Dr. Grammer: “There’s an analgesic effect of marijuana. And pain is one of those things that we don’t treat well in medicine. So for years and years, we used opioids, and that did not work out well. And that was sort of the gold standard for chronic pain for a long period of time. And then we just everyone’s kind of seen that in the news. Nowadays, people are like, Oh, we’re just gonna let you be in pain, and here’s your Motrin, and good luck. And for a lot of folks, that’s not adequate enough. So there are some people that absolutely feel a tremendous sense of relief with marijuana for pain.”

[Life to Live by Grace Mesa (Instrumental Version) begins]

Beyond Depressed is a mental health podcast for people who want to know the science behind emerging treatments and if those treatments are right for them or a loved one. New therapies using psilocybin, magnetic stimulation, ketamine and medical marijuana are bringing people much needed relief. Together, we’ll take a deep dive into depression and how therapy, medications and drugs can help you feel better.

Beyond Depressed is hosted by Dr Geoffrey Grammer. Dr. Grammer is a decorated retired Colonel with the United States Army and is currently serving as the Chief Medical Officer for Greenbrook TMS. He has experience in psychiatry, internal medicine, and behavior neurology.

Disclaimer: The following podcast is for information and educational purposes only and should not be considered official medical advice.

[Life to Live by Grace Mesa (Instrumental Version) ends]

Dr. Grammer 

Welcome back to the podcast. I’m Dr. Geoffrey Grammer. Today we’re going to talk about medical marijuana. Are you taking medical marijuana? How do you know what to take? How do you know when to take it? How do you know if it’s right for you? Those are going to be some of the topics we discuss today. I’m joined today by some repeat co hosts Brianna.

Brianna 

Hi, Dr. Grammer.

Dr. Grammer 

Hi. Thank you for coming. And Joe.

Joe Clements 

Hello.

Dr. Grammer 

As always, thank you for being with us today. So a lot of people I suspect are going to be interested in medical marijuana. Joe, what is your understanding of where this sits within certain societies? I guess we’re down here in a place where there is a medical marijuana program within the state.

Joe Clements 

A big one.

Dr. Grammer 

So what have you seen as far as how people engage with that program?

Joe Clements 

So I think again, kind of where we were at the psilocybin episode, three generations Gen X, me being millennial, Brianna being you know, elder Gen Z, perhaps younger millennial, unclear she’s, she’s borderline. One of the things I think is interesting is the change… So for most of your life, marijuana has been a thing that was as bad as like crack. For me. It transitioned. We, you know, I was in D.A.R.E. in elementary school, and it was as bad as crack. But then by the time I was early to mid-career, legalization for medicinal use was becoming common to the point now where I know literally dozens of people have their medical marijuana card. And then Brianna, do you really ever even remember a time when people are like marijuana is as dangerous as crack?

Brianna 

No, not at all. It’s all been pretty casual for the most part.

Joe Clements 

Yeah. So I think that’s an interesting transition process. And also, you know, I think our viewpoint… Like, what is your viewpoint of someone, if somebody says, Yeah, I, like I love marijuana, what is your thought?

Brianna 

Awesome, great. You know, I have nothing against it. I feel like nowadays its this super casual… and I feel like it’s a very common thing.

Joe Clements 

So for me, if someone says that I’m like, you know, there’s a 50/50 shot, they’re just like, really irresponsible or like 50% have, like, some medical reason for using it. And I want to speak for you. But if someone tells you that you probably think that’s a total slacker – failure to launch over here.

Dr. Grammer 

Well, actually, so I think marijuana is a hard compound to talk about because of the things… this is kind of interesting, and again, to anyone out there who does addictions medicine, I’m going to apologize in advance, but marijuana got caught up in this kind of anti-drug movement. And the idea of Reefer Madness, which was basically propaganda, not necessarily science based, vilified marijuana early on, because it was part of this kind of counterculture. And it for years was illegal in the US, and any use required engagement in criminal activity. And unfortunately, that has disproportionately affected certain segments of our society and led to things like incarceration so forth. It’s been very, very problematic. Now, as we’re kind of coming out of that, and kind of returning to like, hey, how bad is it? I think we’re revisiting where it falls within the spectrum of things. And in some ways, the medical marijuana program is a bit of a proxy fight for recreational use of marijuana. And I’m not going to get too much into that discussion, because that goes down a whole separate pathway. But I will say this, two things in our culture have been very much socialized as normal and acceptable -alcohol and tobacco. And you can make very valid arguments that those two agents have more long term health consequences, adverse health consequences, then the use of marijuana, but you can buy a beer at a concert, but you can’t go up to that same vendor stand and buy a joint. Right? And so I think that it is worth sort of acknowledging that a lot of the adverse kind of opinions about marijuana, were kind of born out of things that weren’t necessarily science based. Now, I do want to point out, Brianna, for you and your generation, it’s it is kind of interesting, because younger folks may underestimate that it is a drug and it can affect your brain. But in particular, when we look at in whom marijuana can be detrimental for, the one group where I think the literature is fairly convincing for an adverse effect is for those under the age of 25. So believe it or not, brain development doesn’t end until we’re about 25. That’s one of the reasons why like you can’t rent a car until you’re 25 because you haven’t finished having all the nerves go where they’re going to go. And marijuana one of the ways it works is the actual THC compound, binds to the cannabinoid receptor. And that cannabinoid receptor is responsible for modeling your brain it helps your nerves kind of make new connections to new nerves and peel away ones that you don’t need. So if your brain is still undergoing a tremendous amount of sort of growth growth and development, it can interfere with that. And what we’ve seen is people under the age of 25, who use marijuana are going to have a lower IQ, performance IQ when they get older, and higher psychiatric morbidity and even potentially a higher rate of psychosis. So one thing that listeners should take away from this is, if you are under the age of 25, you should exercise caution, if you choose to use marijuana.

Joe Clements 

What is psychosis?

Dr. Grammer 

That is a disorder in perception of reality. So that can be either hallucinations, visual or auditory or delusional belief system like that paranoia, that’s kind of the stereotypical FBI is following, you know, like, so and that can happen from people who use marijuana. So what are your thoughts on that Brianna?

Brianna 

Yeah, I actually think that’s very interesting. I feel like nowadays, people around my age, we are moreso concerned about like, it doesn’t do any damage really to the lungs compared to like, cigarettes, you know, it’s like a better option opposed to that. We’re not really thinking of like, oh, this can have a dramatic effect in 10, 20 years or so. So I feel like that’s what our mindset is, is like we can be doing cigarettes instead of smoking weed, you know, but weed is would be a better option. So that’s more so like what we’re coming from in that aspect.

Joe Clements 

I actually think you saying that is a politically controversial statement. Because the line on medical marijuana and marijuana in general, is it’s essentially harmless if used responsibly. So I mean, I think probably most listeners will be surprised to hear somebody who’s familiar with the research say that, because that is not typically what what is said about it?

Dr. Grammer 

Well, and this gets back to your previous point, right? So the problem with things like D.A.R.E., and like, oh, marijuana is all bad marijuana is all bad, is people tune that out. Because they know that actually, for some people, that’s actually not the case, it can actually be a very useful substance to help people deal with a variety of conditions. But there are risks like with any substance that you introduce into your body that you have to contend with. And certainly, it seems like at least the long term psychological and cognitive consequences are in those that are younger. So and that seems pretty convincing. But here’s where some I think some of the literature can get kind of confusing, because, in general, there is a publication bias in the literature that demonizes marijuana. One of the reasons is not because people are out there like, Oh, I hate marijuana, they’re going to prove it’s it’s bad for people, there certainly are people out there that do that. But right now, because marijuana has been illegal all this time, it is really hard to do prospective studies using marijuana, you can only learn from one place that grows it. So and it’s just that one place federally, right. And so it’s not representative of the stuff that people take on the street. It’s not representative of the stuff that’s in the dispensaries. It takes forever to get…

Joe Clements 

Oh, this is interesting, because so much of the research is federally funded. In order to study it, you have to use some federally approved grow operation. But every state that has it is not that.

Dr. Grammer 

Right.

Joe Clements 

Interesting, did not know that.

Dr. Grammer 

Yeah, so the other problem is then all the literature is retrospective, like analyses. And what they will show is that often people who use marijuana have things like higher severity of illness of whatever you want to pick, right and lower social and occupational function. But if you think about it, there’s there’s an uncontrollable population selection bias that occurs with that retrospective research, because think about the severity of symptoms that would cause someone to engage in a criminal activity that could potentially result in incarceration, in an effort to relieve their symptoms. And that is not going to be the same group of patients that you’re studying that did not engage in that behavior. The populations are different. So anytime you see that research, where it says, Oh, this group that did marijuana turn out so much worse, it may just be a selection issue.

Joe Clements 

And you can kind of see this a little bit in places like Colorado, right? Like Colorado has probably introduced more people to marijuana, who never would do it back home or use it back home where they can’t get it. But go to Colorado and just you know, by whatever’s available.

Dr. Grammer 

Yeah, I think hopefully in the future, what we will see is much more well designed prospective control trials, seeing and whom this works best for and in whom should avoid it and what kind of things to look for for adverse effects long term. I see the argument go both ways. So there are people that vilify it to the extreme and let me get a couple things out of the way. Marijuana is not a gateway drug. Like that whole argument, which is another one of those like drugs are bad, don’t do marijuana. Alcohol – gateway drug for sure. Right? Marijuana…

Joe Clements 

Does anybody do hard drugs without having alcohol? Like at, like right before it? That’s exactly right. Please don’t do that. Yeah. But you’re right. So alcohol is much more bothersome. So it’s not like someone smokes weed and they’re like, Oh, now I really feel like doing methamphetamine. Yeah.

Dr. Grammer 

Like that doesn’t… that’s not what happens. On the other hand, you get advocates in the opposite direction. We’re like, everyone should use marijuana. It’s great medicine, it’ll cure your inflammation and it’ll cure all this stuff. And that’s problematic too, because there is no drug, like Tylenol has adverse effects. Aspirin has adverse effects, there is omega threes has adverse effects, right? Anything you introduce into your body can have an unwanted consequence. So somewhere in the middle is truth. And I think people need to be informed if they’re going to incorporate marijuana into their treatment regimen.

Joe Clements 

So on that topic, one question I have that I don’t actually understand the answer to, what is the difference between CBD and THC? And does either one of them have properties for depression, PTSD, OCD, the whole gamut of disease that we’ve been talking about?

Dr. Grammer 

Yeah, so CBD is different than THC in that though it’s part of some marijuana plants. It does not have significant psychoactive components to it, it still binds to the cannabinoid receptor, but it doesn’t make you high. Now, CBD is one of those things that like ballooned into a billion dollar industry overnight. And when the farm bill got passed, and actually, oddly enough, Mitch McConnell that that kind of pushed that through that legalized CBD in the US, I actually went to the literature and was like, Well, what do we know about this? And the answer is nothing. There is like no medical studies that are other than a couple of very circumscribed ones around seizure, where CBD has been adequately studied. And it’s very frustrating, because I’ve never seen anything that was so widely adopted by a population, but we know so little about, okay. So in some ways, we have more experience. I mean, I’m going to say something fairly controversial here, but in my opinion, we have more experience, at least anecdotally with THC than we do with CBD. Now, CBD, one of the challenges is, it’s a fairly unregulated market. So how much is actually in substances, there are some studies that have looked at the different formulations, and some of them don’t even contain CBD. So you’re just taking gummies that have nothing in it that cost 50 bucks, right? So the other problem is the dosing, if you are going to take it, like 25 may not be anywhere near close to how much you need to get pain or sleep relief, which is probably the two things that most people look for. Occasionally things like headaches and trigeminal neuralgia and things like that. And so what I would recommend is if you are going to try CBD, you have a couple of choices, some dispensaries will sell CBD, and then you know what you’re getting is actually what you’re ingesting because all those are tested. Otherwise, you need to go to a reliable vendor out there. None of these sponsor the podcast, so I’ll just throw it out there, but like Charlotte’s Web, for example, is one that seems fairly legitimate. What you’re going to look for is a company that has a legitimate QR code that goes to the laboratory testing sheet that says what is in that strain, that you’re getting ready to ingest. So that’s CBD, that’s a lot harder to kind of look into when people use it for seizure disorders. Just to put this in perspective, you’re looking at doses of like 300 milligrams per dose. And in that group, just to show that can be adverse effects, it can cause hepatic inflammation. So once again, don’t panic…

Joe Clements 

Hepatic inflammation is?

Dr. Grammer 

Oh, liver inflammation. Yeah, so this is another good example of like, nothing is completely safe in anybody. So if you’re going to use heavy doses of CBD, just be aware, we don’t know all the bad things that can do. But one thing you can do is hurt your liver. And certainly in the right upper quadrant pain, darkening your urine, yellowing of your eyes, itching, you definitely want to stop that and go see your doctor right away. And I would recommend trying to keep the dose down to the minimum effective dose needed to control your symptoms.

Joe Clements 

So the answer on CBD and any psychiatric depression is, we don’t know, we really don’t know what it does for most things. Now, let’s move in to THC. We know significantly more about that correct?

Dr. Grammer 

Yeah, at least the good and bad about it. The literature again, is really frustrating. So we’ll take PTSD, there’s a lot of folks with post traumatic stress disorder, that will anecdotally claim almost a curative component to THC use, but when you go look at the literature, again, its victim to that kind of retrospective analysis. And there’s actually literature to suggest that it can worsen symptoms, but I think that’s a very biased kind of analysis. So what I would say at this point is until we have better research studies, if you want to go down that medical marijuana route, you’re going to need to sort of anecdotally assess if it’s right for you, but what do I think it’s good for? Well, the biggest question I get is depression. Right? And actually, I’m going to say something also somewhat controversial. I don’t think that medical marijuana is a particularly good antidepressant. Alright, I think during the period of intoxication, some people can have some temporary euphoria, but the consequence is you’re basically dumping out your bucket of happiness during that period of intoxication, and you get nothing left for the rest of the day.

Joe Clements 

What is causing that?

Dr. Grammer 

So, anytime we use a kind of reinforcing compound, we get this activation of an area of the brain called the nucleus accumbens. And unfortunately, like other physiological mechanisms, like we talked about, it can attenuate when you repeatedly stimulate it. That’s why when you use cocaine, you have to use more and more and more, again, I’m not recommending using cocaine, but it’s just an example, you have to use more and more more to get the same effect. So with marijuana, a lot of people will keep using it and the initial euphoria that they get begins to dissipate. And then they’re just using the marijuana to sort of maintain the status quo. In addition, one of the problems with heavy uses of marijuana is it sits in the body a long time. So we feel high when it’s in our bloodstream, but eventually it moves out of our bloodstream and goes into our fat tissue, where it gets stored for up to like 45 days before it completely leeches out. And that can still have effects within the brain. So some people who are chronic users of marijuana will develop an apathetic syndrome, where you just stop caring about anything, stereotypically think about the kid sitting in their parents basement that’s like 28 years old, and they’re gonna strike out on their own anytime any day now, as soon as they learn how to play guitar, right? So there can be consequences to heavy use that don’t get you to where you want to be. And I think we have other more evidence based treatments for depression that can help if you feel like it takes the edge off, and you can use it in modest quantities. And we’ll talk about that is, I think that’s something you can talk about incorporating into treatment plan. But I see people come in and say, I’m just going to treat my depression with marijuana. And I’m like, I don’t think that’s going to give you the result that you’re looking for.

Joe Clements 

So we didn’t talk about this exactly. But my guess is, alcohol is even a worse treatment for depression?

Dr. Grammer 

Absolutely. Absolutely. So Alcohol is a depressant. If I handed you a bottle of pills, and I said, take one of these a day to induce depression. Would you do it? The answer’s no. Right they’d be like, you’re crazy, Dr. Grammer, and I’m like (shrug) you know

Joe Clements 

Okay, just walk around being happy all the time.

Dr. Grammer 

That’s right. There’s a podcast in and of itself, right? So. And it’s not just when you’re intoxicated. That’s the crazy thing about alcohol. Alcohol is neurotoxic, it damages the brain. Alright. So what we know is that people who drink especially in moderate to heavy amounts are going to have higher rates of depression, even when they’re not drunk. So if you struggle with depression, you absolutely want to work on keeping your alcohol use to a minimum, what is the minimum? Well, it depends on who you ask. But usually, the upper limit of not having adverse medical consequences, is going to be in men… men and women a little bit different because they metabolize it differently, but, you know, it’s usually no more than four drinks in an evening for men, and no more than 14 in a week. In women, you’re going to drop that down to three drinks in a night and 10 in a week. And so if you’re doing more than that, than that is more likely to cause adverse side effects.

Joe Clements 

Every night?

Dr. Grammer 

Well, four in a night, 14 in a week, so you could do like two nights of four, or like three nights a four and then you’re kind of capped out.

Joe Clements 

I feel like that’s problably… That’s a pretty intense level of drinking. I mean, if you’re an intense drinker or not, but I feel like for most people who are just casually like going out to dinner or whatever, that would actually be quite a bit.

Dr. Grammer 

It is it is. And I you know, part of the reason why I tell people that is again, it gets back to this all or none thinking in medicine. I see a lot of patients that come in, and they’re like, my doctor told me I could never drink on this medicine. So I stopped taking the medicine. I’m like, let’s say it’s Sertraline. Right? Okay, sure, you may increase the risk of liver damage, theoretically. Most importantly, the Sertraline will make the alcohol more intoxicating. So you have to be careful that you don’t overshoot the mark, but what I’ll tell people is, listen, if you want to go out to dinner and have a glass of wine, you don’t have an alcohol use disorder. Like if that is so important to you that you would otherwise give up the drug, fine. And again, that’s controversial. There gonna be people out there that disagree with me, but I think this all or none, like, don’t drink, don’t do any of this stuff. I think the end result is patients are like, forget you, I’m going to go do that and not listen to your medical advice anymore. So we have to be realistic with patients and say things in moderation may be allowable in the context of a more comprehensive treatment plan.

Joe Clements 

What is the interactivity between marijuana and antidepressants?

Dr. Grammer 

So relatively unknown, right? But I do think that the marijuana may have a higher intoxicating effect at a given dose if you’re on antidepressants. And what you don’t necessarily know is whether or not it’s going to change the impact of those antidepressants because one of the things that we’re looking for in healing depression is that remodelling of the brain, and we know that marijuana does interfere with that. So again, I think if you’re on antidepressants, and you’re going to smoke marijuana, that that is something you can probably do relatively safely. But if you’re using like an eighth of an ounce every day, that’s too much. Okay. And that’s going to that’s going to interfere with your ability to recover from your depression, I think in the coming years, this is some of the research that really needs to be done much more meticulously than some of the retrospective stuff in the past.

Joe Clements 

Are there other conditions that using marijuana is likely to make worse? You talked a little about depression said it was on on the fence for PTSD. Any other conditions like that where marijuana accelerates it?

Dr. Grammer 

Well, one would be if you do have, unfortunately, schizophrenia, schizoaffective disorder, or any kind of what we call thought disorder, where your ability to perceive reality is going to be impaired. Marijuana induces some kind of hallucinogenic effects and can be, I’ll say psychedelic-like in that it kind of warps reality. So if you’re already struggling to kind of figure out what is real and what is not, marijuana will not make that path easier for you. I also think if you have a history of panic disorder, what can sometimes happen is people can develop not only paranoia during the time, they’re using marijuana, but they may experience an increase in sort of emotional fragility between uses and there is some literature suggests that – that when you use, you’re paying for it by being more fragile, at other times.

Joe Clements 

What conditions is marijuana known to be good for?

Dr. Grammer 

So like, none, but, and I joke with that a little bit, right? So…

Joe Clements 

It’s because we can’t really do these big control studies on them.

Dr. Grammer 

Exactly, exactly. So what do I think folks might find it useful for pain is a big one. There’s an analgesic effect of marijuana. And pain is one of those things that we don’t treat well in medicine. So for years and years, we used opioids, and that did not work out well. And that was sort of the gold standard for chronic pain for a long period of time. And then we just everyone’s kind of seen that in the news. Nowadays, people are like, Oh, we’re just gonna let you be in pain, and here’s your Motrin, and good luck. And for a lot of folks, that’s not adequate enough. So there are some people that absolutely feel a tremendous sense of relief with marijuana for pain. Another one is insomnia, a big one. And granted the literature for sleep on marijuana is definitely very mixed. But the anecdotal reporting on that is fairly undeniable. I think we got to figure out who the best people that could use that. But if you have chronic insomnia from whether it’s PTSD, or anxiety, or even a little bit of depression, and you want to use a little bit of marijuana at night to help with sleep, I think that’s a reasonable thing to do. Headaches is another one of their conditions like trigeminal neuralgia, migraine headaches, and people can often report relief with that. People have used cannabinoids, essentially to treat nausea, and GI distress for a while there were these substances that were pharmaceutical grade to treat cancer related nausea. Now, again, we can quibble on that literature, but even now, some people feel that that can be helpful. And then the last one is some neurodegenerative conditions, MS, Parkinson’s disease and things like that. There’s some suggestion that there may be benefit in some patients with that, including things like muscle spasm, and so forth, that marijuana can be useful for, in the end, what I think ultimately, if you have a condition that’s not getting adequate relief with other modalities, and you try marijuana through a legal mechanism and find it’s helpful, then I think that’s individualized to you. And that’s something that you can pursue, but what I would like to talk about a bit is, how to dose it, how much to take, because I want to make sure that people don’t overshoot the mark.

Joe Clements 

Yeah. So you were mentioning pre-show that there’s a lack of expertise at this, you know, so it’s strain selection, dose, and then method of intake are the three things you look at?

Dr. Grammer 

Yeah, so I’ll ping Brianna on this one. So your friends that may have talked to you about smoking? We think about an eighth of an ounce. And again, it depends the part of the country and whether you’re on the free market or in the dispensary, but it’s going to run your roughly 40, 50 bucks, right? How much do you think is a reasonable amount for your friends to spend on using marijuana?

Brianna 

Often I feel like it’s between $20 and $50, whenever I hear them talking about it, but I am honestly not too sure about pricing with it, honestly.

Dr. Grammer 

But is that every day or is that once a week or once a month?

Brianna 

 I feel like that’s about once a week for them.

Joe Clements 

Yeah. What about you Joe? What do you think would be a reasonable amount of use? I have no idea. I know a bunch of people with their card and it seems like they probably use it every day. But I don’t know. I haven’t paid that close of attention.

Dr. Grammer 

Yeah, so what I have seen is there’s different types of marijuana users, right? There are some people that will treat kind of acute conditions and I get nervous anytime I see someone using more than an eighth every week. Now, there are some exceptions to that. Like listen, if you’ve got a terminal illness, do what you need to do to keep yourself comfortable. If you have a late stage illness, and marijuana is helpful for you, you can do whatever you need to do to feel comfortable. But if you’re a 21 year old male with a busted knee, and you’re doing $40 a day of marijuana, we need to sort of figure out if that is medicinal, or recreational or addiction, because contrary to belief, some people can’t get addicted to marijuana, there is a marijuana use disorder. And there are people that have trouble controlling their intake, and they have trouble discontinuing its use, that can be a problem. It’s not as common as with some other things and certainly there is a lower abuse potential with marijuana than with even alcohol, but it can happen, and I think it’s a mistake for people to say it never happens. So I think people need to take an honest look at how much they’re using. And if it’s more than an eighth a week, and you don’t have some truly extenuating circumstance to justify that you need to start looking at your consumption amounts. Now, let’s talk briefly about how to consume. Okay, there’s smoking, there’s vaping. And that can be with a pen, that can be as a dab, and edibles, would be the most common. You can also do things like patches and tinctures, tinctures are often cannabis that has been dissolved in some soluble carrier. A lot of them are alcohol based. There are some newer methods of emulsifying cannabis to be water based but the general theme from them as they’re usually given via dropper placed underneath the tongue where you hope you have a more rapid absorption and kind of like other oral agents or edibles. The advantage of tinctures is that you can dose those to the exact milligram because you know how much is in whatever you’re taking and you can dispense that because of the measurements on the dropper. So smoking is one of the most common methods of doing it. And there are some people that will describe the intoxication for marijuana during smoking to be different than other things, and perhaps a more complex level of intoxication. The problem is when you combust material, you create carcinogens. And so of all the methods of doing marijuana, that one probably has the most concerns for long term lung damage. And so if you are going to do that, there’s a couple of techniques you can do to kind of minimize the adverse effects from that. While necessarily you don’t want to pick a strain, just because if it’s THC percentage, if you are preferring smoking only a higher THC percentage may mean that you have less inhalations to achieve the same level of intoxication that could potentially be safer for you. The other thing is years ago…

Joe Clements 

Question, in your case, intoxication is not… is that being used interchangeably as getting the desired medicinal effect? Or how are you using the term intoxication?

Dr. Grammer 

That’s actually a great question. Let me come back to that on micro dosing. And please hold me honest and if I forget to bring that up, because you’re absolutely right, there are some people for example, in pain, and they’re gonna have to get high to some level to alleviate that pain. But there are other conditions of pain and anxiety that you can get away with a much lower sub intoxicating dose. Okay. But yeah, if you’re smoking using a higher percentage, and not holding it in – remember back in like the 70s, and 80s, if you watch an old Cheech and Chong movie, they would inhale (imitates cough) and hold it in. Most of what you’re going to absorb is gonna absorb in a couple seconds, right. And so you can just exhale, you don’t have to keep that smoke in your lungs any longer than you have to. Using a bomb can help with the comfort, but it doesn’t make it safer, contrary to popular belief, so whether it’s a joint or Bong, or a one hitter, all those are going to be roughly the same. So another way of doing this is going to be vaping. And it’s probably a little bit safer, because you’re not necessarily combusting, you’re not burning the actual leaf or the flower in this case, sorry, not least the flower. You’re vaporizing the purified, if you will, Rosin, if you will, from a flower, whether that’s gotten through some method of extraction, co2, butane, you know, pressing or whatever, you can do that through a dab rig. Now the problem with that, again, is the amount that you get is is really high, it’s easy to overshoot the mark if you’re dabbing, than with regular flower because you’re taking something that’s like 80% and you’re dropping it into the banger. And then when you inhale it, you can like way way go over the limit. And I worry again, more about younger people doing that that’s a heck of a lot of THC to put onto a developing brain. Vape pens are nice, convenient, they’re discreet, and you can actually measure your dose a little bit easier because if you get like a point three or point five gram pen, you just say, well, this is 80%. So it’s point five grams, I’m you know, 400 milligrams or in this, and therefore I know how much I’m taking each day so you can measure your dosing. The edibles are probably an underutilized and albeit a little bit more complicated method of use, but if you’re trying to control more around the clock symptoms, my recommendation is to look to edibles to maintain that because when you take an edible for THC or for marijuana, it gets metabolized into by the liver into a longer acting compound that will last longer in your system. The problem if you vape or smoke is you’re going to get three to four hours of relief. But if you’re in pain all the time, let’s say you have cancer and you’re in pain all the time. You get to sit there smoke all day, whereas an edible may last six to eight hours and then you’re down to like three times a day dosing. Really good for sleep. If you can’t sleep through the night and you smoke, you’re going to wake up at one or two o’clock in the morning sometimes and then you have to re-smoke and you’ve disturbed your sleep because of that fragmentation. You take an edible, it’ll last you through the night. The other nice thing about edibles is you know exactly how much you’re taking. If you take a 10 milligram edible, you’re getting 10 milligrams of THC. Whereas if you smoke, you know how much is left in the bowl, how much got combusted, you always estimate and it’s harder to figure out. The downside to edibles. The onset is variable and it can be anywhere from like 30 minutes to two hours. edibles are one of those things that half of ER visits are associated with over use of animals and people overshooting the mark, because they’ll take some and like 30 minutes later, I don’t feel anything there, they take some more then 30 minutes later, I don’t feel anything. And next thing you know, they’re like, oh my gosh, right. And you can’t take it back. Right. So be very careful with that. So usually, what I recommend people do if they’re trying to control symptoms is you’re going to do a basal amount of an edible. Let’s say if you’ve never done it before, start with like a 2.5 milligram to, you know, a five milligram dose. Five milligrams, if you’ve never done it before, it will be a lot. 2.5 is probably about right, if you’re smaller, or super sensitive, you know, even 1.25 or whatever would be enough. And then try that out. And each day escalate till you reach your desired effect in that your dose. And then what you can do is figure out how long it lasts for and then repeat dosing when that effect begins to wear off. And if you have breakthrough symptoms, in the meantime, you can use a vape pen or dab or smoke only for breakthrough symptoms. And that minimizes the amount of damage to your lungs. That’s a, I think, a decent way to do the medical administration. I know we’re running short on time. But the last thing we’ll talk about is strains. So in the old days, we used to talk about indica and sativa. Right. And the idea was that indica was like sort of calming and caused couch lock and gave a body high, meaning you got numb. And where sativa has caused, you know, activation, creativity and a head high. All that’s totally blown out of the water. Now because there’s been so much crossbreeding, almost everything is a hybrid. And what we know is that indica and sativa probably was less relevant than the terpene profile. Okay. And there are charts that go over what alpha pinene and all these different things do. In the end, this is what I would say, if you find a strain that works for you. The nice thing about working through a dispensary is you can look at the sheet and see exactly what the terpene profile is. And look at the things that are predominant in that. And then if you can’t get that exact strain next time, you’re going to want to find another strain that has a similar terpene profile. And with a little bit of trial and error, you will find the things in that terpene profile that give you relief, the entourage effect where you add the terpenes to the base THC compound may actually have a synergistic effect that is greater than just THC itself. Alright, so it’s important that people kind of look to that. Micro dosing. So, a lot of people make a mistake where I think they think getting high is the therapeutic effect. But with micro dosing, what we find is a lot of people can get analgesic relief or anxiolysis, anxiety relief, or even sleep induction.

Joe Clements 

What is analgesic?

Dr. Grammer 

 Pain relief with a much lower dose below the amount needed for intoxication. Right. So that’s where like that 2.5 or 5 milligrams, you may not get real high with that. But if it alleviates your symptoms, don’t escalate the dose, that may be all you need. That micro dosing even like a milligram for some people is all they need to take the edge off anxiety, for example, so that they can function throughout the day. And because it’s not causing that huge, intoxicating effect, you don’t want to be impaired. I mean, the last thing you want to do is trade discomfort for impairment. Right, you’re just trading like your symptoms… symptom substitution. You want to alleviate the symptoms, so you can function. And I encourage most people to at least attempt micro dosing and see if that is a better solution for you than using intoxication or getting high as the benchmark for when it’s kicking in

Joe Clements 

Trading discomfort for impairment seems to be the primary trade off people make when they are addressing mental health issues with substances.

Dr. Grammer 

Agreed. Agreed. And that’s – it’s a terrible trade off for sure.

Joe Clements 

So who is an ideal patient? On, you know, for… Are there any for psychiatric illness for medical marijuana?

Dr. Grammer 

Yeah, I mean, I think particularly sleep problems, pain problems, not necessarily panic, but more generalized anxiety, social anxiety, PTSD, I mean, again, there’s a lot of anecdotal evidence may be helpful. Okay. Particularly if other modalities have not brought you relief, or by some chance because you live in a state where perhaps it’s is legal without a card or something like that. Or you’ve just been exposed to it. You’re like, oh my gosh, this really helps me feel really good in a way that makes me more functional then you can use that. There is no FDA approval for medical marijuana. It’s still a schedule one substance federally. And we need good research to better define who it’s useful for. So until then, unfortunately, it’s going to be a little bit of a tried it, I thought it helped a lot, therefore, how do I use it? And then I think folks can fall back on some of the recommendations we gave. We didn’t talk about this, but part of the challenge is, who do you go to for advice? A lot of the medical marijuana doctors are just candidly registered to be able to say, yeah, you’ve got one of the identify conditions for which we allow for medical marijuana, but they don’t tell you how to use it. And then you go and see the bud tender at the dispensary, and some of them are great and can give terrific advice, but some of them may not have had that much training either. So I would encourage people to kind of listen to this podcast and maybe incorporate that into their decision matrix on what works for them.

Joe Clements 

Okay, so of the things we’ve talked about, probably medicinal marijuana has the most question marks around it, even beyond psilocybin, interestingly enough, because there’s just no, no large scale experiments done on it yet.

Dr. Grammer 

Yeah. Prospective randomized control trials. Absolutely.

Joe Clements 

Any last things that we didn’t cover that you think people should know about medicinal marijuana for, you know, depression, OCD, PTSD?

Dr. Grammer 

Yeah, I mean, very frequently, I will have patients come in and say, I tried everything. And then I did this and it saved my life. And I don’t want anyone to walk away from this podcast thinking this was an anti marijuana conversation. I think what I’m… what we’re talking about is pointing out that in some ways, the federal restrictions against marijuana actually make it more difficult to figure out how best to use it. So we can certainly debate the merits of its illegality in many places in the country, and it’s federal illegality. But from a medical standpoint, what would be great is to find ways to appropriately study it and study it in a way that matches real world use and not the artificial constraints that it’s been previously studied in. If you find marijuana is useful, you definitely want to keep the dose as low as possible to control your symptoms. And think about your method of use to minimize the adverse effects and to get better long term control. And then lastly, what I would say is if you’re under the age of 25, you should use marijuana with caution. And you really should avoid high doses of marijuana as part of any treatment regimen or any kind of recreational use. Brianna, did I leave anything out?

Brianna 

No, I think you covered a lot of information. Uh no, actually I have a quick question. I know speaking back to CBD and THC. I know they have different forms nowadays, people will like make lotions or oils or things like that, how does that incorporate with the therapeutic aspect of it?

Dr. Grammer 

Yeah. So one of the neat things will take marijuana base or cannabis based lotions, one of the cool things about that is it does appear to sit locally within the tissue. So if you’ve got a bad knee and you want to rub kind of a THC infused lotion or cream onto your leg, it will stay fairly local and won’t necessarily enter the bloodstream in significant quantities and cause you to get high. So if you have a very localized pain region, you’re right, a cream a topical may give you relief without the adverse mental status effects of the compound. And certainly for some people, that can be extremely helpful. So good question. Well, listen, this is this is great. We are at the end of this season’s podcast series. I hope for all the listeners that this was useful. I think we’ve tried to be a little bit more edgy on this to push the envelope so that people get good information as opposed to conservative information. That’s not as helpful, right. So not everything I said is going to be something that everyone agrees with. But I’ve tried to be earnest and honest in the information provided. As always, if you’re going to be making medical decisions, this should not be the sole source of that information. Anything you do should be with the supervision of a licensed provider who can help monitor and supervise you and advise you on what’s best. I want to thank all of the hosts and particularly Breanna and Joe for this podcast today. Thank you and please listen, subscribe, share, and hopefully we’ll have enough interest that we can bring back a season two and update these topics as well as visit new ones. So everyone take care, stay safe, and stay healthy.

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