Welcome. I'm Dr. Mitch Prywis. I am the session director and moderator for this roundtable on medical cannabis practice. I want to welcome you. This is my actual sixth year with this group coordinating programs relating to medical cannabis. Our emphasis has always been in the science, the practice, and the medical legal and regulatory issues pertaining to this. Traditionally we have done individual presentations. We thought for this year we change the format a little bit to make it a little more interactive because what I've found, I think what we've all found, is that there's many more questions sometimes than answers and this is an evolving specialty in cannabinoid medicine and I am very privileged and honored to be here on this panel. Combined I believe we have over 50 years of experience now working in this evolving field. If you look at where we're at and just in terms of the country, 80% of the country now has medical cannabis and half the states have access via recreational. Just from a show of hands in the audience, I know not everybody's here yet, there's still people coming in, but just to kind of gauge how many of you are either using medical cannabis within your clinical practice or have some experience with it. Just a show of hands. Okay, so there's a smattering of it. That's kind of my assumption is that this is something that none of us have learned in medical school or any of our residency training, but we all feel here on this panel that as physiatrists this is something that we have the potential to be leaders in to educate the public and as I said we have an incredible panel here so I'm going to stop talking and introduce the panel. What we're also going to do is I'm going to ask some questions of our experts and then we're going to open it up to questions. So we're going to make sure that we have at least 15 minutes and that goes for not only the people here in the room but people who are observing us virtually. Okay, to my right I am honored to introduce Dr. Greg Carter. He is, I consider, our fearless leader in this. If it wasn't for Greg I don't think we would be doing as much. Greg has been involved with medical cannabis in the state of Washington for over 20 years. He's chief medical officer of the residency program director at Providence St. Luke's Rehab Medical Center in Spokane. He's helped write the first initiatives in Washington state that allowed for the use of cannabis for medical purposes with physician authorization. His current interests focus on the use of cannabis to treat degenerative neuromuscular disorders including ALS, an area in which he is widely published. To his right we have Dr. Michael Saulino. He's chief of PM&R Cooper University Hospital in Camden, New Jersey. He is professor and chair of PM&R Cooper Medical School of Rowan University. His medical experience has been over five years for the management of neuropathic conditions and chronic pain. Next to Dr. Saulino we have Dr. Ari Grice. He's a clinical assistant professor of rehab medicine at Thomas Jefferson University. He's fellowship trained in sports and spine rehab. He specializes in the non-operative treatment of spine and musculoskeletal disorders and what's most interesting to me is that he's a director of the medical cannabis department within an orthopedic institute, the Rothman Orthopedic Institute. His interests in treating chronic pain with cannabis as an alternative to opioids and he is also an active cannabinoid researcher for the past six years. Lastly we have Dr. Stuart Glassman. Some of you may know him. He's very active within our Academy. He is currently deputy chief of PM&R for the VA, the greater LA health care system. He's also associate professor at David Geffen School of Medicine at UCLA. He's owner of a physiatry practice in Bedford, New Hampshire. He served on the New Hampshire Therapeutic Cannabis Advisory Council for the past six years and he is our national delegate to the AMA and participates in the AMA's cannabis task force. Okay so we're going to get started. I'm going to start with some questions for our panel. Let's start with, I'm going to start with you Ari because I think it our audience would probably be very interested in understanding a little bit about how you are involved in an orthopedic Institute at the same time being a medical cannabis researcher. So maybe you can tell us a little bit about how that evolved and and maybe explain to our audience how it's affected your practice. Sure so thanks for having me here. It's a pleasure to be with you all this morning. I got involved in medical cannabis after practicing at Rothman Orthopedics for close to 10 years and this was this decision was largely fueled by frustrations with treating patients with chronic pain with opioids and you know having lots of chronic pain patients that I would say weren't weren't thriving on these pain medications and I was lucky to be at Thomas Jefferson University where they formed a center for the study of medicinal cannabis and hemp and Rothman Orthopedics is the orthopedic department for Thomas Jefferson University and at Rothman we you know stress the importance of innovation and research and to me it was an opportunity to just offer an alternative and so with the 2018 and so the only way I was able to get a department set up was was through a research angle and so I've I've done over 2,000 medical cannabis certifications in the last five years and each patient that we've certified in the practice has filled out outcome measures at the time of their cannabis certification so pre cannabis use and then at a three-month follow-up and then we try to get and if they renew their cannabis card outcome measures at 12 months and it started off just me doing a this as an experiment to see if it would be feasible and helpful and it was very well received by patients and even clinicians who had frustrating cases and really didn't know what else to do with them and I think as a practice in general we've been trying our hardest to limit the use of opioids perioperatively and to again find other ways to treat chronic pain and so in the last few years we've expanded the program there's about seven physiatrists in our group that are doing medical cannabis certifications and we are trying to publish the results in a prospective observational method we have a open IRB and we have a cannabis research repository of data that we're currently analyzing and trying to figure out what are some of the best methods for introducing cannabis in patient care great thank you very much all right Michael I'm going to ask you a similar question we're going to go from an orthopedic setting to an academic setting you know as professor and chair of a rehab department I mean that's pretty fascinating to me that you were able to incorporate medical cannabis tell us a little bit about your experience so again similarly thank you for the opportunity it's a true honor to be among some of the giants of our field in this little section of our interest I will say that I actually started with a medical cannabis program from a very practical perspective other providers were asking for our records to document the diagnosis so that our patients were going elsewhere and when patients came back and asked us questions about it they were getting better responses and answers from our faculty about how to use the product what it's appropriate for when to be cautious with it then they were from their certifying physician so it actually just became a practicality why are we letting that business go out the door I mean that's what chairs and division chiefs do right they write pro formas and business plans and budgets and all the this sort of thing so it was actually a rather practical application how do we keep this business and we and it's actually been a very fruitful undertaking for our patient population now we get patients referred into us specifically under the auspices of could you certify me for medical cannabis oh by the way there are a few other things that a physiatrist can do for your condition whether it's spinal cord injury or multiple sclerosis or other neurologic conditions which is really the focus of my individual practice so it's almost an entry point for these patients who are out in the community who we could provide tremendous service to and medical cannabis is just a conduit to it having said that working in a big institution nothing gets done without a policy and a procedure and 14 people looking at it and signing off on it I do have some slides that are available to both the online community and the live community afterwards if you want to see some of the tips that I would have about setting up your practice like everything else in academics it can be a long arduous process but once you kind of get it up and running it actually can be very fruitful and drives in a lot of new patient revenue right great thank you I guess it also helps to have it an administration that is somewhat forward looking like yourself because you've had to make a case for it and obviously there must have been a lot of reluctance early on but now they're seeing the benefits of it agreed yeah all right Greg you're up you know as pioneer among our group really with over 20 years of experience in Washington State you know maybe share a little bit with our audience of what you've learned through your research in neuromuscular disorders ALS and and what potential you feel it has within our specialty for our particular patient population and one of the things that we've discussed in the past but we really don't have the opportunity in the 75-minute session to talk about the science and the endocannabinoid system but it's something that we could spend the full day on you know Greg is really a pioneer in a lot of this so I'm gonna give you the floor to speak about it in this area because my ALS and MS patients back in the 1990s were admitting to me that they used cannabis. It was illegal back then. And initially I did not really believe in it. I had used cannabis in college like all of you, even though you'll deny it. But I hadn't really thought about it. And so I started looking into the science of it. And I think what a lot of people don't realize is there are 30,000 articles on cannabinoids, mostly in animal models still. But the human data is beginning to come out. So I certainly have recommended cannabis for pain. But my main interest is in neurodegenerative disorders. Certainly ALS is the focus. But Parkinson's, maybe other forms of movement disorders. One thing I want to say to remind everybody is the endocannabinoid system is the largest homeostatic system throughout the animal kingdom. So we have receptors in our body that bind with cannabinoids from the plant and other compounds as well, including terpenoids. And I would encourage you all to explore this. There's a number of good textbooks. And like Michael, you are welcome to reach out to any of us. I think my contact information is in there. But we did one paper last year looking at endocannabinoid levels in the plasma of patients with ALS. And there are spikes in endaminoids and a few others. So it has the potential to be a biopartner as well as a therapeutic target. And I'm happy to send you a reprint of that. We are now looking at it in cerebrospinal fluid, which has turned out to be pretty difficult. So we don't have any results yet. But I'll leave it at that. Thank you all for coming out. All right. Thank you very much. Lastly, we're going to have Stu Glassman, who's our medical, legal, and regulatory guru. We've been having some discussions recently, and you've probably heard in the press about discussions to reschedule medical cannabis. And that's been something that we're all watching very closely. Stu, if you could give us kind of an update. You're also involved in this task force through the AMA. Where do you see this Schedule III under the Federal Controlled Substance Act? Do you think that this is going to happen based on, you know, what you've been learning? And if this were to occur, how would it change the future of our practice? Well, thanks, everyone, for being here. Glad to be part of this incredible panel, colleagues and friends and researchers. You know, therapeutic cannabis, medical marijuana, pick the phrase you want. It's really an intersection between, you know, medical science, public health, legislative, regulatory issues, and the will of the public. So many of the legalization laws that got through were ballot measures from citizens. It was not bills in the state legislature. And yet, the medical cannabis programs were through the state legislature. So, back on August 30th, one of the members of the Health and Human Services Department for the federal government sent a letter to the DEA requesting that they really strongly consider rescheduling of marijuana from Schedule I to Schedule III at that point. And that would take it from being essentially an illegal, you know, product, drug, whatever you want to call it, to something that could be used, you know, by clinicians, could be used for research. So I think part of that issue is that there really seems to be a strong desire now in the medical community to be able to at least answer the question through research of, you know, this whole question of medical cannabis, therapeutic, you know, cannabis, marijuana. What's the real story, you know? We have research coming from Israel. We have, you know, patient, you know, trials that we see. We have great information here, you know, on this panel about where we're at. But we haven't had the ability to do really large-scale studies. We used to only be able to get research-quality cannabis from the University of Mississippi. Recent bills allowed the expansion to five other locations where research-grade marijuana could be grown. So I think it's an ongoing discussion of trying to figure out how to get better information and better science, because I think the legislators federally are still concerned that until the DEA changes their stance, you see bill after bill coming through to reschedule it, but the majority of Congress is still waiting for something to change, because they don't want to be the first one in. You know, and we talk about PMR bold, of course, here, and that's the theme for our academy. You know, the definition of bold, one of them anyway, is being fearless before danger. So this space of medical cannabis is not the known area of, you know, spasticity or, you know, spinal cord injury treatment. You know, it's taking something that may have potential, but we really don't have all the answers yet, and trying to find a way through that. So the states obviously have been way ahead of the curve of saying, we think there's some value here. If you look at the diagnoses that are listed in almost every state therapeutic cannabis definitions, it's the majority of what we do in PM&R. You know, the five PM&R bold areas, MSK, rehabilitation care, cancer, pediatric rehabilitation, pain in spine, that is us. You know, we can be the specialty that helps on the physical side anyway, you know, psychiatry, mental health, looking at those other areas. We can be the leaders here, and we can be the ones to help the legislators understand, and maybe help get this rescheduling happening. So I do believe that there's a desire to see it happen, but there's still resistance, and it's gonna take concerted effort from all of us in this room, and those watching online, to help convince others that, you know, there's a path forward, and we need to go there. Great, thank you, Stu. I should mention my bio briefly. I'm medical director of the Center for Pain Rehab. It's an integrative medicine practice in Danbury, Connecticut, for the past three, more than three decades. I'm also fellowship trained in integrative medicine, in the Andrew Weil Center for Integrative Medicine, and I'm board certified in medical acupuncture, which I've practiced for 30 years. The emphasis of my practice is really non-opioid, non-pharmaceutical. I'm also trained in osteopathic medicine. So for me, medical cannabis was really an extension of that, offering patients another alternative to treat pain. I've also appointed member of the medical advisory board for our state's Department of Consumer Protection's medical marijuana program. I am the only physiatrist on that eight-member board, and I've been using medical cannabis in my practice, and registering patients for the past eight years. I think we did a really, really good job so far. I have a few slides before we get to the Q and A. Just basically, since there are very few people who are familiar with this, and Dr. Grice has a case history that maybe we can get to briefly, but I just wanted to show you these images. Let's talk about dosing. There's something very simple. These are kind of the products, because when people tend to think of cannabis, they tend to think of the raw flower. I'm gonna smoke it, I'm gonna get high. But the delivery systems are really important when you're working with patients. The vaporization, you've probably seen these in the recreational area, but there are also ways to vaporize raw flower. The vaporized is non-combustion, so it has less irritation. Obviously, edibles. You can do sublingual strips. There's oils. And each of these products has, in addition to the amount of CBD and THC content, there are other things like terpenes which influence how people are affected by this. The general rule is you start low and you start slow. So you microdose with patients, because their tolerance could be different. If I'm dealing with an 80-year-old woman who's never got high, never had any experience with it, you'd be surprised. A lot of the patients that we see are baby boomers like myself and people who are older. And the kinds of comments that you get is it's really changed my life. There was a study done in the AMA Journal not too long ago that showed that in the states where it was approved for medical use, a lot of patients had been able to come off not only their analgesics, but their antidepressants and a lot of their other medications. This is what a sample label looks like. So we are fortunate in Connecticut where we have a pharmaceutical model. So each of the dispensaries are treated like pharmacies and the producers are treated like pharmaceutical companies. So every patient and every product they get has been lab tested, microbiology, mycotoxins, metals, pesticides, different terpenoids as I mentioned, the CBD content. So this is kind of what it looks like. So you know that you're getting a good product because when patients say, look, I want to go recreational, I want to get it from somebody, you don't know the source. This is as pure as pure can be. I've had the opportunity to, as a board member, to be able to go into these facilities. And they're clean facilities. You have to gown up and go into them. So it's really incredible how effective. This is something I found very useful. And these slides are available, as Dr. Salino's slides are available. Because in the state of Connecticut we have four producers and we have many different products but they're similar, I often give this to a patient and say, look, it's a trial and error for you. You're gonna be spending money out of pocket and you don't want to spend the rent money on this. You really want to start slow. But write down, document what you're taking. It's not standardized like taking a pharmaceutical. So you put the date, the time, the route, is it a vape, is it a capsule, what is the THC and CBD ratio, the dose, the time of onset, how long did it last, was there symptom improvements, did my digestion improve, did my sleep improve, what was my pain level, and the side effects or notes. Because if you don't like a product, you don't want to go back and get that product or if you took too much of it. That's something that unfortunately when people go to a recreational dispensary, they don't really know what they're getting and they may get something with a too high a THC level and some of these products can be very dangerously high and patients can get very paranoid and all of the different side effects with high levels. But if you start low and slow, that's less likely to happen. All right, do you want to do this case real quick? Do we have time? Sure. Yeah, I think as Mitch has indicated, the goal here is very similar to other pharmaceutical medications that we're prescribing, right? And it's to limit side effects and potential intoxication. And I think it's analogous to prescribing medications like gabapentin where some people take 100 milligrams of gabapentin and have significant sedation or dizziness and some people can tolerate 800 milligrams. So I think that there's some similarities there. In this case, I had a patient who was habitually using opioids for a decade to treat axial neck and back pain. And like a lot of medications, if you take them for a long period of time, the side effects diminish and you develop tolerance. And so this is the same thing with cannabis. So I had a patient here who was tolerant to opioids. They were not helpful. She came from another practice. She had had all the injections, epidurals, facet blocks, radiofrequency ablation, did not have any radicular symptoms, didn't have significant stenosis and wasn't like a surgical candidate. And this is a patient that just came to me and said, I'm taking these pills four times a day and my pain levels are still a seven or eight out of 10 every single day. And so I did her cannabis certification. I had her check with her pain doctor who was giving her the hydrocodone and said, she told her doctor, I'm gonna try cannabis. Can you help me wean off of the opioids? And I just started with a real low dose, like a less than five milligrams. Almost everyone tolerates, although there are some people that have hypersensitivity to cannabinoids and THC specifically. So two and a half milligrams is a dose that is available in Pennsylvania. That's the lowest dose in a capsule. With tinctures, which are a liquid, you can really, really micro dose with just small amounts. And my general recommendation with patients that are starting off with this is to avoid inhalation methods because you cannot measure how much you're putting into your body when you inhale, how long you inhale, how hard you inhale is gonna affect the amount of THC that you consume. And so you can learn what the right dose is for you with experience, but it's just the potential for overdosing in the beginning is I think too high with inhalation methods. So controlling the oral dose or using topicals is my preferred method or route of delivery. And that combination seems to work for a lot of our orthopedic pain patients. So this patient was using a topical THC lotion, started off with a real low dose of THC and CBD in a one-to-one formula or ratio. And then she titrated up from two and a half to five milligrams and started using some vaporized cannabis before bed to help with sleep. And over six months just gradually reduced her hydrocodone intake to the point where she was able to completely discontinue it. And I think in addition to just having better pain control, better sleep, and all the things that we care about in physiatry, this patient was very proud of herself for getting off of these medications. I think that's one of the downsides of being on opioids long-term is they control you and you feel kind of attached to them. And in this case, not only was she happy about her quality of life, she was really happy to be off these opioid pain medications. I've had several cases like this and they're just very rewarding because I think people feel stuck and like there's nowhere to go from. Right, and along that, if I may add, that one of the major differences between being on cannabis and opioids is that you cannot overdose on cannabis. You can get sick if you're taking too much and there are some issues with that, but it doesn't involve the brainstem. In the way that opioids do. So it's much, much safer for patients with chronic pain. Do you wanna do the second case? Sure. I think we're running a little bit on schedule, so go ahead. So this is another just difficult case in an elderly gentleman who had a lot of other medical comorbidities and he just had severe bone-on-bone hip arthritis and he had tried opioids, could not tolerate them. They were extremely constipating to him. He had kidney disease. He couldn't take NSAIDs. Tylenol was ineffective and he came to me for a hip injection and the injection gave him a couple weeks of relief and then he was back to where he was before the injection. And so many of my patients come to me out of desperation. They've basically been told there's nothing else we can do for you and even 88-year-olds and even I've had patients up to 102 years old who have tried medical cannabis with me. Not all successfully, but this was just an example of someone who was just willing to try anything. And so, if you wanna go to the next slide. Sure. We did a cannabis certification. He started using sublingual tinctures. He increased the dose and in some of our patients that are this old, they're very sensitive to cannabis and I think in other ways, maybe their receptors have been depleted over time and they actually have a higher tolerance than I'm expecting. And so, this patient was telling me nothing was happening. The route of delivery I think makes a difference whether it's sublingual and it bypasses the liver or if it's an oral product that gets metabolized by the liver, that can have an effect on the potency of the drug. And this patient switched over to capsules that seemed to work better for him and he was using a five milligram dose a couple times a day. He was using a topical lotion and he reported a 50% improvement in his pain which for him was very clinically significant and at no point did he experience intoxication or side effects and I think that's the same goal with cannabis as we have with our other pharmaceuticals is finding that therapeutic window where patients are perceiving some benefit without the symptoms of intoxication in the case of cannabis. Okay. Yeah, go ahead. So, I think it's important to remember as you go through the case studies here, none of us are prescribing cannabis. We are certifying patients that they meet the criteria and the diagnoses for their state-based therapeutic cannabis program because it's Schedule I on the Controlled Substance Act. You can't prescribe it. You can prescribe epidiolex for pediatric seizures but you're not prescribing anything yet. But obviously, if a patient comes to you and says, well, Dr. Grice, what dose should I use? Like, should I use a sublingual? Should I use a tincture? Should I use salve? How do we know how to answer that question? Part of this whole space is for us to really get educated on what they're going to see when they go to the dispensary and the bud tenders tell them certain things that may or may not be true. But remember, as of now, we're not prescribing. We're certifying. But we should be getting the questions asked of us of what do we think is gonna work for them. Diagnoses, strains, things like that. Okay, I hope you're getting your questions together because I'm looking to see it online. So we're gonna get to that. We're actually a little bit ahead of schedule which I'm impressed with. Doesn't always happen. I'm gonna ask Stu one more quick question because you're working in the VA system and you're also a medical cannabis expert and you've been on the boards and things like that. Being a federally illegal drug, how do you navigate that with people at the VA? So whatever institution you're in, look for the policies that relate to what it is you're interested in. It turns out that since 2015, the Veterans Administration, now remember, schedule one cannabis is not legal. VA hospitals are federal property. We are in California. They can walk across the street and go to any dispensary they want and talk to a primary care physician, not in the VA, to get a card from the state of California in order to get cannabis. On the VA side, they cannot get the card but this policy that's been there for eight years now says VA physicians will ask their patients about their cannabis use, will document it in the record but cannot advise them on whether they should or should not be on cannabis and it will not limit their benefits for things like pensions from the VA if you're service-connected and things like that. That being said, I will tell you that for a lot of the pain programs within the VA, including ours, if a chronic pain patient is on an opioid and they say that they are on, you're using cannabis or test positive for it, they will likely be told, we cannot renew your opioids for you anymore. So when I got there, coming in from the outside, I said, you know what? That's probably not the best way to do this. So we started talking to the attending, started to the residents and saying, you know what? Ask them what they're using. Don't just say, oh, you're on marijuana and okay, no opioids for you, next question. Find out more, ask better questions of them. We are looking at being able to question veterans on their experience within the VA of this exact issue, which is you know you want to be able to continue getting your opioids for part of the pain you have and also use cannabis for other things. What's it like being told by your VA physician that, well, you know, you've crossed the line, we can't really help you? When the policy itself says you're not gonna do that, you're not gonna limit their benefits, it's still a medical question of the safety of being on opioids, using cannabis, what's the right place to be in? But every policy has the ability to be improved. So I came in with the mindset of, there's a better way to look at this question and there's ways to go through it. Most VA policies are set at the federal level, but they start at some local medical center discussion as well. So I think I've tried to ask our physicians and our residents and our pain fellows to just think about it in a different way, ask better questions and look at your own knowledge and do you actually think this is the best thing for patient care? Remember, your licensure is on a state level. The DEA can take away your DEA prescribing, I suppose, but you're not prescribing cannabis. But the state board of medicine, in theory, is not gonna take away your license if you're doing things the right way for certifying patients. We've had cases where boards of medicine have taken away licensures for physicians because they were not certifying the right way. They were meeting people in a hotel, seeing 100 people in a day. That's bad. Yeah, I would agree with that, although I've heard stories, whether they're true or not, in certain areas where they don't allow dispensaries, where the medical community is very, very conservative, unaware, as most physicians are, I've heard them tie their hospital privileges to whether or not they're registering patients or not for cannabis. I've heard some of these stories and I'm sure they exist around the country. And actually, I heard this story in a state like Colorado where everybody thinks that everybody has access to it, but there are some very rural kind of red state politically places where they don't want cannabis. I think through education, hopefully the state societies all across this country will get on board, too. I can recall a couple of years back where somebody had a question, I think they were from South Dakota, where they didn't have access. The question was, what can I do as a physiatrist where I don't have access because the laws don't support it? It is a very individual, unfortunately, until we reschedule it. You've got to be the advocate. You've got to get out there. You've got resources now to educate your community, the people that you work with, and your society. I think we got one question here, so start getting your questions together. Let me see if I can manipulate this slide. Yeah, go ahead. I wanted to add a quick one. Actually, this was going to be a question for you, too, Michael, but go ahead. Inherent in what Stuart was saying is you have to look at your village. You have to know what the other members of your medical community are doing to make sure that if you initiate a medical cannabis program, you're not going to be in conflict with another member of your institution or your group. For example, if an orthopedic surgeon does drug testing before they do an operative procedure and they turn up positive for cannabis, you don't want the patient calling you up and saying, hey, why did you certify me? I didn't know I couldn't get my knee replacement done because my orthopedist won't allow me. Same with psychiatry and addiction medicine. One particular area that is super sensitive is the use of cannabis in any inpatient setting. The reason for that, as we've said it a couple times now, medical cannabis is illegal under federal law. No hospital wants to risk losing their federal funding because of committing a federal crime. I will tell you just a quick little horror story that really hits home when I say that. I take care of a young man who has a congenital neurodegenerative disorder, had very difficult to control seizure disorder. Am I too close? Oh, sorry. There we are. Thank you. As add-on therapy, not as solo therapy, he was using medical cannabis to help control the seizures. It certainly had a therapeutic benefit. Every time he was admitted to a hospital, he could not use medical cannabis. His seizure disorder got worse. I think there was an incremental decrement in his neurologic status too. Very inherent to Stuart's comments is look how it affects your village. That's excellent information. You really have to know where you're at. For people in California, it's going to be different than Alabama or some of the southern states that still may not have. How many states are there now, Stu, that it's totally illegal for cannabis? Which states are those? Can you hear me? I hope so. Okay, because there's no green light here. We have four states that where it's illegal. I believe it's South Dakota, I think maybe ... Do we have the map there? If we go back to the map, we can see it there. There are four states. It might be Wyoming. Yeah, four states. Wyoming. Yeah. Well, no, no, no. I think it's the ... If you read that there, it's the lavender color there. Let's see what we have there. Yep. Kansas, is it South Carolina as well? There are about four states you can look at. I have a question, and I want to start with Michael on this. It's about setting up a medical cannabis practice. The question is how frequently are patients seen once they're certified or for adjusting the dose? Great question. If I could leave you with one take-home message about setting up your medical cannabis program in your state is go on your state's website, read all the requirements that you need to do, then come back a week later, read it again, and check on it at least once a month. I will tell you that the two states that I can certify, Pennsylvania and New Jersey, I check the website at least once a month. For some patients or for some states, like for example in New Jersey, you need to establish a doctor-patient relationship of at least three visits before you certify someone except in the situation where you are assuming complete care of that case. For example, spinal cord injured patient, I could assume management of that. I could certify the patient on the first case or the first visit. A individual with multiple sclerosis, it's going to be in concert with my neurology colleagues. I need to see that patient three times in New Jersey before I could certify them. Each state will have their own idiosyncrasies. It has changed from before COVID, during COVID, and post-COVID. Many of the states require a live visit. That changed to some remote visits during COVID. Some have gone back to live only. Some have only allow it for recertification. You have to read your individual requirements. We also have a question from the audience. One second. Let me finish on that. In Connecticut, we still allow telemedicine visits since COVID. Generally, in our state, too, you have to document that they have a condition for which they're eligible. Every state has their own list of conditions. You have to have, as Michael mentioned, a doctor-patient relationship. I like to add that patients have tried other things. For me, in my practice, I want to know that they've tried traditional types of treatment before making sure that they're okay with it. The other thing that I do in my practice is I also look at their history if they have any addiction issues. If they have addictions and they're not in treatment for that addiction with a counselor or some documentation, I won't register them. That's something that I look at also. As Michael mentioned, every state has their own criteria for it. All right. I'll take the live question now, and then I think there's some more online. Okay. Ira Rashbaum, Rusk Rehabilitation, Orangulangone Health. Great symposium. Not a question, not a comment. As the American Academy was very, very bold, I recall Dr. Daniel Klawe, March 10th, 2021, National Grand Rounds. Basically, Dr. Klawe said basically have an ER with chronic pain, basically like a marijuana vape pen, a cannabis vape pen, end of the ER. I recall that from Dr. Daniel Klawe from University of Michigan, National Grand Rounds, March 10th, 2021. I'm sorry. Could you slow down your speech? I'm having trouble hearing you. Okay. A little louder, too. I'm sorry. American Academy of Physical and Mental Rehabilitation was very, very bold, but basically on the National Grand Rounds, March 10th, 2021, Dr. Daniel Klawe talked about how if they're going to the ER with chronic pain rather than doing opioids, Dr. Klawe would recommend doing like sort of a cannabis vape pen. Is this just a comment? Yeah. Not a question, not a comment. Oh, okay. Yeah. Are there any questions? Let me add one other comment to that. First of all, I appreciate your comment. Another little caveat to patients, it doesn't happen often, but you should tell patients if they are having an adverse effect, they can seek emergency care to get that treated. I actually did have a patient who had some risk factors for cardiac disease who was getting a claustrophobic feeling and had a bit of chest pain, and she was worried about going to the ER to seek medical care, thinking that she would be arrested in some form because it was a marijuana adverse effect. Relieve your patients of any anxiety over that. I think there's another ... Yeah. Go ahead. Yeah. Hi. Josh Krasin. I certify patients for medical marijuana in Pennsylvania, Allentown, Pennsylvania specifically. I agree with you guys that certainly I've gotten numerous people off opioids using medical marijuana, and I've had great success and can't say enough positive things about it. The one issue that I have a lot that I'm sure you guys have too, is a lot of my patients, especially with chronic pain, aren't always employed and things like that, so cost becomes an issue. I would say that for me, the number one reason why people discontinue it is because of cost. The Percocet, because it was covered under their insurance, they were getting it for $5 a month, and then their medical marijuana is $100 a month, and they say that's a really big difference. I can't really afford that, and they ended up going back to narcotics, and it's very frustrating. I guess the question, mainly for Dr. Glassman, is do you think ... I mean, I know there's no way to totally predict what the government's going to do, but if it doesn't become federally, if it doesn't remain federally illegal, do you think ... I don't know whether it'll be totally subsidized or covered by insurance per se, but do you think there'll always be that big cost differential? Because it's so frustrating that they'll charge $5 a month for Percocet and $100 a month for marijuana, and so people are forced to go back to Percocet. I'll have to use the stool. Yeah. Great question. Thank you so much. Certainly, this issue of cost is relevant. On the one hand, a lot of patients who get their cannabis card find even the cost at the dispensaries is double the cost of getting it on the street. You start to see that certified patients may end up getting their cannabis somewhere else. We might not ever know that, but when you start looking at how the dispensaries are doing from a financial standpoint over time, it's not as lucrative as they might have thought because of this leakage of patients, because there is no coverage, and you can't even use a credit card because of the banking laws, because again, it's Schedule I. So much of this is contingent on the issue of it's got to get rescheduled. Let me comment on that. I would also tell you, because I'm very much aware of that with my patients, and that's why one of the reasons I have that dosing chart, because it is a little bit of trial and error, and it is an expense, so you don't want to get too many products. You want to get one or two to start and see. But the dispensaries, I think that that's the key. A lot of the dispensaries are owned by corporations, and I see like for instance for senior citizens, they're offering discounts, substantial discounts for senior citizens. They have these programs where they're bringing the cost down. The other incentive for having a medical card versus recreational on a state-by-state basis, and we see this across the country, is that it's very lucrative for the states to have recreational because they can tax the products up to 20% if you go from state to state. Whereas if you have a medical card, in most cases you're not taxed or taxed very little. So there is a financial incentive for somebody having their card versus trying to get it recreationally. Yeah, I would agree. There are people who've done recreational because, again, they say it's cheaper, and the card, I mean, the card in Pennsylvania is very insignificant. It's $50 a year, $25 if you're on Medicaid, so that hasn't really been the cost. It's mainly been at the dispensaries, but if there's discounts available, that's great to know. Right. In Connecticut, we used to charge $100 to the patient that went to the state, and they've eliminated that completely. The only fees they have is if you charge, as a practitioner, for your registration, but the state has eliminated that fee completely. All right. There was another question online, and I believe it was for Ari, but I'm having some problems manipulating this. Oh, here it is. How would you prescribe cannabis perioperatively after orthopedic surgery if a patient does not want to take opiates, and they're not cannabis naïve? They are not. They are not cannabis naïve. So cannabis experience. They have it, yes, and you want to prescribe it for them perioperatively after. Yeah, so again, we're never prescribing, but I do think that one of the problems that we see around the country in medically legal states is that, for some physicians, this is a moneymaker. They can charge a few hundred dollars for these certification appointments, and in my experience, the people that aren't taking this seriously are spending less than five minutes doing the certification online through the health department website, and then telling patients, talk to the people at the dispensary, good luck, see you next year. In Pennsylvania, you are supposed to have a follow-up appointment with these patients, and I think it's really our job from a public health and safety point of view to give some patients guidance. So I'm not prescribing, but I'm definitely explaining to them the different products that are available at the dispensary, and for me, that means looking at where they live, where their address is, finding a dispensary close to their home, pulling up the menu on the computer right in front of them, and showing them the breakdown of products and the way that these products are labeled. I have found that to be very, very frustrating because some of the labels are just not informative for patients. In Pennsylvania, there are tinctures where the details of what's in the tincture is in the box that the bottle comes in. People throw the box away, and then they have a bottle that says nothing on it, like just the name of the tincture. So I mentioned we're collecting outcome measures, we're collecting data. We created a questionnaire to ask people what products they're taking and asking them how much THC and CBD is in their product. About 85% of my patients have no idea what's in their cannabis product. It's not that different from their regular med list. If they don't have it printed out with the dosage, they don't know the names of their meds or the dosages. It's the same thing with medical cannabis, unfortunately. So again, for someone who has some experience, I think it still depends on their tolerance. I have patients who are experienced users that still get moderate intoxication with five milligrams of THC. But again, perioperatively, I do think it depends on the area of the body. But topical THC, in my experience, has been surprisingly effective. I think there are cannabinoid receptors in the skin and there are some topical anti-inflammatory properties that THC exhibits. So for joint pain, I think THC lotions are great because they're non-intoxicating and they can be used in combination with other oral products. But I think from a pain perspective, perioperatively, the oral products probably last six to eight hours. I'll tell people it's kind of like a Q8 hour, Q6 hour regimen of a dose that you can function on and that provides some analgesia. Right. That's an important fact that, depending on the product, is also going to depend on how long it lasts. There are sublinguals that you can take that may be more immediate. It's really a vaporized form of the product that's going to hit you within two to three minutes and it's going to last about four hours. The caution that I give with patients, at least starting out in the program, is to avoid edibles because there's a classic story about taking edibles because often, because it is a two-pass system, it has to pass not only through digestion but through the liver, it can take two hours sometimes for it to hit you. When it hits you, it stays in your system much, much longer. It's a typical person who went to a recreational dispensary, got a piece of chocolate, and they didn't feel anything in a half hour and they ended up eating half the chocolate and then certainly six hours later, they're not feeling so great. Depending on the delivery system can also, and that's something that usually is explained to them in the dispensary, but we also go over that medically depending on what they're going to get. All right. Next question. Good morning. My name's Norris Akpan. I'm a fourth-year med student here at New Orleans at LSU. Thank you all for having this panel. It's been really informative and interesting. I was wondering, I know that you're going to approach every patient differently and from an individualized perspective, but have you all seen patterns between certain conditions and the routes or strains? For example, oh, for this patient with chronic pain, this strain usually is more effective and then for neurodegenerative conditions, this route is more effective. Well, I'll answer first and the panel can open it up. As mentioned, we don't prescribe cannabis as physicians, we register them. So from even a medical legal perspective, we identify that they have a condition within our state that they're eligible. We have a doctor-patient relationship, so we feel that they're gonna benefit from it. They then get their medical card and they go to a dispensary. And it's really up to that dispensary person, you know, like I say, in my state, we're fortunate to have pharmacists and some dispensaries may have nurses, some may just have bud tenders, you know, is what they call them. In Colorado, the bud tenders are very experienced, they've been doing this a long time, some of them may be more knowledgeable than some of the other, so it really depends. To your question about strains, what I've often found, and maybe Greg or some of the others can comment, it's not so much the strain, because you'll see, you know, sativa-dominant strains, you'll see indica-dominant strains, and you see hybrids on the menu. I look less at that where I look at the THC and the CBD ratios, and that's really important because the higher the THC, you know, the tendency may be for more euphoria, for more paranoia, but you need both in most cases. Usually a one-to-one ratio works really well for people starting out, but then there's these terpenoids which we're not getting into, but if you look at some of the former lectures we've given, we've spoken more about in detail about the endocannabinoid system, terpenes and so forth, but they also affect sleep. There's also other constituents besides CBD and THC, CBN, CBG, THCA, the acid form, all of this stuff. We don't have time to go into that. But these are components that we can discuss with our patients, but the actual products that they get is really negotiated with the people in the dispenser. And I'll just add real quick that this is a very common question. Everybody wants to know which strain is good for this and which is good for that, and we don't know. The problem is, and this is where future research may be helpful, but I don't think there is a specific strain. A lot of this is trial and error, and patients don't agree. The issue is, this is a business, and these dispensaries are doling out lots of misinformation, and they are telling patients, this one's good for sleep, and this one's good for pain, and this one's good for anxiety. And they're feeding the patients, the consumers, a lot of information that may or may not be true. And I think that's the frustration on our end, is that we know that they're claiming things that aren't based on research or real science. It's very much anecdotal or their own personal experience. And I still think that as much as we'd like to make a recommendation like that, the primary focus is, how do we minimize intoxication and side effects so that you can function on this medicine? And then you're going to have to spend some money figuring out, does a lotion work for you? Does this sativa vape oil work for you? Does this indica strain really make you sleep better or help you fall asleep? But I think in that regard, it is ultimately a personal experience. And I have one question that's online along that line, Ari, is about drug-drug interactions that we should be cognizant of when we're recommending cannabis to patients. This particular individual was concerned about people who might be on benzos, for instance. They asked about respiratory depression. As I mentioned, there's less of a concern about that. But maybe we can discuss drug-drug interactions that we're concerned about. I'm going to take a first swipe at that. The biggest one that you want to pay attention to, and it's been well documented in the literature right now, is warfarin. I've had a handful of patients who have to come off medical cannabis because it just made their warfarin INR levels very, very erratic, especially with the edibles, as Mitch said, that it gets processed through the liver, the hepatic metabolism. Simply using an edible is at risk for having variable effects because there are differences in hepatic metabolism. There have been some reports in the literature about aminoglycosides creating a very prolonged medical cannabis effect. Luckily, aminoglycosides are not routinely available to anyone out on the street, but there's been some discussion about that. Warfarin's the big one. It also depends on the route of administration. Topicals are probably the least likely to have drug-drug interactions, followed by inhaled, followed by sublinguals, and lastly, the edibles being the most common. Anything that has hepatic metabolism can be affected, especially by the edibles. My understanding, and maybe we can get Greg to chime in on this, but my understanding is it's the CBD, particularly, and everybody's taking CBD, that affects the liver enzymes that are affected in drugs like warfarin. Is that your understanding, Greg? Yes. There we go. Yeah. I agree with everything Michael said, and I would advise looking it up if you're not sure. This is all on the internet. Over 25 years, I've never personally had a bad drug-drug interaction, but they can occur, so you should look that up. Okay. I think the other issue that this question brings up, both of them, is that most of the certification forms have a phrase about risks and benefits being explained to the patient that you discussed with them. You want to document in your own progress note or consultation note that you did that. You may want to create your own form in your office that actually the patient will sign that says they were explained the risks and benefits concerning certification. You could mention medications, you know, you can't cover all of it, but again, another way to at least make sure you're doing your due diligence for your patients, you're protecting yourself from any medical license questions, and again, just a better way to handle it. Okay. Next question. Thank you very much. My name is Zeeshan Ahmad. I'm a board-certified physiatrist and fellowship trained in spine sports and musculoskeletal medicine. I practice non-surgical neck and back pain and musculoskeletal care, and the traditional treatments are physical therapy, anti-inflammatories, then people try injections, then referred to surgeons. However, some of the patients still come back even after having surgery, or some patients are not candidates for surgery. So my idea of coming here was to learn a little bit about how I can maybe utilize cannabis in such patients. You all have some time in this field, 20 years, 15 years, but for us, you know, how do we learn these things? Are there any training courses? Are there any specific ways to attend a course in which indications are, you know, taught, and then how to prescribe, what to do in such patients so that the things that some of you have described that other pharmacies are not telling the patients nicely, or, you know, because the idea is to help the patients. Right. That's an excellent question, and it's something that we would love to be able to address formally as an academy here. You know, it really is a state-by-state basis in terms of your ability, you know, through your DEA license to register patients. One great resource that I think is available to anyone who's in the medical or even health field is the Society for Cannabis Clinicians. You can join that. They have educational programs. Actually, Dr. Carter has taught some of the courses involved in there, some of the pioneers. They do Grand Rounds. They do a lot of, they've really evolved over the years. It used to be not too many physicians involved, but there's a big medical presence on that. There are also conferences that you can attend nationally and internationally in terms of cannabinoid research. You know, there's resources out there. You can reach out to any one of us, and we'd be happy to share that, but those are two good resources. Is there anything else that you'd want to follow? So certain states have CME requirements that you cannot certify unless you meet the state requirement for the CME. So check with your state, see if there is CME required, and then if there is, you'll see the list of what courses you can take and will need to take before you can actually certify someone. It's kind of much like states have required opioid prescription, that you have to take a certain number of CME hours in order to be able to do that. It's happening in all of these states that have medical, so yeah, so Dr. Glassman's correct in that. So quick question, show of hands. If we were to form a member community for therapeutic cannabis, how many of you would consider joining? Oh, it's a majority. That's more than 10. That's more than 10? We have five up here. We need 10 in order to get the community up and running. I think we're at that tipping point. Right, so we need at least five people to email one of us that you want to be listed on the origination form to create the therapeutic cannabis physiatrist member community. Once we do that, then we have a voice in the House of Delegates for the AAPMNR, and then we can start looking at bigger things. And if they want to email me at mitchellprywismd at gmail, I'll pass that along, and maybe we can make that happen. Hi, thank you so much for your talk. I'm Erin Kelly. I'm from Thomas Jefferson. I've been lucky to train with some of you up there, so thanks for hosting this. I see a lot of patients with cancer, and I'm certifying for medical cannabis for their pain. Besides the risk of aspergillosis with inhalation, are there any big risks that you cover or that you're worried about with comorbidities of your patients that you're going over in that risk category, such as if I have a patient with severe schizophrenia or bipolar, I'm worried about worsening psychosis, for instance. So just some of those pearls that you use in your risk that you're reviewing. Right. In my state, the only psychological diagnosis for which you can register patients is PTSD. Every state's different. I chose not to register patients in my scope of practice only for pain, but I don't know what the others feel. So Erin, as you know, cancer is a qualifying diagnosis by itself, not cancer-related pain or chemotherapy-induced neuropathy or anything. So you have a squamous cell carcinoma, technically you could qualify for medical cannabis in Pennsylvania. In New Jersey. Yeah, absolutely. So if you keep qualifying them, I guess my question is, though, what they're at risk for product-wise or going forward. I know that's the reliability of the dispensaries. The biggest thing I would be sensitive to in the cancer patient is there certainly is good evidence that cannabis can be used as an anti-emetic for chemo and therapy-induced nausea. Excellent. But simultaneously, there is also a cannabis hyperemesis syndrome. So you have to counsel a patient that you can get that. But that would probably be rare in that. Have you seen that? I thought it was really in heavy users. That would be my biggest caution, that patients may come to you as a cancer rehab specialist and say, I'd like to use this for my upcoming chemotherapy. Just caution them that it can actually, in rare cases, make your nausea worse. I haven't seen it. Thank you. All right. You can reach out to me offline if you want to talk about cannabis use in cancer. Hi. Good afternoon. My name is Tia Passley. I'm an OMS 3 at NYT-COM, Arkansas State University. In the past, I've done some research on the social aspect of medical cannabis. I just was wanting to know if you've seen in your patients there have been greater access to care, medical equity, since you've been able to recommend medical cannabis for your patients. Did you get the question? Yeah. I'm sorry. I couldn't hear the last part of the question. I just wanted to know if you've been able to see greater access to care for your patients since you've been able to recommend medical marijuana, and if that's made it so that you've had greater medical equity. I can tell you that topic was very hotly debated and continues to be very hotly debated in the state of New Jersey. New Jersey was actually about five years earlier than Pennsylvania, my other certifying state. For years, though, New Jersey only had five dispensaries in the entire state where Pennsylvania has hundreds, I think. Over 100. Yeah. Over 100. Now, when you apply to become a dispensary, you have to address access issues because of that. Otherwise also, though, to make it even more complex, it's illegal under federal law. States can make it permissible, but individual municipalities can also prohibit it. Access can have local implications also, but at least in the state of New Jersey, if you're applying for a dispensary license, you have to address access issues. There are a bunch of barriers to access, cost being the number one, but like in Pennsylvania, you can't have a right to carry a firearm or purchase a new gun from certain stores with a medical cannabis card. Like Stu had mentioned, if you work for the federal government, if you have a CDL license, there's all these reasons why certain people can't get access to medical cannabis. It creates these situations where some people, there's the haves and the have-nots. It really is something that needs to be addressed, particularly in the industry where you have certain neighborhoods where the incarceration rates for having cannabis on your person being extraordinarily high, and then suddenly a few blocks down the road, there's a legal cannabis store that's profiting from the sale of these same products. It's definitely a social equity issue, and there are other reasons why people just don't have access to these products. I think we have to de-demonize it because there's, unfortunately, from our political history in this country, the fact that we call it cannabis and not marijuana. It's a plant. It's been around for thousands of years. As Greg mentioned, the mammalian system, we evolved with it, but there's so much education that our colleagues in the general public have to, and all of you have the potential to be emissaries for this, to educate people who really are still left in the dark, including our federal government. We've got 43 seconds left, so I don't know much more. I think we've done a pretty good job. Yeah. I just was going to say that there were a couple of studies that came out two years ago looking at New York State and access issues, and that in lower educated and lower socioeconomic communities, there were less dispensaries. If you went to the better educated, wealthier communities, there were more dispensaries. Certainly that's an access issue. Ownership of dispensaries was also an issue where even though there was a focus to try to get minority ownership of those dispensaries, it really didn't happen. It's part of the problem, for sure. In Colorado, I was told there are more dispensaries in Denver than there are fast food restaurants, including if you combine McDonald's and Starbucks and all of that combined, it wouldn't equal the amount of dispensaries in Denver alone, yet a lot of those dispensaries are now struggling financially because of so much, and they're trying to get rid of their licenses, and they can't even sell them, whereas in some states there aren't enough. There really is an issue with equity. I want to thank you. We're at time right now. Thank you. Again, if there's any questions that you have beyond that, reach out to us, and as Stu mentioned, maybe we can get a community together. My goal for all of us is eventually to have a full day program, maybe a pre-symposium for this. I've been told by the Academy they've already budgeted for next year's assembly in San Diego, but maybe for 2025 we can do something, or maybe we can do a half day, but that's still to be negotiated. If you like what we've done today, please fill out your evaluation forms and let the Academy know, because it's only through your interest that we're actually able to do this. Thank you all for coming. Appreciate it.

medical cannabis practice

research

education

misconceptions

legal issues

chronic pain

neurodegenerative disorders

dosing

patient monitoring

therapeutic option

regulations