurses don't often, nurses are often seen as private entrepreneurs, whereas doctors.

Trevor: You're usually salaried employees. And there are such things, a salaried employee doctors too, that does exist.

Kirk: Certainly there are. And they tend to be specialists that work within hospitals, emergency docs and that sort of stuff. But when I when we interview these doctors and we've done this a couple of times now Cannalogue, we done it with HelloMD, these are physicians that are offering their services to people in other provinces. And this is where it gets very interesting. If I'm in Ontario and I got a patient in B.C., how am I allowed, and it's not considered a prescription, it's called a medical document.

Trevor: Medical document. Yeah.

Kirk: And we were trying to hash this out, you and I off camera. It must be because cannabis is a federally regulated medicine appose to provincial.

Trevor: Yeah, I think yeah. I think we're back into cannabis kind of living in another gray zone. Yeah. So, I'm not I'm not entirely certain how you know, how it would be different from, you know, let's say someone came to Manitoba, had gallbladder surgery, then went back to B.C. and they did a follow up phone call with their Manitoba surgeon, you know, the Manitoba surgeons, his butt is still in Manitoba. The patients in B.C. They've figured that out. But this is this is different.

Kirk: Well, and that's and that's interesting. I'm glad you brought that up, because we've heard this before by other interviews that are Cannabis Doctors tend to see themselves as specialists right. So, but yet when I look at the College of Physicians and Surgeons of Manitoba Standards of Practice document authorizing cannabis for medical purposes, the wording is very interesting. The wording sort of says here, a member who authorizes medical cannabis must not be legally and beneficially involved with licensed producers and dispensers other than for the purpose of providing expert opinion, independent and impartial education and conducting clinical research.

Trevor: And I did bring that up with Dr. Curreri and he talked about it a little bit. Basically, it sounds like in his opinion, he would he would like to change that. He thinks there's a bunch of things with the medical system in Canada that are goofy and that he actually talked about boundaries quite a bit, that basically he thinks medicine should be boundaryless and he should be able to sort of help people across Canada. And I guess that's kind of one of the points of Cannalogue.

Kirk: And I agree with him, but it's  interesting to read the wording. You know, I've been deep into the guidelines, the standard of practice. And I and that led me to the clinical practice guidelines of the College of Canadian Family Physicians. And it led me to read the Authorized Dried Cannabis for Chronic Pain and Anxiety from the College of Canadian Physicians and Surgeons. It's all very interesting language and it really gets back to how cannabis is so separate from the.

Trevor: Everything else.

Kirk: Well, and it's like the even the fact that there's no DIN number for it.

Trevor: Yeah, well, that's and I don't think I'm giving anything away. I'm going to try to get Rahim Dhalla back because he's doing something. He was a pharmacist we interviewed a little while ago, Hybrid Pharm out of Ottawa. He's doing some more interesting stuff. But yeah, the no DIN numbers back to it's not doesn't go through pharmacies, but I'm going to make you take another left turn. Kirk, they have a Covid trial or are hoping to organize a Covid trial with CBD. Thoughts.

Kirk: That leads me back Trevor, to the whole concept of episode fifty-three. The CBD have Covid Aced, you know, so they want to get into it. And what did we learn from that study that episode.

Trevor: Yeah that maybe.  Some of it. And they definitely had some strains that were doing some good things, but some strains might actually be making it worse. Now that was a really, really not important, but it was very different. They were doing very, very specific bench studies. And Cooray is talking about a sort of a broader clinical study. They're both we could learn a lot from both, but they're different. I'm just excited someone else is looking at CBD and Covid

Kirk: Well, it's also I was listening to the way he used his language. And I wonder if he's experienced the same thing that we learned in Episode 48 with Doctor Nurse. And in that right now, it's very easy to get research dollars for recreational cannabis and very difficult to get study dollars for medical cannabis because he said he's hoping to do the study, right?

Trevor: Yeah. No, I wondered the same thing. You know, there does seem to be, you know, is this just general? It is not an easy thing to run a study problem or is this a cannabis specific one? So, yeah, when he was talking about, you know, some of the challenges they were experiencing with this, was that was it cannabis related?

Kirk: You know, we were both are not doctors. But again, part of what we're doing here is asking questions of health professionals. And sometimes when we get answers back, I wonder about stuff. Here's another question I wonder about. These doctors and the team that the team that Cannalogue works with. How do some doctors become canna-positive and some doctors don't? And I wonder, I wonder if it gets back to their initial training and the school that they go to, because McMaster's sounds like a very open school.  Because we've had other guests. Dr. Shelley Turner was a graduate of McMaster's.

Trevor: Yeah. And McMaster is kind of the place in Canada where evidence-based medicine kind of took hold. They were kind of one of the leaders in that. 

Kirk: so how is it that graduates from that program are two very positive cannabis doctors while we meet, we still meet doctors who say there's no evidence, no evidence. And even and even in the literature published by the College of Family Physicians of Canada or even the College of Manitoba, it's very negative...  negative? Often the wording suggests that there's not enough research, there's not enough research. Whereas when we start talking to cannabis, positive scientists, doctors, they say the evidence is there. You have to look for it and find it and recognize it.

Trevor: I don't know if we'll answer that, but I think Dr. Cooray made a nice point that he said, you know, during his 13 years of training, he never heard about the endocannabinoid system. And probably one of the obvious places to start with this is talk about the endocannabinoid system in, you know, pharmacy, school, medical school, nursing school, get it in there. So, you know, at least they've had some exposure before they went out and practice.

Kirk: What a wonderful segue bringing us right back to what I talked about in the front. Now that I'm a Cannabis Competent Nurse, part of that training, part of that training that I took spoke to that how nursing schools, pharmacy schools, medical schools are slow to incorporate the endocannabinoid system and how post registration, postgraduate education is so needed for our professions. For nurses. For pharmacists. You know and also Trevor, you know, when you think about sending you what do you think about the fact that Ontario can have pharmacies, Ontario pharmacies can have cannabis, and Manitoba pharmacies don't have cannabis yet?

Trevor: Well, I think that's bad. But more importantly, that's one of the reasons I want to try and get Rahim from Hybrid Pharm in.

Kirk: Yes.

Trevor: I don't know how he's doing. Like what he was doing before. From what I'm reading on Twitter and some other things, he and I don't know. I don't want to put words in his mouth, but it sounds like you might actually be able to get it at his store. But I'm still a little unclear whether this is he is acting as because we'll go back to Cannabis by Shoppers. So, Shoppers Drug Mart has kind of a cannabis division, but you can't walk into a Shoppers store and get it. You still have to get your medical document from a from a prescriber. You send it to Cannabis by Shoppers and then they mail it to you. There's still no physical walk in dispensary. Is Rahim an independent version of that or is something else going on? I would love to find out. So, yes, I'm going to get a hold of him.

Kirk: All the guidelines in the guidelines. I've been reading the physician guidelines. There is some there is some wordage verbiage that allows the doctor to have cannabis sent to them.

Trevor: That's been true from the beginning of medical cannabis because they want to make sure even if somebody was homeless, they'd have a way to get medical cannabis to them. So, there's always been that option to send it to your doctor's office. Whether or not doctors wanted that to happen or not, I don't know. But that's always kind of been a provision in there.

Kirk: Interesting. You know, we're getting into the high 50s, the number of episodes we have out, and I still see more and more stories that we have to cover. We need to do this full-time man.

Trevor: Sure.

Kirk: Maybe we can find maybe we can find somebody to sponsor this show called Reefer Medness - The Podcast.

Trevor: That would be wonderful. So, tell them to go to the website and maybe send us an email that This email address is being protected from spambots. You need JavaScript enabled to view it.. And we would love to send them a sponsorship package and tell them how they could sponsor this fantastic podcast.

Kirk: Fantastic podcast. Also My Cannabis Stories.

Trevor: Yeah, I've been I've been waiting looking for one. So please, please, please. If you have an interesting story about cannabis or even a dull one, you know, we want to hear about people who are using cannabis and like it. Using cannabis and hate it. Using cannabis for a condition we haven't talked about yet. We just want a one to two-minute video blurb, audio blurb about what you're doing. Easiest just to record the voice mail on your phone and email it to us.  Again, This email address is being protected from spambots. You need JavaScript enabled to view it. or This email address is being protected from spambots. You need JavaScript enabled to view it.. Go to the same place and that would be great. We love hearing them and we know everybody out there loves it when we share, share those stories.

Kirk: I think so too. Yeah. And what I liked about this particular episode is ultimately it was a My Cannabis Story about an Internist.

Trevor: Yeah, yeah. No, that was that was really, really good.

Kirk: So, we want to move on to music. You know what I was thinking. When was the last time you recommended something?

Trevor: Well.

Kirk: For Music?

Trevor: I don't I'm sure this doesn't count at all, but this weekend I've been listening to this guy who's doing heavy metal remakes of songs, and his name is Leo Marcarelli. And he's done everything from Frozen to Adele and at Leo's heavy, heavy metal version of Adele's hello, I loved it. It just made me happy. Now, whether that's something we can use on this or not, I don't know. But that really, really made me smile while we were cooking pasta sauce this weekend.

Kirk:  OK, your voice is all broken, garbled.

Trevor: OK, 30 seconds might have to insist that some kid stop doing what he's doing. Just a second.

Kirk: OK, you're back. You're back. I'm back. No, you paused where you pause.

Trevor: No, no, I'm talking a b c d e f g h i j k l m.

Kirk: I hope you're back. OK, so you're back.

Trevor: Whatever he was doing, he stopped.

 

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