Cannabis And Pain Modalities - Exploring The Potential Of Medical Cannabis - Part 1

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Episode Transcript

(00:01):
From the WA and M Studio onthe campus of Florida A and M University.
This is Mariforum Radio, a weeklyconversation on the education and research or
a medical marijuana being conducted at BMWHI. I'm Heidi Otway, your host
for this Conversations on Cannabis Virtual form, brought to you by the Medical Marijuana
Education and Research Initiative at Florida andM University. In this conversation, we're

(00:26):
talking about cannabis as a treatment forpain management. So let's talk and learn
about this subject with our guests.Doctor Terrell Newton is a medical director for
Total Pain Relief, where he createscomprehensive care plans for acute and chronic pain
patience. He also serves as aFlorida medical director for True Leaf. Doctor

(00:47):
Newton is good to have you backon the forum. Great. Great,
I'm excited to talk to you todayand this is one of my favorite topics,
cannabis and pain management, so I'mlooking forward to I'm ready to dive
in, all right, right,And we also have Abby Folsom who is
a certified nutrition specialists and licensed dietitianwho's conducted clinical research on chronic pain and

(01:08):
medical cannabis. Abby, Welcome backto the forum. Thank you so much
for having me hide. I havea small virtual and in person nutrition practice,
so I do clinical nutrition and Isometimes provide education and coaching given my
clinical research background and clinical experience inprimary care and cannabis. All right,

(01:32):
so to everyone joining us on thislive program, please share posts and tag
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(01:53):
you to tell us what you thinkabout this forum by completing the survey that
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to win a one hundred dollars giftcard provided by one of Mary's partners.
Now, let's get started with thisconversation on cannabis. Doctor Newton, I'm

(02:15):
going to start with you. Tellus about your professional experience recommending medical cannabis
as a treatment for pain. Iknow you've moved, You've started as a
qualified physician here in the state ofFlorida, and now you've been elevated to
this directorship with True Leaf. Sotalk about your experience recommending medical cannabis.

(02:38):
Did we lose doctor Newton? Unfortunately, Newton, you are going in and
out. We have lost you.So I think you're going to have to
restart your computer and join us backagain, sir, Thank you. All
right, so Abby, we're gonnatake it away. Tell us about your
professional experience recommending medical cannabis as atreatment for pain. And I know you're

(02:59):
not qualified physician, but I doknow in your practice when it comes to
nutrition and cannabis use, you docounsel your patients. So tell us a
little bit about that. Well.I came by it honestly working for doctor
John mess and his primary care clinic, and his population is of all ages,
some of them a bit older.And because I have disabilities, they

(03:20):
were comfortable disclosing their pain, theirmedical cannabis use. And a lot of
times the patients within my wheelhouse cometo me for gi discomfort associated with long
term opioid use that can cause constipatientI myself can relate to long term inset
use such as celebrax or biax causingour biox causing intestinal bleeding and ulcers and

(03:46):
lots of GI pain. So sometimesI get chronic pain patients who think that
a food is causing this problem whenit's really a pharmaceutical side effect. So
I've heard lots of tantales about peopleand their experiences as they manage their medications
differently and perhaps use cannabis to tryto decrease their opioid use or decrease their

(04:11):
inset use. And then I wenton to work for a clinical psychologist,
doctor Nikki Ennis at FSU College ofMedicine, and helper implemented some clinical cannabis
research and did chronic pain research forher. So being able to synergize these
topics on the Mariform radio show isamazing, So thank you, Okay,

(04:33):
wonderful. So when it comes tomedical marijuana, what are some of the
potential advantages of using this as apain for pain management compared to the traditional
opioids which you reference a little whileago. Well, the opioids cause increased
dependency with decreased efficacy. So longterm opioid dependency is associated with chronic constipation,

(04:59):
pain old GI and in conjunction withthe inset use that's associated with reflox
and side effects from ulcers and intestinalbleeding. Steroids are also commonly used for
chronic pain, which in terms ofbone degeneration that can increase the cascade.
So osteoporotic or osteoarthritis patients depending onsteroid injections could actually exacerbate their bonetabolism long

(05:30):
term. Wow wow, So earlieryou referenced some of the research that you
were supporting at a university in auniversity setting, Can you tell us a
little bit about those studies that youworked on and then some of the research
findings that you found particularly compelling orinsightful when it comes to medical cannabis for
pain symptoms. I am a fanof the Journal of Cannabis and Cannabinoid Research

(05:56):
published by Mary Anne Liebert Incorporating,so you can find not as an open
access journal, and I generally trustthe articles coming out of there. The
other products that I like to thinkabout or take a look at are ones
that are evidence base. So Charlotte'sWeb is a heavily researched company. The

(06:16):
tucun Alum Products that bide Can Licenseis a heavily researched company and that comes
from Israel, one of the firstcountries to really dominate the medical cannabis research
space. Australia is another highly publishedmedical cannabis research space. Okay, and
what we'll do is we will actuallyshare the links that you provided to our

(06:40):
guests who are watching this live program. And just for those who are watching,
we're working to bring doctor newtonbag butuntil then, we're going to continue
this conversation on cannabis with Abby.Abby is so good to have you on
the show. So tell us alittle bit about some of the important considerations
and precautions that patients and consumers shouldbe aware of when they're thinking about using

(07:00):
cannabis for pain management. Well,I want to talk about a high fat
diet and how that may impact cannabisuse. So the Western diet is notoriously
high in in six fatty acids,so we want to focus on omega three
or in three fatty acids, whichnotoriously the Mediterranean diet is high end.

(07:27):
So I would actually recommend the Mediterraneandiet a diet high and in three omega
fatty acids to support the endocannabinoid system. So there's some evidence to suggest that
a westernized diet high in six canlead to a cannabinoid deficiency insufficiency. And
then the rest of the is thatact on the inflammatory cascade of lucotriine synthesis.

(07:57):
So we want to focus on theico s annoid metabolism of down regulating
inflammation through polyphenols and fighter nutrients suchas cannabis. Yeah, dotor In,
we got you back. Yeah,yeah, Well what we might what you
might could do is block my cameraif it goes out again. Maybe it's

(08:18):
something we lost your audio as well, So thank you for coming back.
Abbie was just talking about some ofthe nutritional factors that folks should be thinking
about when it comes to considering medicalcannabis. So I'm gonna bring you back
into the conversation and have you tellus a little bit about your experience recommending

(08:39):
cannabis as a medical treatment for thosewho have pain conditions. Absolutely. Yeah,
it's fairly extensive. For a numberof years here in Florida, and
when we first licensed the dispensaries here, I had the pleasure of taking tours
and being involved in different events.For the first five licensed dispensaries and it
was just one full experience, youknow, connecting with other physicians and speaking

(09:03):
at conferences which I continue to thisday. But also in Vermont. So
in Vermont they have medical cannabis availablethere for any condition that the provider be
medically necessary. So it gives youa lot of flexibility in terms of giving
your recommendations. And I think it'sbeen very tremendous here. We're in Florida
where we have almost a million patientsnow that has access to the medication.

(09:24):
And as we have these different awarenessmonths coming up, we should also you
know, just remind physicians and remindpatients that this is an option. So
for this month, PTSD Awareness Mothand so cannabis is wonderful for a lot
of patients for PTSD. And wehave next month being a National Minority Mental
Health Awareness Month. So there's somany different opportunities to apply the education of

(09:46):
the medicine and then also to connectwith physicians, nurses and patients nutritionists on
so many different levels. Yeah,I want to touch on that you mentioned
the PTSD and you know we're talkingabout pain management, So a are the
pain symptoms that someone with PTSD wouldexperience and how would cannabis medical cannabis help

(10:07):
them. So, yeah, onething to understand is that pain is an
unpleasant, sensory and emotional experience.So even within the pain pathways, as
the signal comes up into our brain, it goes to those emotional pathways.
It goes to the areas where wesense and where we can understand Okay,
this is a painful sensation, soburning, stabbing, shooting. But what

(10:28):
they also go into the emotional centers. We can interrupt those pathways. So
one thing you see with traumatic injuriesis where patients may have nightmares about the
injury. You see patients become anxious, become depressed because they can't function the
way they could prior to an injury. So PTSD has a lot of overlap
with pain, with them both beingemotional experiences. Adding your practice when it

(10:52):
comes to providing nutritional support to yourpatients, any of them also experiencing PTSD,
And what's the impact of nutrition andpotentially the impact of cannabis use in
your practice when you're talking to yourclients. The neurobiology suggests that presynaptic cannabinoid
one receptors and the accumbents are uncoupledand in three fatty acid deficiency, So

(11:20):
the nutritional psychiatry components are impaired,emotional and mood responses, increased anxiety depression
because the synaptic function is dependent onessential fatty acids that we cannot synthesize.
So, you know, kind ofalluding to the theory of cannabinoid deficiency,
perhaps in three omega fatty acid deficiency. These are synergistic into how well are

(11:46):
icosinoid metabolism and lucotraining synthesis functions.Another way to say that, I would
say Another way to say that iswe have healthy facts in our body and
the endocannabinoid system is focused on homealstasis, and well, we have these
healthy facts and we're not making them. So we're talking about the endocannabinois.

(12:07):
So we actually have cannabis in ourbodies, but when we add the phytocannabinoids,
add the plant based cannabinois, we'resupplementing that deficiency. And with healthy
oils, you know, such ascbd TC in the combination of more than
one hundred cannabinoids in the plants,there's many ways to help a patient reach
that homeo stasis, reach that steadystates so they feel more normal. Most

(12:28):
patients that's dealing with traumatic injuries,that's dealing with pain and anxiety PTSD,
they don't really want to feel high. They just want to feel more normal,
and we can do that by graduallyreplacing and replenishing the endocannabinoid system where
it's deficient. So does the endocannabinoidsystem have a role when it comes to
a person experiencing pain? Oh?Yes, So there's actually several ways.

(12:54):
One and some patients are deficient intheir body's cannabis. This is seen in
fibermalgia. This is seen in migraines. This is seen in IBS so.
IBS is irritable Boots syndrome. That'swhere you have alternating diarrhea and constipation.
A lot of painful conditions are basedoff of inflammation, so that's things like
IBD. SO IBD is like inflammatoryabout disease that's chrons, that's all sort

(13:16):
of colitis. Also, traumatic injuriesare associated with inflammation. So the cannabis
medicine is working different ways, dependon the condition, and some situations is
replacing what the body is deficient in. In other ways, it's reducing inflammation
in the body. Yeah, andAbby, I want you to come in
on that because you were just talkingabout if someone is using opioids or pharmaceuticals

(13:39):
that could lead to problems with theirGI tracks. So let's circle back to
what you were saying earlier about theimpact of nutrition and you know on cannabis
use for those who are using cannabisfor pain management, Can you circle back
on that for me? Yes,So to circle back to the nutrition components,
are these essential fatty oils, theoils of the Mediterranean diet, olive

(14:01):
oil, seeds, avocado oil,those really rich omega three fatty acids that
we need to support healthy icosinoid metabolism. The thing that I got so excited
about studying pain and cannabinoid receptors versusopioid move receptors is that they actually work
synergistically. So you want to thinkabout I don't want to say it enhances

(14:24):
efficacy, but you need less opioidswhen combines with CBD and thhc oral products
because it occupies the receptor and enhancesaction. From the open. You're smiling,
doctor News, speaking my language.You know when you talk about pain
and pain pathways, and it's amazingthat the Cannabis can actually interrupt the pain

(14:48):
pathway in several areas, and soone of those is what we call the
peripheral area. So let's say someoneinjures their shoulder or injures their arm,
so it's reduced in inflammation. Butthen as the pain signal comes up into
the spinal cord, it's slowing thatpain signal there, which that's where opiates
work. But then also as thepain signal comes up into the brain,

(15:09):
it's slowing the activation of the emotionalcenters, and it's also slowing the connection
of the pain signal from one nerveto another into the sensory modality. So
it's basically one of the few medicinesthat can interrupt the pain pathway in several
areas, and it's more powerful thanopiates because it can also treat the emotional

(15:31):
component of the pain as well,where opiates don't treat the emotional component,
and actually opiates often make it worse. So one of the side effects of
opiates is depression. And if youhave a severe injury and you can't function
like you normally can, you alreadyare probably going to have some depression.
And opiates are more likely to makethat worse compared to cannabis. And Doctor
Newton, now that I know you'rewell versed in addiction medicine, do you

(15:54):
mind touching on how that differs frommales versus females. Well, there's a
few things to look at. Butfirst of all, addiction is a feature
of the individual. It's not afeature of whether you're a male or female.
So some people have a tendency toexperiment on themself. So if you
or me or hide he had cocainein front of us, you know,

(16:17):
we probably we wouldn't have a tendencyto try that cocaine. But some people
have that within their genetics that theywant to experiment and see what's going to
happen if I take this cocaine.So that's one of the number one things
with addiction, and it's the individual. It's not the substance. But when
we look at hormonal levels, sowith men we have more testosterone. Women
also have testosterone, it's a loweramount. You know, some hormonal imbalances

(16:41):
might put you at risk for certainactivities. So if you have you heard
of a bipolar disorder, so whenthe hormone cycle, you might be more
active, more likely to try somethingthat you wouldn't normally try because there's a
hormonal imbalance. And then bipolar notonly cycles with what we call manage,
which is where you take impulsive behaviors. Sometimes there's depression and right, and

(17:03):
somebody's very depressed and they want totake their life, they might overdose.
So all these um different areas ofhormonal imbalance. They're very complex. And
when you get to that point towhere you're dealing you think you're dealing with
addiction, you definitely need to havea professional. So that's what we want
to have a medical professional involved,because if somebody's dealing with addiction, they

(17:27):
could potentially kill themselves. If they'redealing with you know, these manic these
impulsive behaviors, they might do somethingthat is permanent. And unfortunately, with
opiates, you take too much opiates, it stops your breathing and patient can
die. So on that note,nutrition and lifestyle medicine has always been my

(17:48):
favorite harm reduction tool, which Ithink brings us back to cannabis being an
alternative. Yeah, I always wantto say, you know, when we
think of like different approaches to medicine, one is called complementary and so we
can't have the traditional and the holisticat the same time. If someone is
actually dealing with addiction, I thinkthey should be guided. You know nutrition

(18:12):
number one, right, So thefirst physician, Hippocrits. Hyppocrites said,
let thy food be thy medicine.I agree, that's one hundred percent.
But if someone is dealing with thesituation where they feel overwhelmed, where they're
thinking about hurting themselves, where they'redoing these harmful behaviors, you know,
being addicted to alcohol, if theystop in the wrong way, it could

(18:32):
cause the worse problem. So forexample, somebody's dealing with alcohol and they
drink in a case of beer aday and they quit cold turkey, they
might have a seizure. An alcoholwithdraw sees is called delirium tremens. So
you know, when you're dealing withaddiction, it's very complex and it should
be a network, right, Soit should be a network your physician,
your nutritionist, your counselor your supportsystems, your family. So you know,

(18:53):
one one way to approach it isnot enough. We're dealing with addiction,
you need a teamwork. You needa teamwork to reach that level of
success, and you need follow upand you need a consistent plan, a
consistent program. And there is evidenceto suggest that CBD and THHC helps with
the cravings and withdrawal symptoms when usedclinically. Not readily accessible for those who

(19:15):
are outpatient attempting to do this ontheir own. So emphasis on what doctor
Newton says about an interdisciplinary team.Yeah, so let's go back to pain.
Let's talk about pain a little bitmore. And I want to think
about So we're talking about folks whoare considering cannabis use, considering cannabis for

(19:36):
their pain management. And so forthose who are considering it, what are
the precautions or what should they beaware of when it comes to using cannabis
your pool management. Well, let'stalk about oral bio availability being low.
So the first pass through deliver hepaticmetabolism, not a lot gets activated.

(20:00):
It's not until the second or thirdpass through the liver that one might start
to feel the oral bioavailability of thecannabis that they consumed, and that can
take hours, two to four hoursto activate that. So do you have
thoughts on that, doctor Night,Well, one thing with pain is first
you know what is the goal andwhat is the diagnosis because there's so many

(20:22):
different causes of pain, and youknow, if you think about, let's
divide it into four categories that youwould discuss with your recommending physician. One,
what is the goal and what isyour medical history? Number two,
what are your allergies and what areyou sensitive to? Number three, what
are the current medications and supplements thatyou're taking? And in number four,
what is your previous experience with cannabis. So let's say, you know,

(20:44):
you have a patient that wants totake cannabis from migraines and they've taken it
before and done very well with CBDproducts, So that might be a shorter
conversation with your doctor. If you'retreating migraines, you already had something that
worked, you know, it's basicallyjust continuing your program. But if you
have pain from a spinical word injury, then you might also have PTSD from
that spinal cord injury, So thenthat might be a much more complex conversation

(21:06):
with your physician. So the greatthing about cannabis is you can coordinate what
I call monopharmacy. Right, Sowith traditional medicine, there's polypharmacy, So
it's one medicine for your pain,one medicine for your sleep, one medicine
for your anxiety. But you canhave cannabis treat all of those things.
And that's where you and your physiciancan have an open dialogue and you all

(21:30):
can talk about your goals for yourtreatment. So you might say, well,
I want something to help at night, and so that you're a physician,
and you might decide on one typeof cannabis for pain at night and
for sleep, you might have adifferent type of cannabis that you take that
might have a different potency, right, a different strength where you can function
in a daytime. So if you'redealing with spasms and nausea in the daytime,

(21:51):
you might have a different type ofcannabis for that. And then let's
say in the mid day, asyou're getting later in a day, you're
getting more fatigued and dealing with pain, that you might have a third type
of cannabis for fatigue and pain inthe mid day when you're trying to,
you know, maintain your level offunction. So that's the wonderful thing about
the versatility of cannabis is that youcan take different types of cannabis for different
situations and whether you're dealing with somethingas a headache or dealing with the spinal

(22:15):
cord injury and anything in between.Cannabis has the potential to help all almost
all types of patients dealing with painissues. Yeah, Abby, did you
want to add to that? Ithink he said it best to be quite
honestly. So I want to talkabout dosing because you know, one of
the things that we hear when we'redoing this program, we have folks,

(22:36):
you know, asking how much doI take? And Doctor Newton you just
kind of touched on that where yousay you could take different ones or you
know, at different times for differentsymptoms. So can we talk a little
bit about dosing. Yeah. Onething I would like to see is more
more conversations on potencies. You know, I think we did a wonderful job
of talking about CBD and TC.But when we think about potency, Let's

(22:59):
say we have have, for example, a bottle, right a thirty email
bottle with three hundred milligrams. Ifthat bottle is CBD only, that's going
to have a different poemcy than ifit's TC. So CBD is going to
be more what we call a week. So that's going to be more like
a ceda menifin more like you know, out of profan, whereas the TC
is going to be strong, that'sgoing to be more like oxycodon where you're

(23:22):
dosing at like five milligrams per doseand things like that. But what if
it's half and half, so wecall that a one to one. So
if there's equal parts CBD and TC, if it says three hundred milligrams on
the bottle, one hundred and fiftyis going to be CBD and one hundred
and fifty is going to be TC. Well, this was such a great
and enriched conversation. I have Abbeand I were both writing happy while you

(23:44):
were talking too hundred and so Iknow that our viewers and our listeners will
be doing the same. And Iwant to thank you both for being guests
on this Conversations on Cannabis Virtual form, brought to you by the Medical Marijuana
Education and Research Initiative at Florida andUniverse. Thank you to everyone watching this
program. Tell us what you thinkabout this form by completing the survey that

(24:07):
will be posted in the comment boxeson YouTube and Facebook after this live program.
If you complete the survey, yourname will be entered into a drawing
on July thirteenth, twenty twenty three, to one a one hundred dollars gift
card provided by one of Mary's partners. We also again want to encourage you
to go to the Florida Department ofHealth Office of Medical Marijuana Used website to

(24:27):
learn how to obtain a legal medicalmarijuana card in the state of Florida.
And we also encourage you to goto Florida and M University's Marry website to
learn more about this initiative, it'seducational programs and additional information about cannabis use
in Florida. Thanks everybody. Theviews and opinions of our invited guests are

(24:51):
not necessarily the views and opinions areFlorida Agricultural and Mechanical University or the Medical
Marijuana Education and Research Initiative.