As a physician practicing both internal medicine and cannabis medicine, I was particularly pleased to hear recent statements from the White House as well as our State Legislators widening the Cannabis playing field.

However, before we all begin to applaud too loudly, I would like to see this in some formal written statement. That statement must include two key points:
1. The States can run their own Medical Cannabis programs without any Federal interference.

2. Physicians should be able to run their own clinical trials on cannabis and begin answering many of the pro and con issues with the medication.

I suspect and feel comfortable that allowing physicians and scientists to finally legally study this amazing group of medications will lead to various therapies we only currently dream about.

Re: LA County Proposed Ordinance to Severely Control Edibles and Concentrates in Dispensaries

To the Honorable Councilmember Ed P. Reyes

I am a Board Certified Internist having practiced in Santa Monica and Venice for 30 years. My sub-specialty is in psychopharmacology, so my transition to becoming a practicing Cannabinologist was very comfortable.

I am not a politician or “activist”. I am a Physician. My responsibility is solely to my patients and my positions in this letter are entirely on their behalf. During my patient visits, I determine whether some form of Cannabis might be of benefit to them. Then together, through an education process, the patient and I determine whether this might be the case for them.

My patients use various methods to medicate themselves with cannabis products. Most of them are very motivated to look for non-combustible means of medication administration. Vaporizing is certainly an answer and is commonly used, but this is not always practical. It is for this and other reasons that many of my patients, not wanting to smoke, turn to tinctures, concentrates, hash, (which is just cannabis) and edibles. It would be a great loss to my patients if these alternative means of ingestion disappeared. I love the idea of everyone growing their own cannabis, but that will not happen easily or quickly and my patients need help now. In addition, in certain jurisdictions, growing at home would guarantee a visit from child protective services. The current system may not be perfect and perhaps is not entirely legal, but it gives tremendous relief to my patients.

I have found Cannabis, in many forms, to help most of my patients. They are usually on other medications and I frequently speak with their Physician as to how to best move forward. There is no doubt in my mind, that nearly 100% of the Physicians I have personally met and/or spoken with, are primarily concerned about their patients smoking their Cannabis. Not a single MD I have spoken with is comfortable having their patients use Cannabis in a smoked form, but nearly all of them are very much behind tinctures, concentrates and edibles.

Attached to this letter is a photo of a wall in my exam room. It shows, as if on an old pharmacy shelf from the 1800’s – 1900’s, many Cannabis tinctures in both Sativa and Indica forms – all were manufactured by major pharmaceutical companies still in business today. “Active ingredients” were not listed,  the physicians of the day tested the “strength” of these tinctures physiologically, meaning they had patients try it and see what happens.  This process is similar to what I have done for the last 30 years with current pharmaceuticals. As I like to say, back to the past…

Many of my patients use tinctures and edibles exclusively. Many have either never smoked and haven’t since college or have no intention of  ever smoking. I know for certain that if my patients were left only the smoke-able form of cannabis, they would be extremely unhappy. More to the point, I would not be able, as their physician to advise them what to do. We should all be careful to monitor and regulate the concentrates and edibles, however, on behalf of my many patients who rely upon these products.

There is another significant group of patients who are being forgotten and these are the patients that everyone agrees the Compassionate Use Act was meant to address. I am referring to the most ill patients with cancer or HIV that have a depressed immune system. Many oncology doctors and HIV specialists are reluctant to have these patients smoke cannabis as there are various types of mold that once inhaled can at times lead to a fatal infection in these immune compromised patients. They need tinctures, edibles and even hash suppositories.

There may be additional regulations and controls required in the dispensary systems, however, the wholesale destruction of the current system would leave many thousands of patients without their medicine. If the above arguments and those made by others to protect the product selection, lead to a reasonable and rational “dispensing solution”, we have all done our job. However, if  all sides cannot reach accord, I would propose another solution that might be inflammatory to some, but IF required, could be a tenable solution: raise the minimum age to 21, unless accompanied by a parent.  As well, institute some strict but patient-friendly regulations and move forward with the city of Los Angeles working together to allow the safe growth of LA based cannabis medicine.

On behalf of my many patients, I would ask that we seriously consider holding off on major dispensary changes until this issue is given adequate consideration by all involved.

Kind Regards,

Allan I Frankel, MD

Below are listed the important people involved. Calls and/or emails from all of us would be helpful to all….thanks, allan

Councilmember Ed P. Reyes
200 North Spring Street, Room 410
Los Angeles, CA 90012
Phone: 213-473-7001
Fax: 213-485-8907
E-mail: councilmemeber.reyes@lacity.org

Councilmember Rosendahl
councilman.rosendahl@lacity.org

Councilmember Hahn
councilmember.hahn@lacity.org

Councilmember Zine
councilmember.zine@lacity.org, councilmember.zine@lacity.org

I often hear that patients are worried about being on a “list”. This can and does create a lot of fear over losing privacy – as it should. So, here are a few key points to help clarify what is really going on:

1. There is a “State/County” Card. This is always issued by the local county where the patient resides. It is NOT MANDATORY. This is a voluntary card.

2. When you see a Cannabis Physician, you receive the “Doctor Letter”. This letter enables the patient to visit any Dispensary in the State of California. It also allows you to purchase the VOLUNTARY Card.

3. In my experience, both the police and dispensaries in Southern California better recognize the Physician Letter. Additionally, often even if a dispensary “accepts” the card, they still want to see the letter.

4. The “List” is generated only when a patient purchases the card.

5. So, save $200, save a trip to the county and remain private – just don’t purchase the state card after seeing the Physician.

I realize that many people believe that the basic ID for Medical Cannabis is the “card”; in fact it is the letter that physicians create. I hope all of this helps.

I was initially going to post some thoughts I have concerning Cannabis causing psychosis, but decided not to because in summary, I believe the data for this is at best weak.

Of much more general interest is the relationship between Cannabis and anxiety. There are hundreds of articles/blogs claiming that either Cannabis causes anxiety or that it helps anxiety. I believe this is primarily strain related and will address this further, but wanted to first comment that many, many medications I have prescribed in the past have been for anxiety. However, in a certain percentage of patients, these pharmaceuticals would at times increase anxiety. So, this is certainly not rare and should not be a reason to dismiss the patients for whom Cannabis works well for anxiety.

So, back to the strains. In general those patients, who become agitated, paranoid or even perhaps borderline psychotic, have been using sedating strains of Indica. These strains tend to worsen our ability to focus and this results in calmness and sleep for most of us. However, for some patients with anxiety, this loss of focus triggers a loss of connection to their environment and paranoia may creep in. On the other hand, low doses of more activating strains of Cannabis very rarely, if ever, cause these symptoms.

In my personal clinical experience, the patients who seem to become increasingly anxious from Indicas, do very well on Sativa strains.

As the Obama team begins deciding how to handle the Cannabis situation, we all need to review what we really want to happen. Naturally, many of us would want total “legalization”. This will just not happen as there would be way too many people upset that it is being handled even looser than alcohol. People will not tolerate seeing weed in every grocery store.

So, perhaps “decriminalization”? This would be similar to alcohol. Age and access restrictions would apply.

What about the re-scheduling of Cannabis into Schedule II? Then it could be written on a typical MD “triplicate” form and every MD could prescribe it.

The final option is for the Feds to just stay out of the states and allow the states to decide about distribution and related details. Also, this would also allow scientists to study Cannabis – a major issue for all of us.

Complete legalization is not going to happen. What happens if it is re-scheduled but all Cannabis products would probably be produced by Pharma and controlled by the Feds since they control the triplicate Rx’s of physicians.

Personally I would be most content with a Federal hands-off approach and de-schedule Cannabis and classify it as a Herb. In this manner, both Pharma and “organic” solutions can be pursued.

For more than 2 years I have been cautioning patients regarding edibles. The time of onset is delayed as compared with tinctures or smoking/inhaling and the Cannabinoid dosage is often “higher” than expected.

So, frequently a very intense and sedating “indica” type feeling overcomes the patient for many, many hours – i.e. way too stoned. A 91 year old patient of mine manages her pain strictly with edibles. She came in recently for a renewal and during the visit, I asked her how she was using her edibles so successfully. She told me she nibbles on her edible often over a two day period. After speaking with her further and then discussing the same issue with a number of patients I have come up with an “Edibles for Dummies” suggestion list:

1. Regardless of how you are told how strong the edible is, it is generally best to ignore what is said.

2. Take a very small morsel or nibble – dime size or a bit less at a time when you have the entire day available…just in case.

3. Wait 90 minutes and see how you are feeling.

4. If you are feeling medicated or probably medicated, do nothing more and wait another hour and re-evaluate.

5. If you feel nothing, take 2 nibbles and wait a couple of more hours.

6. Continue a similar version of the above until you begin to learn what works best for you.

I would appreciate feedback on this one??

BBC Interviews Dr. Frankel

Peanut Butter   9 and counting

Marijuana           0