Check out this article: http://www.huffingtonpost.com/2009/08/30/colorado-attorney-general_n_272227.html

Apparently in Colorado, there are 10,000 Medical Cannabis patients. The latest issue is that there are claims that these patients for the most part are being seen by a small number of Cannabis Physicians. In other words, they are concerned that docs are “raking it in” by seeing tons of patients every day.

For example, it is claimed in this article that a number of the docs see 10% of the state’s cannabis patients. This would represent approximately 1000 patients per year.

So, let’s assume that there are only 10 Cannabis Docs in Colorado (many more in reality). If each of these docs saw 10% of the state’s patients, that would be 1000 patients per doctor. As there are approximately 250 work days in a year, this would mean that each doctor is seeing 4 patients per day. This is certainly NOT very rushed. Assume it is double, and a solo doctor in Colorado sees 8 patients daily. This would mean that he/she is seeing 20% of the state’s patients. This would allow each patient nearly one hour.

So, is an investigation warranted? I doubt it considering that most primary care docs see 30 or more patients per day!!

So, where should the investigation begin?

By Jay R. Cavanaugh, Ph.D.

Many patients who utilize and benefit from medical cannabis do not wish to smoke due to the perceived health hazards of smoking or for other personal reasons. These patients are in something of a bind. Smoking cannabis delivers the active cannabinoids within seconds. Medicine is absorbed in the lungs and goes directly to the brain and general circulation. The same effect can be achieved with a vaporizer, which is safer than smoking burning vegetable matter. Since the effects of inhaled cannabis are so quick, it is easy for patients to titrate their dose by simply waiting a minute or two in between puffs.
Oral cannabis, such as our Better Bud Butter, is absorbed in a very different fashion from smoking or inhalation. The GI tract gradually absorbs Cannabinoids over the course of one to two hours. Medicine is processed first by the liver, which converts some cannabinoids such as delta nine to delta 11 version of THC. Orally delivered cannabis requires four to ten times the amount of the smoked version in order to achieve the same effect. Orally delivered cannabis can present a problem in achieving the required or desired dose level in any consistent fashion.
Tincture is designed to address the problems of rapid medicine delivery and consistent dosing. Most tinctures are made to be used under the tongue or sublingually. English pharmaceutical companies are presently working on a cannabis extract “spray” that can be used under the tongue in a similar fashion. These sprays are not expected to be approved for use in the United States for years and will be very expensive. Absorption by the arterial blood supply under the tongue is completed in seconds. One trick is to not swallow the dose as, if swallowed, absorption will be in the GI tract. Many patients, though, add their tincture to a cup of tea or cranberry juice for easy delivery. When tincture is used in a beverage, absorption will be slower than if absorbed under the tongue. While tincture absorbed in an empty stomach is accomplished in minutes, conversion in the liver remains, as does the difficulty in titrating dose. Usually, a tincture dose is delivered by means of a medicine dropper or a teaspoon. A rule of thumb on dose is that patients receive benefit from 3-4 drops to a couple of full droppers depending upon the potency of the tincture and the patient’s own unique requirements among other factors.
The methods listed below will detail two major methods of preparing tincture. While the methods are optimized for purity and potency, ultimately these will largely be determined by the purity and potency of the cannabis from which the tincture is made. Another item of note in regard to starting material for tincture is the patient or caregiver selection of strain. A rough rule of thumb is to select Indica dominant strains for cramping and muscle spasticity and Sativa dominant strains for pain relief. The reality, though, is often that the strain is unknown or not well characterized. Trial and error is usually required to acquire the appropriate strain and the proper dose level.
General Rules:
Tincture is an extraction of active cannabinoids from plant material. Cannabis contains many chemicals that can either upset the stomach or taste nasty. One of the goals of extraction is to secure the cannabinoids while leaving out as many of the terpenes and chlorophylls as possible. Both heat and light adversely effect cannabinoids and should be avoided or minimized. Tincture should be stored in airtight dark glass containers kept at room temperature or below. Avoid plastic containers. The ethanol in the tincture may solubilize some of the free vinyls in the plastic.
Cold Method with Ethanol
Making tincture cold preserves the integrity of cannabinoids. To be potent, this method requires starting material high in cannabinoid content such as flowers or kief made from trim and leaf. The material must be mold free and dry. Drying can be accomplished in the freezer (-4-10 degrees Celsius) or better yet by placing in a liquid proof bag into a dry ice/ethanol ice bath (-70 degrees Celsius). Once water has been removed then the surface area of the starting material requires expansion. This can be accomplished a number of ways but two ways stand out:
Using flowers (bud)- Place dried buds in a coffee grinder and pulse until thoroughly ground but not powdered.
Making kief- Rub dry trim and leaves over a silk screen. Collect the powder the comes through the screen. It should be a very pale green. “Kiefing” is an age old way of extracting trichomes from plant material.
Whether kief or ground bud is used both should kept ice cold for this preparation. Similarly, the ethanol to be used should also be ice cold throughout the process.
Selection of alcohol- ethanol or ethyl alcohol is the form of alcohol that can be used by humans. The proof listed on commercial alcohol refers to the percentage of ethanol that the beverage contains. The proof is twice the percentage, so 80 “proof” means that the mixture contains 40% ethanol. The higher the alcohol content used, the better the extraction will work. Ideally, 200 proof ethanol would be best except that ethanol cannot be distilled to this proof so benzene is used to remove the last vestiges of water. This makes “pure” ethanol poisonous.
Many folks use “Everclear” which stands at 190 proof or 95% ethanol. Everclear has no taste. Apparently, Everclear is not available in all States. A close second choice is 151 proof rum. This is a light amber liquid that is 75% ethanol that has a sweet taste. One of our caregiver writers will use nothing but Korbel brandy because she likes the taste. Others use iced Russian vodka. These “normal” distilled spirits are 40% to 50% ethanol. Some patients find that the higher proofs ethanols like Everclear and 151 rum burn too much under the tongue. If burning is a concern consider a high quality 90-100 proof Vodka.
Cold Extraction and purification- Use at least one ounce of starting material to each pint of ethanol. Place cold powdered kief or ground cannabis flowers together with ethanol in a glass quart-mixing jar. Close the jar tightly and vigorously shake for five minutes then return to the freezer. Continue to agitate the mixture every few hours with refreezing. Continue for a period of two to three days.
Pour the cold mixture through a double thickness of sterile cheesecloth. Save the cheesecloth “ball” for topical uses or use the material to make bud butter once dried. The liquid collected through the cheesecloth should then be filtered twice through a paper coffee filter. Use gloves throughout the process, as it is necessary to squeeze the cheesecloth and coffee filters to facilitate the extraction. Without gloves some of the material will be absorbed on the skin.
If Everclear is used the tincture will be pale green to golden. If 151 rum is used an amber tincture results. Dark green tinctures mean that excess plant material is present. This does not mean that the tincture will not be potent, just taste nasty. When Everclear is used, various flavor extracts may be added (vanilla, raspberry, etc.). Be careful to use only a few drop of flavor extract.
Traditional or Warm Method
The old fashioned (and effective) way to make tincture from trim, leaf or “shake” is to grind the plant material to expose surface area. A fine grind is not needed and will just make the tincture cloudy. A rough chop will do. Most folks can’t afford to use kief or bud for tincture but may have leaf handy. If so, this is the way to go. Use ethanol as described above in the same proportions. The key difference is that in this preparation the materials are kept warm (not hot). Light must be avoided.
Place the ethanol and chopped cannabis in a large glass Mason jar. Shake at least once a day. Place the jar in a brown paper bag or otherwise shield the jar from light. Leave in a warm spot (near a window) for 30-60 days. The mixture will turn a very dark green. Strain as previously described through cheesecloth. Save the “shake ball” for topical applications.
While this method produces a nasty tasting tincture, it is powerful. It may upset some fragile stomachs. It is recommended that Warm Tincture be used orally in cranberry juice or coffee with sugar. Keep the filtered tincture in light blocking glass jars or bottles in a cool dry place (refrigerator or freezer is fine). The shake ball should also be kept in the freezer. For topical applications, just take out the cold shake ball and apply a few drops of fresh tincture to the cloth then hold it on the affected area for a few minutes with gentle rubbing.
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Glycerine-based Tincture
by Leanne Barron

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You need to use food grade U.S.P glycerine, this can be relatively hard to find inexpensively but a gallon lasts a LONG time.Glycerines have a shorter shelf life than alcohol based tinctures and while they can sit on the shelf I refrigerate mine. Vegetable glycerine has nearly no impact on blood sugar or insulin and is very low in calories (4.3 per gram). It’s sweet taste makes the tincture more palatable than the alcohol based tincture and is a suitable substitute for those concerned with alcohol consumption.Add the amount of cannabis that you desire for potency. I added 6 oz of roughly trimmed (finger trimmed the leaves off) cannabis to 1 gallon of glycerine. For your personal preference add more cannabis or less depending on desired potency. I blend mine, using a coffee grinder, blender or if you are lucky enough to have a Vita Mix. Make sure there is no other product matter in whatever you use. I use a clean basting brush to clean out my Vita Mix when I am done powdering my cannabis.

Place in a crockpot on low. Some crockpot’s low settings are too high so you may not be able to use yours. A “Keep Warm” setting if you have it is the best choice. Too hot, and you are killing the properties you are trying to extract, you want the mixture to be as warm as possible without boiling, I left my tincture like this for 24 hours. I have heard people leaving the tincture from anywhere from 4-6 hours to 3 days. You can try the tincture at intervals to decide when you are done. REMEMBER that glycerine tincture retains heat VERY WELL, do not burn yourself!!
If you do not have a crockpot you can place the herbs in a clear, sealed jar in a warm, sunny spot and accomplish the same thing over 4 weeks. Some people make their “sunshine tinctures” over 2 weeks. I do not feel that is long enough, especially in colder weather. Some leave them in the sun for up to 12 weeks. I have never seen a need to go that long myself. Shake each day to mix the herbs in.
When ready to strain use cheesecloth and a strainer to extract the cannabis debris, the THC has been extracted and the tincture is ready to use. The best way to store is in a glass amber bottle. A good place to obtain a large bottle for the bulk of your tincture is a brewery store that has supplies to make wine or beer. I also obtained a few small amber bottles with eye droppers for convenience. It takes a lot longer to strain glycerine than it does alcohol, the tincture will drip when strained instead of flow.

Dear Dr. Frankel,

I cannot thank you enough for the consultation and education you gave me last week. After flailing around for many years, I am so grateful to have found you and to have my world open up to additional tools for treating fibromyalgia.

When we met I was feeling desperate and at the end of my rope, having just been told by the rheumatologist how dangerously close I was to a severe episode of increased chronic pain. Your recommendations prevented that, and I am feeling incredible relief.

I am still figuring out what is correct for me each day and I thank you so much for leading me toward a regimen that will work with efficacy. I have spoken to others who paid less for consultations but they were in no way thorough or enlightening. The consultation with you was a seminar.

Thank you sincerely,
JTS

Yesterday, I saw another MS patient. This one was different than the prior one who had severe MS neuropathy. BTW, she remains pain free using the Sativa Tincture AM and PM! Very exciting.

The MS patient I saw yesterday did not have very much pain. She had a lot of spasticity of her upper and lower extremities making it nearly impossible to walk without her husband’s assistance as well as a walker. After the visit she went and purchased a Sativa Tincture and took her first dose. She had a very dramatic improvement and drove back with her husband just to show me how she could walk into my office without her walker or husbands assistance.

I am extremely excited by these two patients and will keep reporting results over time.

Yup, clearly no medical benefit here.

Over 31 million Americans suffer from arthritis. There are two common types, rheumatoid arthritis and osteoarthritis. Both affect the joints causing stiffness, pain and swelling.

The use of cannabis for musclo-skeletal pain in western medicine dates to the 1700s. Recent research suggests that cannabis-based therapies are effective in the treatment of arthritis and other hip, joint and connective tissue disorders.

The well-documented analgesic properties of cannabis make it useful in treating the pain associated with arthritis, on its own or in conjunction with other medications. Cannabis has demonstrated an ability to improve mobility and reduce morning stiffness and inflammation.

Human studies have shown cannabis to be an effective treatment for rheumatoid arthritis. Research has also shown that patients are able to reduce their usage of potentially harmful Non-Steroidal Anti-Inflammatory drugs (NSAIDs) when using cannabis as an adjunct therapy.

Cannabis has been shown to have powerful immune-modulation and anti-inflammatory properties. It could, in turn, play a role in actually treating arthritis and not just in symptom management. One of the earliest records of medical use of cannabis, a Chinese text from around 2000 BC, notes that cannabis “undoes rheumatism,” suggesting these effects were known even then.

I know I already blogged once on this topic. However, so many patients call and ask about the level of their privacy and the so-called “list”. Here are the facts:

1. The state/county card is OPTIONAL. If a patient chooses for whatever reason to get the card, their name is then on state and probably federal lists. I don’t know that these hurt anything, but I certainly cannot be ok with them

2. The physician letter a patient leaves my office with is all that is required legally or to enter dispensaries.

No “card” means ———–> all is private.

I practiced “straight” Internal Medicine for 24 years. Over those years, I would estimate that 1/3 of my patients were seeing me for various mood disorders. I became very active working with these patients with low dose medications. I didn’t have cannabis available to use in those days.

Currently, many of my patients come in on various psychopharm meds and I frequently work with their prescribing physician thereby co-managing both the cannabis and psychopharm/meds side.

Now in my third year of working with these patients, I am very comfortable managing both sides when appropriate. Very frequently, this has enabled the patient to use less medications along with the cannabis tinctures.