The Dr. Hyman Show - Healing Insomnia, Reducing Pain, And Other Benefits Of Medicinal Cannabis

Episode Date: November 7, 2022

This episode is brought to you by Rupa Health, InsideTracker, and Essentia. There are actually many proven benefits of medical marijuana when it’s used the right way. In fact, cannabis may be one of the oldest documented herbal medicines on earth. And the body has a remarkable built-in system of endocannabinoid receptors that pair with it to reduce pain, improve sleep, increase mood, reduce nausea, and much more.  In today’s episode, I talk with Dr. Misha Kogan, Dr. Josh Axe, and Jamie Wheal about the many benefits of cannabis, and we take a look at how the body’s built-in endocannabinoid healing system works in tandem with this plant medicine. Dr. Mikhail “Misha” Kogan is the medical director of the George Washington University Center for Integrative Medicine and associate professor of medicine at the George Washington University School of Medicine. Dr. Kogan has recommended medical marijuana to thousands of patients and is a frequent lecturer on medical cannabis to professional audiences across the nation. Dr. Josh Axe is a certified doctor of natural medicine, a doctor of chiropractic, and a clinical nutritionist with a passion to help people get healthy by empowering them to use nutrition to fuel their health. He is the bestselling author of Keto Diet, Eat Dirt, and Collagen Diet and author of the book Ancient Remedies. He is also the cofounder of Ancient Nutrition, which provides protein powders, holistic supplements, vitamins, essential oils, and more to the modern world. Dr. Axe founded the natural health website DrAxe.com, one of the top natural health websites in the world today. Jamie Wheal is the author of Recapture the Rapture: Rethinking God, Sex, and Death in a World That's Lost Its Mind and the global bestseller Stealing Fire: How Silicon Valley, Navy SEALs, and Maverick Scientists Are Revolutionizing the Way We Live and Work and the founder of the Flow Genome Project, an international organization dedicated to the research and training of human performance. This episode is brought to you by Rupa Health, InsideTracker, and Essentia. Rupa Health is a place where Functional Medicine practitioners can access more than 2,000 specialty lab tests from over 20 labs like DUTCH, Vibrant America, Genova, and Great Plains. You can check out a free, live demo with a Q&A or create an account at RupaHealth.com. InsideTracker is a personalized health and wellness platform like no other. Right now they’re offering my community 20% off at insidetracker.com/drhyman. Right now you can get an extra $100 off your mattress purchase, on top of Essentia’s Black Friday sale of 25% OFF, plus you'll receive two FREE organic pillows (a $330 value) with your mattress purchase. Go to myessentia.com/drmarkhyman to learn more. Full-length episodes of these interviews can be found here: Dr. Misha Kogan Josh Axe Jamie Wheal

Coming up on this episode of The Doctor's Pharmacy. How come we co-evolved on this earth with a plant that allows us to have this fascinating interaction with it? Almost every cell in our body has the receptors. It may be the oldest documented medical tool we have on earth. Hey everyone, it's Dr. Mark. As a busy doctor with multiple jobs, I'm all about tools that make my life simpler. And since testing is something I rely on to help almost all my patients, I was really excited to learn about Rupa Health. Hormones, organic acids, nutrient levels, inflammatory factors, and gut bacteria are just some of the many things I look at to find the

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and providing a noticeably better patient experience. This is really a very much needed option in the functional medicine space that I'm so excited about. You can check out our free live demo and a Q&A or create an account at rupahealth.com. That's R-U-P-A health.com. If I've learned one thing during my two decades in functional medicine, it's that we're all unique. No two people are alike, which means we can all benefit from personalized medicine. But for most of the history of medicine, individualized healthcare just was not possible. We couldn't look inside the body and see what was really going on. But now, thanks

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That's D-R-H-Y-M-A-N. That's insidetracker, I-N-S-I-D-E-T-R-A-C-K-E-R.com And you'll see the discount code in your cart. Hi, this is Lauren Fee and one of the producers of the Doctors Pharmacy Podcast. When used the right way, there are many proven benefits to medicinal cannabis, including soothing pain, improving sleep, healing skin problems, and reducing nausea. In fact, cannabis may be one of the oldest documented herbal medicines on earth. In today's episode, we feature three conversations from the doctor's pharmacy on the many benefits of cannabis, and we take a look at how the body's built-in endocannabinoid healing system works in tandem with this plant medicine. Dr. Hyman speaks with Dr. Hyman speaks with

Dr. Misha Kogan on what the data currently shows us on medicinal cannabis and the top symptoms that has been proven to help with Josh Axe on the difference between THC and CBD and with Jamie Wheel on using the body's endocannabinoid system to promote health and well-being. Let's dive in. Let's talk about what the top clinical indications what are the top reasons you're going to use it what are the conditions you treat and what are you seeing in your practice right so we mentioned pain nausea insomnia spasticity it doesn't have to be multiple sclerosis related spasticity i think any spasticity actually quite often when person has a sudden locked in muscles for example let's say a neck you can actually apply topical sometimes it's really effective all kinds of skin conditions

lately i find things like psoriasis things like even like literally herpes flares you mean it helps it helps reduce the it helps reduce the skin lesions or just prevents no it actually treats underlying problems. And, you know, it's more complex than just THC, CBD. We don't actually exactly know which molecule is more important, but I often even use it for like a typical eczema in older age. I often use it now as a first line. You can even start with just trying CBD

creams. Sometimes even those work. So, you know, all kinds of skin conditions. I actually think, well, the way I kind of- And you use it topically for the skin conditions? Topically, topically. And you use THC as well as CBD for the skin conditions? Yeah. So for psoriasis, I like to use mix. So I like to use more THC than CBD. For eczema, I start with just CBD. And sometimes that's enough. Sometimes you have to add THC. I had a longstanding kind of a crack in the lip, which was from just cold sore from herpes.

I had it for about two decades. And it would flare in the winter when I go skiing, especially when, you know, the lips get dry. And it took about three months, twice a day application of low concentration THC. And now it's been what, six, five, six years. I don't know, like the problem completely went away. Amazing. So it has definitely THC as antiviral properties. So you literally can use it on a low grade topical infections at almost no risk. If it doesn't work, you have time to try something else. Um, what else? Lots of different gastrointestinal problems, IBS, uh, you know, preferably prefer irritable bowel syndrome. Yeah. Preferably in the form where it goes down. So

swallowing form in edible form. Shockingly, inflammatory bowel disease. So Crohn's and ulcerative colitis. You can use it orally, but actually if the disease is mostly in the rectal area, you can use suppositories. It's a very effective method. The data for that is mixed, but there's a lot of people who try. IBD can be very persistent and very poorly controlled, even with new biologic drugs. And biologic drugs have a lot of risks and side effects and high

costs. So I had a good number of patients in whom IBD has been controlled just using cannabis alone. It sounds crazy, but I think cancer is probably one of the most controversial topics we can spend a whole hour talking about. Yeah. Well, let's talk about that for a minute because I've sort of been in this world and one of the things that I've heard people say is that it can be CBD and other concentration specific forms, specific plants can be effective in cancer. Right. Is there any data about that? There's very little data. I think we have kind of an early data.

We have a little bit of positive data in brain cancer. We have a lot of data in preclinicals. So if you take a petri dish and you put the cancer cells on and then you put cannabinoids, literally almost all cancers get killed off. Now, how does that translate into what's happening in our bodies is very hard to figure out. I mean, unfortunately, cancer translation science generally is slow. But I will tell you, those of us who use cannabis heavy in the practice, it's just the patients find us and often they will do things without our, you know, they'll just do things, right?

And they'll come in to check in with us. And I'll tell you the most crazy cures I've seen in my practice, they all have cannabis. They all have cannabis. That wasn't the only thing the patients were using. Don't get me wrong. It's always other. So was it just CBD or a combination? It's no, it has to be some THC. The ratios are not very

clear. I tend to think that it's much more complex than just THC and CBD. We do know that acidic forms, which call CBD and THCA, have anti-cancer property. And then even some of the newer molecules that we're just beginning to grow in our practice, like CBG, for example, cannabidiol with a G, like in Georgia. So even a molecule like that one has some clear anti-cancer properties. So nobody truly understands yet. I know there are experts with way more knowledge than me who do this, much more in their practice. But I just don't think that

there's evidence enough to sort of put that into mainstream. It's happening whether we want it or not. I think there has to be research and it's happening slowly. I use it for almost all cancer patients, but not for cancer itself. I simply use it because, well, think of it this way, right? Most patients, they're going to have some cancer-related pain. They're going to have some cancer-related nausea. They may or may not have anxiety and insomnia. But think about this. If I were to recommend the medications for this, it's at least four pills.

And here I have one product that can control it all. The dosing can be precise. The route of administration can be variable and according to the patient's liking. And guess what? You know what the side effect is, right? Somewhat slightly getting high. So in literature, it's a side effect. I'm yet to see any cancer patients tell me, yeah, I really sort of, it's a bad side effect. The reason medical marijuana works is it's tapping into a biological system that already exists in our bodies and brains. And it's called the endocannabinoid system. So can you talk just a little bit about

that, Misha, and what it does, what it's for, and what the benefits of this system are to our health? Right, right. Well, I think that's actually critical we talk about this because that's the core understanding of how actual exogenous or cannabis from plant works, right? And by the way, this system was named after cannabis, right? So it's like the doctors discovered it in a way. And they named it after the molecule that they realized was working on it, which isn't like the only reason it's there. That's right. You actually have to sort of, well, let's talk about that first. And then we'll, because I have one philosophical point that I think you're going to have a great take on this.

So we all have, just like we have an endorphin system, so the endogenous opiates, we have this endogenous cannabinoid system. It's actually a lot older and a lot more complicated and a lot more important compared to endorphin system. Why? That's not necessarily clear, but it appears that it's just more rudimentary. And historically, it appeared in our evolution first. So it's one of the oldest regulatory systems in our body. We have literally, so the tetrahydrocannabinoid, which everybody after recreationally, the THC, right? So we have molecules in our body that are very similar. Anandamide is a good example. It's probably one of the more common. It's not the only one. We have

multiple similar molecules internally, and we make them. Like we literally make our own cannabis constantly in our body. And then there are a set of receptors. The more commonly known ones are CB1 and CB2. So this, so you can think of them like, it's a gross analogy. It's not necessarily 100% accurate, but it's a good one. Key and a lock. So your key is our endogenous cannabis molecules, or let's say anandamide, and the lock of the CB1 and CB2 receptors. So when you open the lock, something occurs, like your door opens, and then you have a cascade of effects. So if you're open CB1 receptor, then you have some kind of likely neurologic impact. So say pain control or, you know some anxiety decrease in anxiety better sleep those

kind of things if you open cb2 receptors which are on the periphery you can have immune up regulation so better stronger immune system you can have metabolic improvement like you know your your certain metabolic parameters can improve you can have your your bones lay down more bones so that your bones are stronger. So the impact, the list of impacts that occurs when this happens is so long, we'll sit here and we'll have a whole lecture on it. Bottom line, it affects almost the entire system. Almost every cell in our body except for one area has the CB1 or CB2 receptors. Here we're the sort of the most crazy and amazing mystery comes in, except for one area, and that's the brainstem. So it turns out in the brainstem, which controls our breathing, there's not as many CB1 receptors.

So no matter how much cannabis you take in, your breathing is not going to get suppressed compared to if you take a lot of opioids, then we know what's going to happen. So why that happens, nobody knows. The second mystery, that's what I really want to touch on. Think about this. We co-evolved with a plant, which is a weed, meaning it grows everywhere, right? It's called weed. They call it a weed right so how come we co-evolved on this earth together with a plant that allows us to have this fascinating interaction with it and we sort of we're coming back to the the plan's been used

for thousands of years in fact it may be the the oldest documented medical tool we have on earth if you go back to some of the original chinese medicine um works it's been listed there as one of the first chinese medicine herbs and it's not a lot it's not discussed on a lot of circles it's kind of hard to appreciate right right? But it's there. It's there as one of the original herbs that they've used. And, you know, and then over the centuries, it was used in different ways. And then it finally kind of ended up in more modern civilization. But it almost feels like we're now re-discovering.

Yeah. But here's a question here's a question for you so in the opioid system we have receptors for the opioids like narcotics right heroin morphine and it's because we have our own system of pain control called endorphins right that bind to those receptors is there a similar set of molecules in the body that naturally occur it's almost our natural marijuana right as the endorphins are our natural opiate so what are those molecules and what role do they play and how do they well i think for for listeners anandamide is probably the most important one to remember uh their long list of those anandamide right yeah that's probably the it's one of the. There are a long list of those. Anandamide, right.

Yeah. That's probably the, it's one of the most common. It's one of the best understood. What's interesting that in addition to this sort of endocannabinoid system through cannabis receptors, and let's call them what they are, CB1, CB2. There may be others too, by the way. There are lots of other impacts. So the plant has other

active molecules. Terpenes, I'm sure we'll talk about this. It has flavonoids and all of them also have some impact. In fact, there's a lot of research now going into terpenes because turns out that if you just isolate THC and you take it in, the effect is going to be limited. If you combine that impact with what terpenes can do, suddenly you have a whole lot more complex interaction with the body. And that's where I think the gold of cannabis will be. And that's why I'm not worried much about sort of pharma taking all of it over because recreating some of these interactions, what we often call an entourage effect, is very difficult. I mean, that's the typical efforts of medicine, which is to find something that works,

to reduce it to the one molecule, and to isolate it, reproduce it, and distribute it, and market it and patent it. And what you're saying is really important to underscore, which is that it's the complex interaction of all the plant molecules and phytochemicals in marijuana that make it work. So if you just take any one of them out, it may be synergistic effects that you can't reproduce by just isolating it as a single drug. Right, right, right, right, right. The simple example is, so, you know, historically, we had this sativa and indica strains. We're trying to sort of walk away from this because it's actually more confusing than anything. Oh, really? Why? since most of the modern strains are now hybrids or many of them, this separation of is this indica, is it sativa, is it two parts indica, one part sativa, it just confuses everything. So you're really going to, in the future, it's going to be,

you're going to look at the label and you're going to say, okay, well, there's X amount of THC and there's this concentration, and then there's these terpenes. So you're going to have some kind of a key on a label that says, you know, it's a predominantly relaxing terpenes like say linalool and it will allow you to say okay well that's probably good for sleep or for anxiety because that's what it's going to help with so that's the future and that's how we're beginning to think we're looking at okay this terpene is going to mix this way

and it's going to have this kind of total entourage effect, and that's what we're going to clinically use it for. I think you just said a very important phrase, the entourage effect. It's the entourage of all the molecules in the plant that has the benefit, not just an isolated component. So let's get down into the details of this, because I shared my story about its effect for me um but you know what is the what are the most robust research findings on the therapeutic effects of cannabis yeah so i mean definitely the pain i mentioned already i think in terms of talked about yeah i

think in terms of our overall evidence i think there's just most of it and probably second closest is nausea especially when nausea comes in settings of some kind of a cancer, whether it's a nausea from chemotherapy or a nausea from cancer itself, doesn't matter. But that seems like there's really robust evidence. And the third, I think, is multiple sclerosis related specificity. So those are the three original big ones that were in the National Academies or NAS report. I think there's honestly underscoring and there's tons of evidence for insomnia. I think it's just not really, we don't have like one large control study to say this, but if you kind of look at collective amount of evidence and more importantly, what we

actually see in practice, we see that in my opinion, efficacy of cannabis for sleep is way over 90%. I mean, I don't have to. You know, it's true. And it's way more effective than all the other sleep medications. It's so much more effective than all the meds. You know, it's unbelievable. And it's so much safer. Like if you, well, you know me, I'm a geriatrician.

So half of my practice people over 65 and, you know, insomnia in my practice used to be like one of the hardest thing to deal with. Cause I know I don't want to write for any drugs for sleep. And then cognitive behavioral therapy is not covered by insurance. If I send them for acupuncture, it's also often not covered, even though it's a great tool. And so I didn't have my toolbox was sort of all non-pharmacological i couldn't give anything to people and if i would give something then like maybe trazodone i was always like writing the script with shaking hands am i doing more harm than benefit so suddenly you know in 2011 12 i started seeing what what cannabis can do and it was just it's just turned my practice completely upside down in about two or three years. I just stopped talking about almost anything if the patient is really suffering.

I said, okay, we got to try cannabis first, and we'll see what happens. So are all your nursing home patients smoking pot and listening to Rachel Dead? Well, I wish. No, not quite yet. That's a whole separate. You just opened the can of worms that if we go there, it's not going to come out of it. Well, actually, it's interesting that it's shifting. I wasn't expecting that nursing homes and assisted living facilities will sort of start actually opening up.

I thought it would be sort of like, forget it, we're never going to talk about this. No, actually, in the states where it's medically illegal, there's gradual shift. There's gradual movement. And some facilities are actually very, those who have a really open mind and medical directors. A couple of years ago, American Directors Association, it's AMDA, A-M-D-A. So they are the kind of docs who run nursing homes organization. They actually put out extremely supportive comment. When I read it, I almost fell off the chair.

It was one of the most supportive comments saying, yeah, we have to assure that if in our state cannabis is allowed, that any interested patient will have some safe access, of course, considering the safety of others in the facility. That's the difficult part. Because A, if you're going to light up in the nursing home, you know, the fire hazard. If you're not lighting up, what else? I mean, how do you store something which is Schedule 1?

You know, well, I mean, unfortunately, in a lot of situations, cannabis problems come only to two things. The price and logistics and nothing else, and not the efficacy. Yeah. Hey everybody, it's Dr. Mark here. We all know how critical getting good quality sleep is to our overall wellbeing and optimizing our health. But if your mattress is not holding up to its end of the bargain, getting a good night's sleep can be almost impossible. And that's where Essentia comes in. It's handmade in Canada. These organic, non-toxic latex mattresses are packed with technology to promote sleep. An Essentia mattress is the perfect environment for you to experience unmatched REM sleep

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are reluctant to use it in practice um yeah a lot of misinformation um can you share a little bit about um how people can learn about this in the right way and what the most important things you've seen clinically from this are? There's sort of two separate questions in there. Yeah. Well, I mean, I think outside of insomnia, to be honest with you, it's still not my first choice for a lot of things. So I think I'm assuming that the patient who's coming to try it or thinking about it trying sort of either exhausted other things or simply they just feel like their symptoms not controlled enough by other things. So, I mean, I think, well, first, the condition for which you're going to use it should be evidenced. You know, there are lots of hype out there with CBD that it treats pretty much everything under the sun. And I will actually

tell you that in contrast to evidence for THC, evidence for CBD is dramatically more limited and maybe outside of anxiety and high doses for some forms of insomnia, there's not just that much evidence for CBD. Yeah. But, but the evidence, but if you look into, you know, I walked into Walmart to get something. Or was it? No, Walgreens. I walked into Walgreens a couple of weeks ago to get something. I'm walking along the lines to find, and there you have it, CBD of every kind, Walgreens. And it's their brand.

I know. It's everywhere. You can buy it at the gas station. Right, right. Well, you know, what happens is simple. Certain things for which it tends to work. Let's say you have one or two things. Let's say you have a bruise.

And so putting CBD on a bruise can actually ease it up or there's a placebo effect. But next thing you know, now it's getting translated all over the place. Anyway, so bottom line, you got to start with what's evidenced. Next, you have to figure out logistics. Logistics sometimes where things bug down. So let's say one of your listeners is not in a state where it's legal.

Well, that creates a significant challenge. If you still want to try it, you're going to have to travel to a legal state and then cross the lines, which is actually federal crime, to bring the cannabis from one state to another. A lot of people don't want to get involved because it feels like you're violating policies, even though, to be honest... But there's medical marijuana that you can prescribe as a doctor, right? Right. Well, but again, it's only for the residents of the given state. I mean, I can prescribe it to anybody. Let's say the patient travels to my state and I feel appropriately to say you should be, but there's no way for me to recommend it., I don't know, oxycodone prescription, it goes straight to the pharmacy. Here, patient is separated from physician completely. So you have to get a medical card, which is always authorized by a state. So you have to follow

the state guidelines to get the card. If you're not a resident, well, you're out of luck. You can't get it. So then once you get a card then you have to identify a dispenser and go there and if your doctor tells you okay get some get this this and that okay great but most doctors don't tell you that they simply say well go and talk to the butt tenders we call them right so go talk to them it's like the lady in the vitamin store who's recommending your medical exactly and you. And some of those ladies are really good. They know a lot. And they probably know more than some doctors.

Well, not probably for sure. But some of them are clueless. They're like high school students. And so, not that I have one, but that's not the – No, point being, it's a dramatic – There's just no standardization across the field. It's a dramatic, there's just no standardization across the field. It's a maturing business. I think in the future, it'll self-regulate better.

And I think there's already some states that took really hard, like Connecticut and Maryland, for example, and others. So they took really hard. They say, look, you've got to have some kind of an educational directory. In Connecticut, you actually have to have a pharmacist on staff in every dispensary. So it's a pharmacist who's going to sort of guide the products, guide the education of the dispensary. It sort of has to happen this way. If we're saying that this is medical, it has to look medical, right? And it shouldn't look like alcoholic beverages. Okay, so I'm going

to say something and I hope somebody from district government is listening. So get a load of this. In District of Columbia, where my main license is, I don't know who was the miracle worker who said, oh, why wouldn't we move cannabis into alcoholic beverages industry? So literally when patient applies for DC medical cannabis license, what they see is that this is department of alcoholic beverages, not a department of health department of alcoholic beverages, who in the right mind came up with this stupidity is just sort of, so, you know, and then you have, so, so you have, you have some States that are thinking about this, right? And you have some states where it's a mess. Tell us what would be the take-homes for people?

Like, what are the things that people should know before they walk into the dispensary? Right. I think the first take-home should be know what condition are you going to use it for and get a basic sense for that condition. What are the experts would recommend? So if you get my book and you look up your condition in my book, can see what i would recommend there's tons of other great books i'm not it's not the only one and lots of experts in some ways there are lots of experts who actually know a lot more than me and you know but um you know start start at least from some basics because otherwise if you go and

you rely just on butt tender there it's probably not the smartest thing. I hope in the future, in 10 years, I can say, oh no, just go. And there's going to be an educator in the dispenser is going to tell you exactly what you need. And there are some dispensers that are starting to do that. So sometimes if I'm totally strapped for time, and I know a few dispensers in my area that do that well, I would send the patient there. Unfortunately, even with those situations, often we have issues because, you know, you'd have a sensitive patient and they will just start so much higher. So, but then after you get some core basics and you started trying, you have to be persistent. Often just starting with one product is not going to work very well.

You have to try two or three until you find your own personal kind of, and not only one product. Often people need between two to three. That's my general experience. And why would you need two or three products? Well, let's talk about pain for a second. That's an easy example. Let's say you have some kind of a chronic pain, let's say fibromyalgia. If you get a product

that's more, that has terpenes that are more activating and you take that past five o'clock at night, you're going to stay up till midnight or past. So you don't want to do that. You want to take that early in the day. But the opposite is true too. If you take a calming, more sedating strain in the morning, you're not going to be able to function very well if you're sleepy all day. So here's a simple example. If your pain needs to be controlled more than with once a day, which often the case, you want to take something activating in the morning, something sedating at night.

That's one simple, simple statement. But often you also can use different routes of administration. For example, edibles can be great if you wake up late in the morning and can't sleep. Let's say your insomnia goes at 3 a.m. You just wake up and then you're up and you can't go back to sleep. The edibles will work great. But if you have both... They won't make you too sleepy? Well, you have to dose appropriately, right? You have to titrate to dosing.

So that's the principle, start low, go slow. You'll start with a very low dose. And I usually start with sublingual form. So they kind of... There's this idea of therapeutic widening of the window. So if you start sub-therapeutically for a couple of days, three to five days, and then you start increasing, you're running much, much lower risk of side effects. If you start and you very quickly titrate up, let's say each next dose adds 20, 30%, which is commonly

done for pain, you may actually end up overdosing quickly. And be groggy in the morning. And be groggy in the morning. But if you do this carefully and you get to a point where it's working, so you could actually use sublingual right at bedtime or a few minutes before because it will kick in quick. And then you can also take an edible that will kick in a lot later. So some people can do that. Often it's not even needed. You can just take the oral

a little bit earlier, but it takes time to figure all these combinations. And you need to either have a very knowledgeable provider who will be sort of like an advisor and say, look, okay, well, this is what happened. This is why it didn't work, or this is why it had side effect. Or you have to try it on your own if you have no access um so the book is written both to help people who are complete novices but also people who've already tried something because it outlines some of those pitfalls sort of what happens if you overdose and you're afraid of going back to it how are you going to do that um you know and that's uh that's why still a lot of people take inhaled because the predictability of the effect is better. You take a drug and you know how it's going to make you feel, especially if you found the strain that works for you.

I have nothing against it. It's just often for medical reasoning, that may not be the best approach. But often, if the patient comes to me and says, look, I've been smoking my whole life. This is what I do. This is how it works for my pain. I often don't say anything because I find it not often easy to transition person from smokable product to something else. I would tell them what I think and then give it up, sort of up to them to say if they want to try. I had a number of people who switched over the years. What would be the best sort of sleep recommendations because a lot of people have

insomnia 70 million people have sleep disorders in this country and sleep issues it's a lot of people i'm just wondering what what your starting recommendations are for people and where they could kind of begin to think about using it right so find the product find a sublingual product like an oil a drops or we'll call FICO, full extra cannabis oil. I don't like alcohol because alcohol can burn the mouth. There are some tinctures that are alcohol-based. I tend to like oils more, whether it's olive oil or MCT oil.

So find the product oil like that. A lot of the products that are specifically designed for sleep, they're going to have a couple of simple features. The Indica is, again, outdated, but that's the kind of original term. So you're looking for Indica products, right? But now that we're going away from it, you can look for a couple other things. You can look for this molecule called CBN. C-B-N as Nancy.

Instead of CBD. So products that have high CBN in mix with THC sometimes are really effective. And often the products would have the terpenes that are coming, inhibiting, like linolel is one, but there are others. And the products would often say that on a label, like a sleep or tranquility or whatever, you know, and frankly, those products often design specifically for sleep. The good news is that a lot of the times, butt tenders would know that. So if you come into the...

They would know that, yeah. And even though there are a lot of edibles for sleep too, there are edibles specifically designed to have the same sedating impact. I always tell people, start with sublingual. You're running less risk of the next morning grogginess. You don't know your particular THC need. It's actually very interesting.

The THC need for insomnia varies quite a bit. I would say somewhere between 3 milligrams is probably the lowest, all the way to maybe 10, 15, 20 milligrams. And most people fall somewhere between five to 10 milligrams, what I've been seeing. But again, my population on average is a little older and sicker and more frail and more sensitive. So I may be seeing a bit of a lower spectrum in my clinic. So I understand there are probably people who work with other groups of patients where the dosing may need to my clinic. So I understand there are probably people who work with other groups of patients where the dosing may need to be higher. So for pain, for pain, which...

Start with sublingual for sleep. Start with sublingual. Maybe an edible. Maybe an edible. And it takes about an hour to set in? Edible will take at least an hour, maybe a little bit less. Sublingual can take 20, 30 minutes. Sublingual tend to work a little bit faster. So plan accordingly. If you need to fully sleep at 11 and you take it right at 11, you may with either form stay up for a little bit longer than you want.

So you may want to time it a little bit ahead of time. Again, that's why people like smokable, right? Because it hits right in and there's no lag time. Yeah, you're very quick. Right. And again, as I said, in the literature out there, I often speak about non-inhaled forms simply because they're safer. But it doesn't mean that if you have a problem that you feel needs to be addressed urgently, I think some amount of inhaled products is totally fine. If it's limited and done in a smart way. And again, yeah, so the lower temperature of inhaled product, the better.

So the vape, if you get a quality vape, it's probably safer than burning a flower if you can vape the flower. Now there's devices that are literally, like I'm not kidding, iPhone-controlled or computer-controlled, where we can pick precise temperature and the dosing. So that's the next generation. Yeah, there's some devices where you can tell the vape, you want to take 10 milligrams.

And if you know the cartridge concentration, it will calculate it precisely. So when you inhale, it will dose it right for that dose. So that's a future. It's already here, actually. It's not even a future. Is it commercially available? Yeah.

Yeah, they're commercially available. You can buy them. The one system that I'm aware of called PAX, P-A-X, they are doing that already. Of course, it's not cheap, you can imagine. So, you know, it's not a typical, Penvape can be 10, $20. Those things can be hundreds of dollars, if not more.

So they're not cheap. And they're controlled by your iPhone. They can be controlled by your phone. Well, most of the time it is phone because it's most convenient. Because you want to set up a certain parameters on the device to be precisely, precise at delivery. Amazing. Now, there's been some noise about COVID and cannabis, especially for long haulers.

What do we know? What do we not know? I mean, it can't be that there's that much research on it now. So the big noise was, I think, about a year ago when somebody, and there was a researcher in Canada that made a splash saying that cannabinoids could be used as anti-COVID. I honestly think that was just a hype. The study, I looked at that study, was very, very preclinical. And, you know, we know that THC has a very potent antiviral effect. So there's nothing surprising there. But translating that to the human, I think it went from,

it was a preclinical study to the Facebook saying cannabis cures COVID everywhere. And I was like, oh my God. You know, now it's fascinating you brought up long COVID. I actually feel strongly that in the last year, I feel like a third, if not half of everything I do is gearing that direction simply because we have an influx of patients. And there, cannabis can be a godsend for a lot of symptoms. A lot of people still have horrendous insomnia. And fascinatingly, they have really bad cognitive problems like the attention lock, brain fog. Actually, I have seen some patients do really well with a very low doses of THC and CBD.

I don't necessarily going to use it on everybody. It's sort of, it's still evolving as to who should we pick for that. A lot of people have, they lose a lot of weight and then they have this kind of general fatigability and they're not eating well and they don't have an appetite definitely cannabis can be occasionally helpful for that i would say there's actually i didn't mention that as one of the most evidence based approach everybody know that you smoke and next thing you know, you really want to eat. Turns out the evidence for that is very mixed. It's not as clear as you would think. There are definitely people who benefit from it. When you look at the studies, the studies have never been conclusive in contrast to pain or things like nausea. So I still use it. I think that newer molecules like CBG, for example, have tremendous promise for that.

But again, we need a lot more data to be conclusive, but definitely can use it. So it can be a very supportive additional tool for everything we do. But of course, you know more than anybody that a lot of these patients with long COVID, they have chronic inflammatory response, they have a mitochondrial suppression and kind of just general low energy states where, you know, you really want to boost the cellular function first. I don't necessarily think of cannabis being their first line. In fact, I'd be cautious if somebody's going to start smoking for some of the relief of their symptoms.

Actually, energy can be drained to some degree. Yeah, no, no. We've done a... It's true. I mean, we've done a bunch of podcasts on long COVID, and I think there's more to learn for sure, but it's... Exactly. For those that are listening and want to know about what to do about that, which now seems to be between 10% and 30% of people who get COVID, which has been millions and millions...

And now it seems like the Delta is also going to give us long-term post-COVID kids at somewhere between 5% to 10% of kids. So it's scary. Yeah. I mean, I think people are worried about COVID, but I'm more worried about long-haul COVID because most people don't die when they get COVID. But you think of 30% of 200 million people, we're talking 60 million people are sick. than a thousand patients at GW on the wait list in just one clinic just on waitlist because we can't get them in quick enough it's it's a complex process yeah I think it's really a problem but from a functional medicine perspective it's a lot people can do and I think you know symptom management through medical marijuana can be part

of it but it's not it not really the only thing. Exactly. So, Misha, when people are listening to this, they're like, okay, well, I've got some of these conditions. I have sleep issues. I have pain. I have digestive problems. I have MS. I have whatever it is that we've been talking about.

How do they go about finding a good dispensary, a doctor who can guide them? Where do people start? It's a little overwhelming. It is overwhelming. So there are some really good online resources. I think Leafly is one, Weedmaps is another. So a lot of this websites will have a list of practitioners in the area. If you're in a state where it's. Can you, can you give the websites for both of those?

Sure. Leafly. Oh, spelling. You ask a Russian guy to spell something. I have to look it up. I think it's L-E-A-F-L-Y. Yeah, I think that's right. And it is an app also. We'll put it in the show notes too. Yeah. L-E-A-F-L-Y.

That one. Most of the states would have a list of the doctors who are formally authorized to recommend so if you're in a state where it's legal the first step go to the actual state website that's responsible for medical cannabis and there will be a website and it'll explain to you typically the process of how to do it. If you can't figure it out, there are websites, other websites that will help you. Like I really like one called NORML.

N-O-R-M-L. Okay, I got to spell that too. Interestingly, most of my spelling efficacy is when I type things because I remember what my hands are doing. N-O-R-M-L. So it's a national organization for the reform of marijuana laws. So they have a list for each state, how you apply, like what is the process? What are the pitfalls? So, so for, cause you got to get a card first. So once you get a

card, hopefully you have way to access who are the physicians, because to get a card, you have to get a medical recommendation. So you went to a physician or a healthcare practitioner who's approved for this state, like nurse practitioner or naturopathic doctor, etc. So hopefully they're knowledgeable. Now, what if they're not knowledgeable? Well, then your next level is either you're going to find someone who actually understands something and it doesn't have to be a doctor there's a lot of people who call themselves now canna coaches some of them are great in fact uh in the beginning 10 years ago one of my sort of most informative colleagues was one such person i mean basically beth self-learned the topic because she was basically almost dead from all kinds of medical problems.

She was taking 30 pills. Her bills were in thousands of dollars a month. And she said, screw all this, went to Colorado, learned all this stuff, got herself all of all the pills and said, look, I got to teach. So some people there have just, you know, through their life knowledge, they became so interested and engaged and that becomes their whole world. So people like that end up usually being the masters, I would say. And if you can't find one of those, great. If you can't, you're going to have to rely on your butt tender. So then the road can be split.

If you get a good one, you're in luck. You may hit a jackpot right away, and'll be fine and it will work. And if it's not and something happens, you have to kind of go back and again, look for a provider or source of information that's going to work. So I know it's not a satisfactory answer, but the reason is we have to teach our colleagues. So I kind of, the way I took it on myself, you know, I'm not a researcher. There are experts in this field who are on myself, you know, I'm not a researcher. There are experts in this field who are way deeper than me, but I'm in university, right? I'm a full-time faculty.

So we said, look, we got to do something. And instead of creating yet another attempt at forming academic program that's very expensive, we said, look, we got to establish some kind of a cohesive process where we will create a consent of competencies. So, the way medical education happens this way, you have to prove to the larger administrative body of medicine education, medical education, that this topic has a set of competencies that can be followed as a standard. If you have a couple of schools here and there and few students can learn, that's fine. But the next step really have to be every medical student coming out of medical schools must know this topic. And they're not just need to know,

oh, there are potheads and there are none, and there's some little bit of evidence. No, they have to know how to recommend it. They have to know basics of laws in states where they practice. They have to understand basic clinical application, basics of toxicity, and how to actually practically recommend it. And if we create set of competencies and then try to go to American College of Graduate Medical Education and say, look, you got to approve this, then that's the next step. So that's actually what we're doing. We got a grant from industry to organize this.

So we already started a process. It'll probably take, you know, some months to get this, but we're hopeful that we'll go and try to publish this in a decent journal and then try to push this. But it has to start something like that. We have to start pushing the future of cannabis to be away from the industry or not away from industry, you can't do it, but also towards more academia and more standardization. Otherwise, industry is going to standardize it,

not necessarily the way we want to see it the other thing i wanted to sort of dig into was something you wrote about in your book which uh you know it's getting a lot of press which is cbd and endocabininoid system and how all that works and what we should know about that because it's one of the plant remedies that you do talk about which is a little controversial and people are really scared of it oh my god if i'm gonna take cbd i'm gonna get uh drugs and i'm gonna get stoned. I can't do it because my work doesn't let me smoke pot. What is all the hubbub about it? And what do we know? And what is the best application of CBD? What do we use it for? Well, first off, I do agree I'm a hemp farmer. I own a thousand acres of certified organic land

where we grow organic hemp. That being said, you know, there are different ways to grow the plant to where it has larger levels of different compounds. So to make compounds in hemp, also known as cannabis, and you're going to have THC and CBD. THC as a compound has hallucinogenic effects. That's what's going to get somebody high. CBD is a very, very different compound. CBD is just calming. It's in actually, it comes from the bud of a flower of the hemp plant. And it's more similar to chamomile or hops or even lavender. It's more similar in compounds there. So you have these two compounds in a plan Chinese medicine, it's known as a yin tonic. So it's going to help if you're in a sympathetic

state, you're in a fight or flight response, which so many, so many, so many of us are today. It's going to help bring you down from that. In fact, I would say CBD is maybe the most effective herbal I've ever used at getting people out of that fight or flight state, which is why I do think it is so powerful for people to use. If you, if you really need to get better sleep, CBD is the best herb I've used. If you want to improve and help reduce inflammation and joints, it's a really good one for that. I also think it's good for, um, uh, for, for digestion, if it's stress related and some other things, but sleep inflammation, biggest benefits of CBD THC though, do I do want to give this warning. I do think doing a medicinal blend

of those two, a lot of doctors will prescribe that. And I think that can be good to replace opioid drugs. And if somebody has major chronic pain, but I really think chronic pain is about the only category out there to where THC should be used for a longer period of time. Because here's the thing, according to Chinese medicine, and I've seen this with people, there is a big side effect with THC and that it's a drains your adrenal glands. Your adrenals in Chinese medicine was also known that it's what gives you motivation. It gives you energy saying, Hey, I want to go out and do things. I want to be active. You'll notice when people overdo, you know, that labeled them potheads for overdoing THC cannabis, it zaps their motivation. And actually in Chinese medicine, it's known to deplete their Jing, which is essentially their

sperm cow and their libido as well. So anyways, all that being said, I'm not the biggest fan of using THC in most cases, but CBD is a non... There are really just benefits there and none of the side effects. A couple of big metronomes to our entire physiological systems, as you well know, are the endocannabinoid system, which most folks aren't even aware of. In fact, I think there was a study maybe about 10 years ago but it said that 90 of U.S physicians weren't even kind of conversant in it as a system or its impact but I mean there's been phenomenal studies in Israel on that since the 1960s Rafael machulam is the pioneering physician he actually did it with NIH grants from the U.S for that whole time. And it's the system into which cannabis interacts, but it's not because of cannabis. That's just a lucky thing.

No, the body already had that going for it. Yeah, right, right. The body, I mean, sea sponges from 500 million years ago have an endocannabinoid system. So the fact is, is that it governs everything from bone growth to stem cells to brain health I mean the Israeli military studied it for TB eyes right for traumatic brain injuries and being able to flood the body in all of those things there's studies at Cornell Medical Center on the impact on mood and and fundamentally anandamide is what they call the bliss molecule which is endogenous to human brains and that is

what the endocannabinoid system produces. Yeah, we call it endocannabinoid receptors or opioid receptors. They're actually metabolizing and interacting with molecules that our body already has. Absolutely. And in fact, there's an interesting genetic variant where Nigerians have an unusually higher amount of anandamide. And there's a couple of other cultures around the world that do. And typically, it reflects in less anxiety, greater fear extinction from adverse events, and overall, a generally higher set point. So that's amazing and has all these profound impacts that virtually none of us are aware of, but it governs huge swaths of our physiology and resilience. And then the vagus nerve which is

becoming increasingly more known through Stephen Porges work and Bessel van der Kooke and others but it's largely unknown and it you know goes from our brainstem all the way down to our root and again is this huge metronome governing all kinds of internal regulation and you can you can improve it by gargling by singing by humming by massaging your throat there's pacemaker interventions there's more kind of high-tech pharmacological stuff but like just those alone just fascia endocannabinoid system and vagal nerve tone can you don't have to become an athlete you don't have to become a yogi there's nothing

you know extreme about it it's just learning how to adjust the knobs and levers of our bodies and brains for greater health, greater resilience, and overall higher well-being. And the practices that help you do these things are in the book, right? Yeah, absolutely. I mean, and particularly easy ones like respiration, here's just ways to become more in charge of your respiratory awareness. And I'm sure that many of your listeners are probably familiar with breathwork. They might have heard of folks like Wim Hof or other folks. Yeah, we've had a number of those folks on the podcast. Progressing the conversation, James Nestor wrote that great book, Breathe. But I

think people often these days still fixate on a specific version of breathing, often a hyperventilatory state-shifting one, assume that's what breathwork kind of is, versus, hey, the goal is to be conversant across the entire range of rate, rhythm, and depth for desired outcome, and then we can kind of just be in our own skin. And then breathwork, you know, I was a yoga teacher before as a doctor, they call it pranayama, which is all these different techniques for modulating your breath and changing your biology through breathing. Yeah.

I mean, and Aleister Crowley, right? The sort of infamous Western sex magician who wrote dozens of books and never said anything straight. It was always hidden in riddles and verses and all this kind of stuff. The one thing he says out loud on the page is pranayama, pranayama, pranayama, pranayama alone is everything. Yeah. It's so powerful. So you have breathing, you have being in your body, you have sexuality, and then you have substances and music. Yeah. So you can kind of consider those depending on how you want to make the argument, right? Ron Siegel at UCLA has talked about the urge for animals to

seek non-ordinary states or intoxication is not only ubiquitous across human cultures, it's not only ubiquitous across primates or even mammals, it even goes to birds. Really? Who seek non-ordinary states of consciousness? What do you mean, they're stripping parakeets? Yes. Yes. Absolutely. And fundamentally, he was saying that other than air, food, and sex, you can make a case it's our fourth biological drive. Interesting. So you can either see it as an amplifier. Oliver Sacks, the famous neuroscientist, said, say what you will about drugs, but they offer

transcendence on demand. They actually work in a predictable way, which is part of the reason why the psychedelic renaissance is generating so many radical insights into theories of mind and consciousness is because, you know, you can predictably give somebody a molecule, a compound, park them in an fMRI machine or whatever other measurement you're going to be doing and you will get a repeatable result versus getting a tibetan you know lama to be chanting or meditating or something harder to pin down or more esoteric um so substances and specifically state shifting and you know my inquiry in the book tended to focus on those compounds which were both available and accessible they weren't either

strictly controlled or wildly esoteric. So they were available over the counter, off the shelf by prescription, schedule three, four compounds, those kinds of things. But also from functional, what do they do? Compounds that typically, some of the most interesting compounds to provide that kind of peak state experience,

that kind of peak state experience that kind of death rebirth experience or those that drop your neural EEG down into Delta wave states yeah which is what you get from meditation or well very esoteric meditation I mean into the Vajrayana traditions most a lot of meditations are sort of alpha to theta I mean a aid there's no singular meditation they're all very different, produce different things, as you well know. And their neuroelectric signatures vary comparably. So deep delta, waking, like delta is typically only accessible to most of us in deep and dreamless sleep. Waking delta is a very rare, pretty esoteric state because it's down to damn near brain dead, so four hertz and less.

And that has super intriguing correlates with near-death experiences. So, Carl Dyseroth at Stanford has done all that work on optogenetics and the ability to source different states via tweaking things, obviously, in mice and that kind of stuff. But in human patients, they had epileptic patients, and they gave them the compound ketamine, which is a dissociative anesthetic, which induces delta wave states, and then correlated that with a sense of egolessness or ego death, and correlated that with antidepressive effects. And so what they realized is that they isolated the region of the brain

that was coming in at right around three hertz was the sort of signature that they were picking up when patients were under the influence of ketamine and reporting a sort of selflessness or an out-of-body experience. Then what was really interesting is that they then went back in and electrically stimulated that same three hertz signal in that same region without the drug, without ketamine, and patients were still reported the same out-of-body experience. Wow.

And then as a result of that work, another group started researching nitrous oxide for its potential- Wrapping gas. Yes. Exactly what folks use at dentists, what doulas and midwives use to ease childbirth, that compound. Because they were like, oh, maybe there is an analog for nitrous oxide as an antidepressant also. And it has actually proven out as well. And then the anesthesiology team at MIT did research on nitrous oxide and were shocked to find that it actually doesn't, not only does it induce delta wave sleep or state for three to 12 minutes after a 50-50 oxygen nitrous oxide gas blend infusion, so wearing a mask and breathing it, but for three

to 12 minutes, you get double the amplitude delta wave oscillations in the brain before the brain then normalizes out. So you get all of these experiences and you realize, oh, delta wave activity is arguably the signature of a sort of quote unquote near death experience, right? AKA what has been, as you were saying in the wisdom traditions, a death rebirth initiation protocol. So you're like, okay, so those are potentially super interesting because always it's not just that, you know,

this is like that old movie Flatliners, you know, with all the med students, right? Go into the basement and like take turns paddling each other. And there's always the cautionary tale of don't play God, right? But we are close to getting to do that in more controlled and more responsible ways now. And the interior content of those experiences are often quite profound and provide as much, you know, access to the healing, to the antidepressive, anti-anxiety effects as the physiological experience itself. And they can help heal traumas?

Well, I mean, there's strong evidence to suggest that, and I just don't think we are anywhere near teasing this apart. And you and I talked about this at lunch, of like isolating factors. What of, even more broadly, all of the research into the psychedelic Renaissance whether that's ayahuasca MDMA ibogaine psilocybin you know that this the compounds that are under fairly intensive comprehensive study it's hard

at this stage to really separate out what is pure neurochemistry mm-hmm resulting in decrease in depressive symptoms, anxiety, et cetera, whatever they're studying versus what is the interior content, the ineffability, the mysterious nature, the profundity, whatever it might be. Once you see God, how can you turn back and not see it, right? Yeah. And I don't know if we'll ever truly unravel which tail is wagging which dog on that. Yeah. So, you know, in the sort of service of this sort of conversation,

you know, there are some substances you talked about that are accessible and legal, whether it's ketamine or nitrous oxide, in many states, cannabis, as sort of doorways to help us access these altered states, which you say are non-ordinary states of consciousness that humans and primates and other animals seek, which is say are non-ordinary states of consciousness that humans and primates and other animals seek, which is actually interesting to me.

And I think we're all looking for that, whether it's we pray or whether we dance or whether we listen to music or whether we take substances or addictions. They're all attempts to change our state, right? Because it's somehow disconnected from something that makes us feel whole and complete. But these are sort of, in a way, more adaptive and more therapeutic strategies than often we've used. And you've sort of codified them in a way that is very interesting. And you actually created a research project to look at these things in a more objective way.

And I'd love for you to talk about this research project because essentially you took people and put them through a three-month program and measured objective scientific metrics to look at the changes in their state and the change in their biology and the changes in their psychology um and and you discovered some pretty interesting things so i love you to sort of share about this concept of hedonic engineering which is sort of what the larger frame of this conversation is. It's not about hedonism. It's about how do you activate these altered states, which help us then be more connected to ourselves, be more connected to our partners, be more connected to the social fabric in which we live. And how did you sort of create these experiences for people? What were the elements of them? And what were the findings of the study?

Yeah, I mean, it was really interesting because as I was doing this research, I basically just started just keeping my eyes and ears open for any published research that was indicating any interaction with the body and the brain in the realms of neuroanatomy neuroelectricity neurochemistry so what was going on and where was it going on what parts of the brain was was it being informed by um cardiac state or coherence or condition um endocrine system uh any any sort of just how you know does does any intervention positively inform or help boost the metrics of well-being and all the way into non-ordinary states? I hope you enjoyed today's episode. One of the best ways you can support this podcast is by leaving us a rating and review below. Until next time, thanks for tuning in.

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