Don't Get High….. Get Well

Posts Tagged ‘medical marijuana’

As with most medications, they should be titrated. This means start with a very low dose and add additional drops or sprays one or two at a time every 30 minutes. You will find out what dose is effective this way. With regard to how frequently, it is difficult to say for certain, but my experience from what my patients tell me is:
1. If the tincture has only THC and no CBD, the duration will most likely be 3-4 hours
2. If the tincture has CBD content, patients seem to only need to be dosed every 8-12 hours.

The CBD slows down the THC metabolism in the liver and increases greatly the duration.

With regard to how long and when to decrease, I think this is something we just don’t know. If treating a chronic condition, it is likely that the tincture will be helpful long term. If symptoms are more intermittent, I would suggest using the tincture intermittently as well.

The new super critical Co2 extracted tinctures are working very well in the community. New tinctures are being released by collectives a batch at a time. They all have different effects that are determined by the THC level, CBD level, ratio of the two as well as perhaps a hundred different terpenes. So the clinical effect is determined by all of these factors and perhaps more. Right now we do believe that CBD in close balance seems to be a very good way to create a non psycho-active tincture, but with some patients this appears to either be too much THC or some terpene effect. As new batches of tincture are made, the terpene extraction is getting better and better and we may begin seeing some psycho-active effect even when the CBD>THC.

This is a complicated issue and will require time and research. In the meantime, how should we best classify a tincture?

1. For certain we should measure and label as much cannabinoid and terpene content as possible

2. There must be some initial trials with groups of patients to determine the effect to get an initial scale for that tincture. This can be adjusted over time

With this in mind, I am suggesting we perhaps could employ a “psycho-active” scale. It would go from 0 to 10, with 0 being no perceived psycho activity and

10 being “make no plans”. I am suggesting that we consider placing this number of every batch. It should even be the “name” of the tincture. At least it should be clear and simple.

For those of you interested in learning about the potential future of CBD and treatment of cancer, read on:

http://www.ncbi.nlm.nih.gov/pubmed/20053780

http://www.ncbi.nlm.nih.gov/pubmed/16728591

http://www.ncbi.nlm.nih.gov/pubmed/21566064

http://www.ncbi.nlm.nih.gov/pubmed/18833429

Tumor Studies:

http://www.ncbi.nlm.nih.gov/pubmed/18035205

http://www.ncbi.nlm.nih.gov/pubmed/14617682

Clinical Trials:

http://clinicaltrials.gov/ct2/results?term=cannabidiol

http://www.cannabis-med.org/studies/ww_en_db_study_search.php

I thought it was overdue to share more of my experiences with CBD rich cannabis tinctures. I am actually still not certain what in fact CBD Rich means, but am fine with adapting Project CBD’s definition. A CBD rich tincture is one that has at least 4 mg of CBD/cc. I would love to hear any ideas regarding to all the new nomenclature of this new world of cannabis medicine.

Last week there was a period when the production and availability of these tinctures was in question. When I thought what that would mean for me as a cannabis physician, I was both happy and sad. I was happy that this truly new world has opened up for patients. Truly amazing. However, it became clear to me that if these wonderful new medications were to cease, I don’t think I could do the recommendations any more. I would not be sure what to even discuss with patients. I guess I have perhaps painted myself into a corner, however I think I would in fact do something different. There are many things to do in this world, but signing “recs” without truly believing the patient was being cheated out of the best medicine would be difficult and painful.

These balanced THC/CBD tinctures, where the CBD is at least 4 mg/cc, are truly amazing. Altered mental status is rare and anxiety, pain, neuritis, irritable colon, PMS, chronic neurological disorders, tumor suppression, appetite suppression……..more and more

This is almost 100% of the time achieve with 2 mg of CBD twice daily. It feels so good to be able to tell someone an actual dose. I know this is frowned upon, but there is that old Hippocratic oath. Right? Doesn’t that obligate me to share any/all information I deem helpful to a patient? How could it be otherwise.

Let’s not forget, the Feds patented CBD in 2003 as discussed in several prior blogs. How can they really say CBD is horrible? How can anyone say that any caring physician would not want to help his patients find the best medicine for them? Nothing else makes any sense to me.

Up until very recently, I always advised patients to use use a “sedating” Indica for sleep. I think the current dogma is that Sativa is for the day and Indica for the night. I truly believed this and wrote much on it. It is still on the back of my cards.

I am not saying this is entire bunk, but it was what we understood at the time. My current understanding, which will always remain open to change, is that whether using allopathic meds (sedatives, tranquilizers, SSRI’s) or cannabis it is just NOT necessary to sedate the patient to help with sleep.

Of course I understand at first blush this seems ridiculous, but I do believe this to be the case for the vast majority of patients. I have already heard back from over 100 patients who have very recently stopped using for sleep at night and are just using 2 mg CBD in the AM and 2 mg at night. They seem to do great and you avoid the munchies. BTW, CBD really, really decreases ones appetite. No wonder the Feds patented it in 2003. !! YES, THIS IS CORRECT. CHECK THE LINK. Let me digress, CAN ANYONE EXPLAIN TO ME HOW/WHY CANNABIS IS CONSIDERED USELESS AND DANGEROUS WHILE BEING PATENTED BY THE FEDERAL GOVERNMENT??? How/why can this be?

Back to Insomnia. In my 34 years of experience as an internist, it has always been clear to me that knocking people out to sleep was ridiculous and more to the point, just not necessary or helpful. If the patient can simply get some help slowing down the “spinning” in their head, they just go to sleep and have a way better quality of sleep.

With regard to Cannabis and Insomnia, this appears to translate to using CBD both during the day and during the night, that is two times/day. This 12 hour dosing seems to work fine and this is what GW Pharma says on it’s package insert.

So, if you have never tried it, for a few days just try using a small amount of balanced CBD/THC AM and PM and see how you feel and how your sleep is. Try not to smoke for some days, although I don’t think it will matter UNLESS you smoke a rich THC flower at night and that could certainly keep you awake. Of course, knowing how much THC you are ingesting by smoking at night is entirely impossible. Even if the patient knew EXACTLY types and levels of cannabinoids and terpenes in their smoke, what in the world is “a puff”?? For sure, no two puffs are ever the same.

Most of us have tried edibles; food with active cannabis inside. I have always thought it so silly as the patient has no idea what medicine is inside, how much medicine, etc etc. We all either have had or know people who have had toxic reactions. However, many patients just love edibles. If they are using edibles JUST to prevent smoking, they should just use tinctures.

These paranoid/agitated reactions are actually pretty common. My guess is that it is over 20% for all patients. This is almost as bad as “pills” and is just not acceptable. Patients are told to start slow, wait 2 hrs before the next bite, etc, but in reality it is rarely done.

I have always felt that the actual medicine should be in a simple capsule. The patient can purchase food if they wish t, o eat with it. The capsules would always, I think, contain a little CBD and come as 2.5 mg, 5 mg or 10 mg of THC and perhaps around 2 mg of CBD inside each capsule. This would allow very simple titration. The small amount of CBD should also nearly eliminate the THC toxicity.

If you do the math, the clinical effect is MUCH less expensive this way.

So, what about the patients who just love edibles and don’t want to use tinctures? How about a “tincture mix” that allows any baker to obtain the PRECISE amount of THC/CBD and ?? even Terpenes, per brownie? In this situation, an amount of cannabinoid substrate could be provided to make X number of brownies or any other food units. The baker would know EXACTLY what medicine is inside each item. A little CBD could be part of the “magic goo” if desired as well.

Patients in a very short time would learn their precise dose and from then on always know exactly what they need.

Does this seem impossible or way down the line??? Well, I just tried a few last week with 10 mg THC and 5 mg CBD per brownie and it felt like the same tincture, but just lasted a very long and wonderful time.

Currently, there are two very different certified (i.e. we KNOW for sure what is in them/cc) tinctures.
1. the “CBD” tincture, which is 5 mg/cc of each cbd and 5 mg of thc.

2. The THC tincture is 11 mg/cc THC and 2 mg/cc CBD. For the time being, I feel from a lot of
“studies” both locally and internationally, that a little CBD seems to prevent THC
toxicity(paranoia, anxiety, agitation, panic, etc).

Currently I am thinking that for now, all tinctures should have some CBD to balance it out and prevent the toxicity which is a really important deal. We are studying how little CBD is needed to accomplish this. In addition, with the rich CBD tinctures, we are trying to see how little THC is needed to achieve the same results. For example, do we absolutely need ANY THC?? Just don’t really know. For many reasons, this is critical information and here are two:

1. if some patients who need the medicine, but are tested at work, the zero or nearly zero THC should prevent any positive tests.

2. We are collaborating with some docs in Canada. We are helping them do exactly what we are doing here, but with female Hemp flowers and whole plants. If this is effective, it could be in Savon and would be as legal as a hemp shirt. We shall see.

Having some CBD in every product, at least for now, is turning out to be a bit confusing up front, as having ANY CBD seems to lead folks to assume it is the rich CBD. I am thinking that we should go back to just calling them either T or C and ignoring the fine points until patients begin to get the hang of looking at the ratios, terpenes, etc and obtain their medication based upon the actual medicine and begin to ignore all other labels. Any thoughts?

I have been asked what I mean by a single payor health care system for any medical cannabis patient. The most difficult part of the entire plan is defining who is a medical cannabis patient and that will have to eventually be worked out.

Regardless, there are many reasons that this particular demographic would be ideal to insure:

1. As a group I would say there is 90+ % concordance in thought and feeling among cannabis patients. For example, if every cannabis patient voted on same sex marriage, we know the outcome and it would be virtually 100%. Other significant actuarial issues are:
a. somewhat younger population
b. even with a zero dollar deductible, the vast majority of cannabis patients would still rather not go to the doctor at all. Then when at the doctor, they fight every prescription, test, etc. In other words, as a group, they would automatically be low utilizers.
c. Cannabis can be given away for free in tincture form to every patient just for signing up for the health plan. This will further decrease trivial and DANGEROUS visits to clinics who only understand volume and volume discount.
d. So, although much study would be needed, the insurance companies probably already have tons of data showing med can patients to be low risk.

2. Numbers of patients in the hundreds of thousands is not impossible and it would be very possible to approach one million with time. Over years on a national level, it would be tens of milliions of citizens.

3. These citizens could be certain that they would NEVER lose this group coverage, no matter what.
4. As I have had a fair amount of experience in building an insurance company, I believe this would be by far the easiest one to insure. There would be internal coverage up to $50,000/person/year. Above that, for the rare disasters, we would re-insure with Lloyds or any other competitive proposal.
5. I believe that with a few months of actuarial study, we would find that as long as we can control the quality of the primary care (A HUGE, HUGE ISSUE IN MY OPINION), patient satisfaction will be through the roof and costs will be way, way down.
6. we reward doctors by paying them more if they are open to cannabis and have taken classes on cannabinoid medicine and pass a pretty tough test. They will study VERY hard, else they lose their practice.
7. The group might also consider a kaiser model where the group screens every doctor and we hire them, giving them the PROPER REWARDS AND PROPER PENALTIES. We all know what all these are and the list could easily be agreed upon.

I believe the profit from this would partially go back to the patients as a reduction in premium but much of it would be earmarked for various projects, free clinics, anything we agree upon. Also, agreeing will be VERY easy

FRED: the reasons to large extent for the few bucks per month are:
1. you then have a list of potential voters, letter writers, big contributors, insurance buyers
2. this is a huge war chest to build the insurance company, hopefully a pharma company and a PAC to weight heavily upon local, state and Federal elections.

If this became national over the next 6 years, the tens of millions of patients across the nation could probably control a LOT.

Anyone reading this is of the ilk to agree and feel strongly about this blog. Those who don’t, may think I am quite crazy.

I think there is a way to accomplish some of the following goals for $1/month. Here is my version of the list of issues:

1. Cannabis is only on lease to us from the Federal Government; They will take it back as soon as the pharmaceutical versions of our medical cannabis tinctures are released through GW Pharma/Gayer. Many others to follow. In fact, over 50 growing licenses were very recently issues by the Feds to Pharma. No question. Right? Pharma will destroy anything they can that we have built. I am certain this is their intent.

2. The same as #1, but apply to our virtual entire loss of our democracy. No details needed. You all know better than I.

It seems impossible to solve either of these issues. I have felt despair over what has happened in recent political years. I love the Medicine of our plant, but fear it is to be taken away again in a very big way.

So, here is a solution:
1. Every Cannabis Patient pays $1/month. There are nearly 1.5 million patients just in California.
2. As these are horrible financial times, the patients will be reimbursed twice their monthly $ donation in collective coupons
3. The list and money is used very simply:
a. Fight EVERY case against patient, collective or physician that in any way takes away our rights. In my we can change their “bad behavior” fairly quickly.
b. Actively change the laws that need to be changed
c. fund research and donate grants
d. Not last and certainly not least:

CREATE A OUR OWN SINGLE PAYOR SYSTEM IN THE STATE OF CALIFORNIA FOR EVERY CANNABIS PATIENT. THINK ABOUT IT. MORE TO FOLLOW

How about an old and brand new medication that:
1. controls anxiety
2. helps control pain of many kinds
3. significantly reduces appetite

I suppose nobody should be surprised. Typical THC containing cannabis causes the munchies. THC decreases focus. CBD decreases appetite and increases focus.

In years past the cannabis plant had lots of both CBD and THC occurring naturally. The CBD was slowly and accidentally bred out to make way for just the real stony plants.

As CBD plants are being brought back, we are learning a lot and cannabis has become an even more amazing plant. Need to increase your appetite – use mostly THC and no or little CBD. If you are eating too much due to simple over-eating, CBD very comfortably and powerfully will reduce your appetite.

I wonder if instead of creating fixed tinctures, how about giving patients options to use nearly pure THC OR CBD. The patient can then do their own internal study. How much T? How much C? What order? Let us know and these patients will teach us much of what we need to learn. Hmmmm, a Duo-Pak??? Spray-spray??

As discussed in prior blogs, CBD CAN and does to a ?? extent interfere with drugs patients take that are metabolized in the liver by the Cytochrome P450 system.

As promised, here is a list:

CBD DRUG INTERACTIONS:

I am thrilled to report the results of two meetings with the CEO of a public company which, although it is not a bank, does handle merchant accounts, all major credit cards AND a very cool “Smart Card” which I tested. This is a cool card and already being used by many collectives.

So, this company just delivered a “letter of intent” to work with any credit worthy collective. No discrimination AND I am 90% certain they will offer a two year contract. Usually this is the WORST thing anyone would want, but in this situation, it is likely in my opinion, that every collective will want it.

On Wednesday evening I am talking at “The Greater Los Angeles Caregivers Alliance”(GLACA), on CBD and tinctures, but I will turn this connection over to GLACA to do with as they best see fit.

I would really love to see GLACA grow 10X and become a true force. This requires money. Perhaps with all the savings in credit card fees, merchant accounts lost business, etc, a portion of the savings can be donated to a Cannabis Club “Legal and Survival” fund.

I hope this helps.

What are Terpenes and what is their effect in making Cannabis Tinctures?

The Terpenes are multi-carbon chained molecules ubiquitous in the plant kingdom. They give the plant it’s “character”, similar to the wine industry. In addition, the Terpenes are responsible for communication in nature, plant to plant and plant to animal.

There is one Terpene which I recently read about, that is released when it’s leaves are crushed by a herbivore. These terpens attract carnivores who are then more likely to eat the herbivore before the plant is all eaten. Terpenes are “balancers and communicators”.

Clearly we have receptors for Terpenes and some Terpenes interact with the CB 1 receptor. Terpenes are probably the most improtant variable other than the THC and CBD. There is much to learn, but it is clear that including the Terpenes in the extraction and re-infusing them into the tincture is a good if not at least, interesting concept.

So, our team has been looking into adding Terpenes back into various tinctures. It is more a messy than difficult process, assuming you are using C02 extraction. I don’t know how else to do it.

Anyway, the Terpenes are large, but volutile molecules and upon any processessing tend to just float away.

As far as I know, there are two methods used to capture the Terpenes in water. Once this is done, you just cook it all up. So, in the first, one just allows the Terpenes to circulate and re-circulate with the CO2 itself. A water bath near the end collects the Terpenes and this “Terpene” extract is tested. I just consulted on my first Terpene extraction and much was learned.

The other method, which I have read about but not tried – YET! Here you give up on any attempts to re-circulate the C02, and each “run”/”batch” you need to replenish the C02. This is only a cost issue. So, the C02 is not kept under pressure and is just released into the atmosphere. Again, sterile water is used to flush the Terpenes and all efforts are made to keep the Terpenes in solution in a closed system.

Either way, the Terpene flush is mixed with the cannabinoids and presto!

With regard to effects, for SURE, it helps with achieving many altered states.

Allan I Frankel, MD

I am always amazed but never surprised about our government’s bizzarre behavior – particularly with relationship to Cannabis. Most recently, I have heard from a number of collective personel that banks and bank cards as well as merchant accounts are being interfered with by the banks in exchange for various governmental “perks”.

For SURE many collective stores are having trouble with merchant accounts and the cards, such as AMEX, VISA and MC. The salvos come and go, but everyone is testing the waters of attempting to help kill dispensary stores by giving perks to the card companies in exchange for ratting on “suspicious behavior”.

I am meeting tomorrow with a gentleman who works as a banker and specializes in smart cards. I am thinking perhaps we can have patients load up their card on a little machine at each dispensary. It can even be the same machine that swipes for standard credit cards.

So, we would be creating a nearly free “dispensary card” that any patient can load up when at any participating location. There are a couple of bugs to work out, but assuming it can be done, what does everyone think?

Allan

ps, I expect to hear from each and everyone of you.

I WON!!