Welcome. I am Dr. Mitchell Pryor, Session Director for this on-demand AAPMNR session entitled Medical Cannabis, Separating Fact from Fiction. It is my distinct privilege to serve as Session Director for a fourth consecutive year at our annual assembly with a dynamic and scholarly group of practitioners who have consistently elevated the conversation surrounding medical cannabis education, research, and practice. While this year we don't have the benefit of connecting with you in person, it is my fervent hope that the limitations of this virtual on-demand 60-minute experience will be equally valuable and informative, and that hopefully next year we may all be reunited in Nashville. I have been in private practice for over three decades in Danbury, Connecticut specializing in integrative medicine pain management. I'm a graduate of the Arizona Center for Integrative Medicine Fellowship with Dr. Andrew Weil, and I've been practicing medical acupuncture for over 25 years. I offer patients with acute and chronic pain conditions alternatives to opioids, including osteopathic medicine, PT, medical acupuncture, herbal and nutritional medicine, and for the past five years, registration in our state's medical cannabis program where I serve on the eight-member medical advisory board. There are three learning objectives for this course. They are simply to identify at least five myths about cannabis, gain an understanding of the emerging role of the endocannabinoid system in neurodegenerative disorders, and identify the current regulatory and legislative issues concerning the therapeutic use of medical cannabis. I will now introduce our esteemed faculty. Their presentations will immediately follow my introductions. If we're able to complete the presentations before our allotted time, a brief panel discussion will follow. I am honored to introduce and welcome our first presenter, Dr. David Bierman. While I was organizing this session a year ago for submission, it was expected that we would all be together at our annual assembly in California, so I immediately thought of inviting Dr. Bierman, a California native and cannabinoid medicine pioneer. I had the pleasure of meeting him at a medical cannabis conference in Colorado four years ago. Dr. Bierman is one of the most clinically knowledgeable physicians in the United States in the field of medicinal cannabis. He was a pioneer in the free and community clinic movement. He has over 50 years experience providing substance abuse treatment and prevention. His career is split evenly between clinical and administrative medicine and includes public health, administrative medicine, and provision of primary care, pain management, and cannabinology. Dr. Bierman has been in private practice, pain management, cannabinoid medicine, and general practice since 2000. He is the co-author of Cannabis Medicine, a Guide to the Practice of Cannabinoid Medicine. He was named to the 2020 list of the 20 most in-demand cannabis experts. Dr. Bierman will be talking about medicinal cannabis, fictional allegations, and the real facts. Our second speaker is Gregory Carter. We are extremely pleased to welcome back our esteemed colleague, Dr. Carter, especially after his brave battle with throat cancer. I have assured Greg that our membership would not be freaked out by his need to use an electrolarynx device for his presentation. Dr. Carter is the chief medical officer for St. Luke's Rehab Institute in Spokane, Washington. He's also the clinical professor and fellow of the Gleason Institute for Neuroscience at Washington State University, Elson Floyd College of Medicine. His research focuses on improving management of neuromuscular disorders, including ALS. He was the first researcher to document the effectiveness of cannabis in treating the symptoms of ALS, which spawned a new field of research. His preclinical research involves studying the electrophysiology of animal models of neuromuscular disease. Dr. Carter has over 120 peer-reviewed publications in these areas and has co-authored the only two peer-reviewed scientifically-based and researched articles dealing with medical cannabis dosage. He has many acolytes associated with the American Association of Neuromuscular and Electrodiagnostic Medicine, and he also received the Ernie Johnson Outstanding Educator Award in PMR from the AANEM. He is also president of the American Academy of Cannabinoid Medicine, serving on its board of directors with Dr. Bierman. Dr. Carter will be giving us an update on cannabinoid and neurodegenerative disorders. And finally, our third speaker is Dr. Stuart Glassman. Dr. Glassman comes to us from New Hampshire, the Granite State. He is the owner and president of Granite Physiatry, a solo PMR general practice in Concord, New Hampshire. Many people in the academy are familiar with Dr. Glassman. He has been past president also of the New Hampshire Medical Society, member of the New Hampshire Governor's Commission. He is also a clinical assistant professor in the Department of Community Medicine, Family Medicine at the Geisel School of Medicine at Dartmouth. And also, he is currently the delegate of the AAPMNR for the AMA, vice chair of the AMA's PMR section council. Dr. Glassman also has an MBA, and he most recently used his financial MBA knowledge to assist and educate colleagues who were applying for COVID-19 economic relief and in the CARES funding. It should also be noted that Dr. Glassman with Dr. Julie Silver received the 2020 Distinguished Public Service Award this year. Dr. Glassman will be giving us an update on medical, legal, and regulatory updates associated with medical cannabis. Dr. Bierman. Thank you very much for inviting me to be a member of this prestigious panel. I think it's really important for the attendees to recognize how useful it would be to add cannabis to their medical toolbox, because cannabis is not only an anti-inflammatory, but also an analgesic and prevents anxiety. Now, the sad thing is, is that there's been an enormous amount of misinformation and stigma that's come out over the last hundred years. And we're going to talk a little bit right now about some of the myths that are out there. I'll try to set you straight on things. I don't have any relevant financial disclosures to make. I am the executive vice president of the American Academy of Cannabinoid Medicine, and I encourage you to check us out. We have a lot of good information. So here's an overview. We're going to talk a little bit about cannabis as medicine. It's not something that the hippies invented in the 60s. It's been around for over 4,000 years. And then we're going to take a look at 10 common allegations that are not true. And plus a couple of bonus ones. And then I'll give you a few clinical tips. So let's move on. So in China, according to Chinese oral tradition, in 2637 BC, the second emperor of China, Shan Nen, wrote what's thought to be the first materia medica ever produced. And it contained cannabis, or ma, as it was called at that time. And it continued to appear and be used on a regular basis throughout the world. This is evidence that it was used thousands of years ago in China. They checked out a tomb and they had the doctor in there. I don't think I'd want to be buried with my patient. But anyway, in the doctor's medicine bag was some cannabis. And so they figured it must have been used therapeutically. Also, it's in the Ebers papyrus, which was written in 1500 BC. So the top 10 fictions about cannabis is that cannabis is not medicine. By any definition, cannabis is. Cannabis has never been widely relied on for medicinal use. That's absolutely false. Organized medicine has consistently opposed the medicinal use of cannabis. That too, couldn't be more false. Every government commission that has studied policy supports the legalization of cannabis for recreational use. And that's in several countries in the world. So that's not true. Cannabis is not safe. That's not true. When I have individual slides on each one of these 10 allegations, which have no truth in them. And it's important for you to recognize that cannabis is medicine and that cannabis is one of the safest therapeutic medicines known to man. And that was said by the chief administrative law judge for the DEA in his finding of fact in 1988 in a rescheduling hearing. So there are two other bonus myths that are out there. That cannabis has a high dependency risk. Well, if you call being less than coffee, then that's high. And that the idea that cannabis is a gateway drug, that too is a myth. And the fact of the matter is, is that it's a fine exit drug, as we'll see as we go through these. So cannabis, as we've already alluded to, has been in every major materia medica ever written. When it was reintroduced into Europe and England in 1839 by Sir William Osler, it caught on quite quickly. And by 1854, it was in the United States Pharmacopeia. There were a number of pharmaceutical companies that produced cannabis products, whole leaf, powdered, what have you. And so cannabis has been widely used. In the 19th to the 20th century, cannabis was the third most common ingredient in patent medicines and prescription medicines after alcohol and opium. And then, of course, in the 1920s, American physicians were writing two and three million prescriptions a year that contained cannabis, as well as there being over 25 patent medicines on the market that also contained cannabis. So no more a revered figure than Sir William Osler touted cannabis for treating migraine headaches. In fact, he said that cannabis was the best treatment for migraines. And when you stop and think about it, that makes sense. So what migraines do is they cause an increase in the speed of neurotransmission in a particular spot in the brain. What does the endocannabinoid system do? It slows down the speed of neurotransmission. So, of course, it's going to be helpful for a lot of people, not everybody, but a lot of people that have migraines. Let's move on here. And we find that over across the pond that the Queen's Royal Doctors, Sir Russell Reynolds, was writing an article in The Lancet in 1894 talking about the benefits of cannabis. And, of course, he famously treated Queen Victoria for her PMS with cannabis, which is still done. Where else we got here? Yeah, in 1937, Dr. William Woodward, boy, he has a long pedigree. He was a commissioner of health for Washington, DC, Boston, past president of the American Public Health Association. He was a doctor and a lawyer, and he had been the AMA's chief counsel since 1924. And in 1937, he testified vigorously against the Marijuana Tax Act, saying that the AMA knows of no danger from the use of cannabis and was also quite critical of the act being called the Marijuana Tax Act because he said nobody will know what you're talking about, which maybe that was the idea. So there's Dr. Woodward, a fine looking young man, and you see his pedigree. So we're going to move on here. OK, so we continue to have figures in organized medicine that were supportive of cannabis. You see in 1942, the longtime editor of JAMA said that cannabis was the best treatment for migraine. In the 40s, things continued with the Military Medicine Editorial, with the LaGuardia Crime Commission Report, and it goes on and on. So in 1953, you had Colonel Phelan jumping in again. So there just isn't any truth to the fact that organized medicine has not from time to time approved or endorsed or embraced cannabis. As a matter of fact, in 2009, the House of Delegates voted to recommend to the federal government that they reschedule cannabis. It would make it easier to do research with it. So we've got all these government commissions in India and England, the Wooten Commission in Canada, and then we have the Nixon Commission. And what did they do? They recommended that cannabis be legalized for recreational purposes. And the physicians that were in the Nixon administration, Dr. Bert Brown and the head of NIMH, Sidney, I forgot Sidney's last name, but at any rate, Sidney Cohen, they said to Nixon, this stuff is no more dangerous than a parking ticket. Nixon, of course, thought otherwise. He did not follow the recommendations of his committee. So there's a myth out there that cannabis isn't safe. And of course, cannabis is safe. It's been around for 4,000 years. Tincture cannabis, which is a whole plant alcohol extract that has been on the market in Canada since 2005 and the European Union since 2010, has been very safe. There haven't been a lot of problems with it. And of course, THC itself is quite safe in that the FDA has a schedule three, which means it does not particularly need to be closely observed. Of course, in 2009, the House of Delegates of the AMA recommended that the federal government reschedule cannabis to schedule two. So cannabis is not harmful to developing fetus. I'll just tell you that there's a marvelous article by Dr. Torres Vargas in which she reviewed 30 studies and found that there was no reasonable evidence that cannabis taken during pregnancy caused difficulty. That's not mean that we're saying go ahead and take it, but we're saying if you do, we don't have any evidence that it causes a problem. And of course, in the Jamaican study by Dr. Dreyer, which was shut down because the results were too good, that the children of moms who use cannabis during pregnancy found themselves with kids who met their developmental landmarks sooner and did better in school than the children of women who didn't use cannabis during pregnancy. Kind of counterintuitive. And this is the Dr. Torres report, and I think that's recently appeared in a journal article. And cannabis does not cause brain damage. The studies that purport to show that have not been, they haven't accounted for other things like traumatic brain injury, stroke, use of other drugs, home environment, that sort of thing. The best study that I think was done out there was the one that was done between the University of Minnesota and UCLA comparing twins. The twins who did not use cannabis, IQ dropped by four points. The twin who did use cannabis, IQ dropped by four points. There you have it. This is the study I just told you about. Just anecdotally, some of the smartest kids in my medical school class were using cannabis. Interesting point. They've gone on to have very successful medical careers. The study that purports to show that cannabis causes brain damage was where the researcher was overly zealous and deprived the monkeys of oxygen and proved that if you deprive monkeys of oxygen, you'll get brain damage. He didn't prove that cannabis causes brain damage. Some people have said, I don't want to use it, it's not standardized. You need to talk to the state of California about that. They're the ones that set the regulations. They're the ones that go and inspect the laboratories. In terms of standardized and not standardized, yeah, it is, and furthermore, THC is standardized. Marinol's been on the market since 1985, and Epidiolex, which is CBD, is a Schedule 5 drug. You've got a lot out there that are options that you can get involved with. In regards to cannabis' proven therapeutic value, apparently 24 countries think enough of it to have legalized it for prescription use. It also appears in every major materia medica ever written. One of the big things that does a piece of research that you should be aware of is the study that was done in the UK showing that it extended the life of people with glioblastoma by about 40%, that is 330 days for the control group, 550 for conventional medicine plus cannabis. Obviously, you are not dealing directly with cancer, but I think that it's exciting to realize that the House of Delegates was absolutely right that this should be rescheduled so we can do more research. Cannabis is not addictive. There's reams of paper on that. As a matter of fact, the term addiction has gone out of favor. The Nixon Marijuana Commission said most people voluntarily quit cannabis. Benowitz and Henningfield found that cannabis had less dependency risk than coffee, so let's go after all those coffee drinkers. The idea that cannabis is addictive, we could talk about that for a great length, but if you're interested, I have a couple of pages in my book, Drugs Are Not the Devil's Tools. Some people try to say cannabis is a gateway drug, and that, of course, is torturing the data to get the result that you want. It is true that 100% of cocaine users have used marijuana, but only 1% of marijuana users have used cocaine, so hey, where's your gateway theory? On the other hand, a lot of us that practice cannabinoid medicine have noticed that 1%, 2%, 3% of our patients are using this as a harm reduction substitute. I have an assistant DA who has been sober from alcohol for over 20 years. A number of people who have been able to decrease or eliminate their opiates as a result of the use of cannabis, so it does not lead to the use of other drugs, and in fact, cannabis can be helpful in terms of dealing with that. I put this thing about cannabis being a tool of the devil in there, sort of chiding history, I guess, a little bit, and that is that the pope in the 15th century said that cannabis was a tool of the devil because it decreased the pain of childbirth, which I guess is everybody knew at the time, was Eve's punishment for eating from the tree of knowledge. Okay, let's see if I can move this forward. No, I can't. Okay, so here's a few clinical tips to those of you out there that I have sort of convinced that this might be a good idea. You need to educate your patients about the endocannabinoid system in the plant. Of course, that means you need to educate yourself. You want to start with a low dose of THC and then only slowly increase that dose, and you want to address how to treat side effects that might occur from people taking too high a dose. You want to do a follow-up visit to adjust the dose, and you should have some educational handouts that are present in order to help educate the patient. If you do all this, I think you're going to have a very happy patient. Patients who are using cannabis for pain relief, if you don't roll your eyes at them, if you give their history credibility, which is what we're taught in medical school, that patient is going to bond with you in a very satisfactory doctor-patient relationship. By bonding, I mean they're going to listen to your good advice and not just ignore it. If you just ignore the fact that they're telling you that cannabis is something that's useful. This is a book for any of you that are interested in history. It's Drugs Are Not the Devil's Tools, How Greed and Discrimination Led to a Dysfunctional Drug Policy and What to Do About It. It goes into lots of drugs. I think those of you that are history buffs would really like this. This is one for those of you that are interested in applying cannabis in your practice. You can get it by going to my website or by going to Amazon, Cannabis Medicine, A Guide to the Practice of Cannabinoid Medicine. I guess I'm going to close so you have my email address. I really want to thank Mitch and Stu and Greg for inviting me to sit on the panel with them. They are brilliant. I want to thank you guys all for having me and urge you to learn more about cannabis, cannabinoids and the endocannabinoid system. Thank you very much. Thank you, Dr. Bierman. Our next speaker is Dr. Carter. Thank you, Mitch. It is an honor to be back as part of this great team. My presentation is going to be fairly brief today. I just wanted to give a brief update on the role of cannabis in neurodegenerative disorders. We now know that the endocannabinoid system is really huge, as Dr. Bierman also mentioned, and there are also additional lipids that appear to interact with the endocannabinoids. The end result is effective ways to manage spasticity, pain, sleep, mood, appetite, among many others. So some of the mechanisms by which this occurs include neuromodulation by way of micromolecule cell modulators, modulating tumor necrosis factor, among many other things. The cannabinoids are also antioxidants and are fairly potent free-radical scavengers. Through these mechanisms, they have fairly strong anti-inflammatory properties, and the endocannabinoid system really helps regulate our immune system. In addition, there are anti-apoptotic effects, which has applicability in cancer management and enhancement of neurotrophic growth factors and mitochondrial function. The pertinent clinical effects include analgesic properties, reduction of spasticity and tone, sleep induction and maintenance, mood enhancement, and appetite stimulation. So some recent work that I was involved in, we were able to show that there are alterations in the endocannabinoid system in amyotrophic lateral sclerosis. The work is still fairly preliminary, but it looks like the endocannabinoid system is a potential biomarker for disease status and also represents a possible therapeutic target. We need further research in this area. Thank you very much. Thank you. Thank you, Greg. Our next speaker is Dr. Glassman. All right. Welcome everyone from the Academy. Glad to be with you virtually. I'm Dr. Stuart Glassman from Concord, New Hampshire. I'm honored to be on this panel with Dr. Pryor-West, Dr. Bierman, and Dr. Carter. I'm going to review the updates on the medical, legal, legislative, and regulatory issues concerning therapeutic and medical cannabis. No financial disclosures to disclose. So the objectives for my talk are going to be to discuss current and proposed state medical cannabis laws. Today is October 7th, but by the time you see this, it will likely have been after many states will have voted on their updated medical cannabis proposed legislation. We'll also review proposed federal marijuana legislation, where things are at with some of those bills. We'll discuss the progress of the American Medical Association's Cannabis Task Force, which was established less than a year ago at the last meeting of the AMA in person in November of 2019. Also review some medical organization guidelines and position statements concerning therapeutic cannabis, and also discuss the COVID-19 impact on marijuana usage, and also the question of workplace marijuana testing, and we'll have one or two other surprises as well. So this is our famous medical cannabis map that we've shown every year for the last four years, starting with the darkest color first, the sort of dark brown color. Those are the states that have both adult use and medical use. There are 11 states plus the District of Columbia. We then see what I'll call the hunter green, the darker green states. There are 22 states which have medical cannabis laws. The lighter green or lime green colors are the CBD or low THC therapeutic or compassionate use states, and there are 13 of those. And then the remaining four states don't have any use at all, but some of those states have proposed legislation which we'll go over, and those states include Idaho, South Dakota, Nebraska, and Kansas. We are not in Kansas anymore. All right, so some of the proposed therapeutic cannabis laws for this session for 2020. Alabama, and these states are either the, if we go back, they're either in the lime green areas or in the white areas for medical cannabis, because if they were in the other areas, they already would have had medical cannabis approved already. Alabama has SP-165 for their proposed Medical Marijuana Cannabis Act. Idaho, which currently has no access to marijuana whatsoever, has the Medical Marijuana Act, which requires signatures to get on the ballot. So what that kind of tells you is that the legislators themselves don't want to actually come up with the law, so it's up to the citizens to try to get it on the ballot, and that's where the signatures come from. Kentucky has a Medical Cannabis Proposed Act, House Bill 136. Mississippi has the Medical Cannabis Initiative. There's two of them, actually, Initiative 65 and 65A. Initiative 65 has many more specific requirements within the legislation, whereas the alternative 65A is a little more freewheeling, so you can look at both of those and see what the differences are, but certainly Initiative 65 seems to have been the first one that was proposed with much more requirements in it. Nebraska, one of those four states where cannabis is not accessible at this point in time, also has a Medical Cannabis Ballot Initiative as well. And just for fun, Missouri passed their medical cannabis law in 2018, but their problem has been that they don't have any testing facilities available online right now in order to ensure that cannabis that would be sold at their dispensaries would be safe for the public, so therefore they have no product being sold yet until they can get the testing facilities up and running. So what about proposed federal marijuana legislation? The House of Representatives has H.R. 601, the Medical Cannabis Research Act of 2019. This proposes to increase the number of manufacturers that are registered under the Controlled Substance Act to manufacture cannabis for legitimate research purposes. If you all remember, cannabis is still part of a Schedule I classification, so doing research is really limited to federally approved areas. And in addition, this Research Cannabis Act strives to authorize healthcare providers for the Department of Veterans Affairs to provide recommendations to veterans regarding participation in federally approved cannabis clinical trials and for other purposes. We'll talk more about the Veterans Administration access to cannabis towards the end of the talk. There's another legislative proposed act, which is H.R. 3884, Marijuana Opportunity Reinvestment and Expungement Act of 2019, or the MORE Act. This is to decriminalize and deschedule cannabis, to provide for reinvestment in certain persons who are adversely impacted by the war on drugs, if you remember that phrase from the 1980s, and to provide for expungement of certain cannabis offenses and for other purposes. It was due for a House vote on September 21st, but the vote has been delayed, unfortunately. Okay. So there is an American Medical Association Cannabis Task Force that was established by the House of Delegates of the AMA last November. One of the delegates for the AAPMNR to the American Medical Association, and I actually got to testify both in the reference committee and on the floor of the House of Delegates concerning the importance of establishing a task force. If for nothing else, then to help guide oversight and understanding of where cannabis is heading for physicians and for the public. There are many member organizations of which our academy was selected to be one of the member organizations for the Cannabis Task Force. Our representative on that task force is Dr. Camisha DeLeeser from Virginia. She's also on the Academy's Health Policy and Legislation Committee, and she and I spoke yesterday and the first meeting of the Cannabis Task Force for the AMA is going to be the week of October 12th. So we should hopefully have some great updates over the next few weeks by the time that you see this recording. All right, what about guidelines and recommendations from organizations? Because our academy doesn't have any guidelines or recommendations at this point. The World Health Organization did recommend cannabis to be rescheduled, and they recommended that in January 2019, so over a year and about nine months ago. In July of 2020, a few months ago, the Food and Drug Administration issued some draft guidance to encourage cannabis-related clinical research, and the link is there for you to look at that as well. So again, some major organizations talking about the importance of considering rescheduling cannabis for research purposes. Medical cannabis guidelines for chronic pain were discussed last month at the Pain Week virtual meeting, which oversees some of the chronic pain initiatives, and there have been position papers about therapeutic cannabis guidelines or recommendations through the American Academy of Neurology and the American Academy of Family Physicians in 2018 and 2019. So we'll look for those recommendations, and hopefully at some point, our own academy can come up with some guidelines, white papers, recommendations as well, given the fact that we are part of the AMA Cannabis Task Force. All right, so what about workplace marijuana testing in 2020? And this is sort of pre-COVID. Some states have prohibited pre-employment screening for marijuana. In northern New England, Maine came up with this because Maine is one of the 11 states where adult usage is legal, and there's medical programs as well. So for non-federal work positions, employers in Maine, as an example, cannot test pre-employment for marijuana. And I'm a medical review officer, and I've gotten a couple of cases where tests came in and they were pre-employment, and they had tested for marijuana. So therefore, they had to go back and retest. And certainly the 11 states where marijuana is legalized affects drug screening evaluations. And again, many states have laws that do prohibit employers from discriminating against medical marijuana patients for off-duty usage. Some of these include Arkansas, Arizona, Delaware, and Minnesota. But they do not have to accommodate for on-duty use or working under the influence. It's important to remember that marijuana use is not covered by the Americans with Disabilities Act, again, because marijuana federally is still Schedule I and it's illegal. Okay, what about medical marijuana and COVID-19? Turns out that the medical marijuana dispensaries were deemed essential businesses in many states, so they remained open. And because of quarantining and isolation, medical marijuana use actually increased during COVID-19. This is from New Frontier Data. They published information in the Journal for Addictive Diseases last month. They looked at over 1,200 patients. Basically what they found was that especially for patients who had mental health use for cannabis, cannabis use increased by 91% of those patients. So again, it's important to realize that with this ongoing pandemic, medical marijuana use will likely go up as well. So a couple more slides so we can get to hopefully our panel discussion. So the Veterans Administration, the clinicians who work there, and remember this was referenced in that House of Representatives Bill 601. VA clinicians cannot recommend medical marijuana to their patients because it's still federally illegal. However, veterans themselves will not be denied VA benefits because of marijuana use. Even though for anyone who knows about applying for student loans, one of the questions is always, do you use marijuana? Because if it comes up that you do, you could lose your student loans. However, veterans are encouraged, and this is official VA policy, to discuss marijuana use with their VA providers. And those VA healthcare providers will record marijuana use in the veteran's VA medical record in order to have that information available for treatment planning. VA clinicians cannot complete paperwork or forms required for veterans who are participating in the state-approved marijuana programs, and the VA will not pay for medical marijuana prescriptions from any source. And that last part sort of goes to the final slide here, which is, well, what about health insurance coverage for medical marijuana? You can access it in your state. Maybe it's legal in your state, but who's gonna pay for it? So health insurance companies, for the majority, if not all cases, will not pay for therapeutic cannabis or medical marijuana for a couple of reasons. One, it's Schedule I federal distinction. And that sort of triggers what's called an Illegal Acts Exclusion for healthcare coverage, which says that for most healthcare plans, if you, the patient, participate in voluntary involvement of an illegal act of which medical marijuana, even though it's state-approved, is federally illegal, they're not required to pay for it. One of those sort of fine print things in almost all health plans. This also looks at the aspect of the drug formulary issue, which is healthcare plans pay for what's on their formulary and you'll have to appeal in order to get something not on the formulary approved. So their pharmacy and therapeutics committee would have to add marijuana to its drug formulary, which they're likely not going to do because it's federally illegal. That would be the only way for it to become a covered benefit of the health insurance plan. And those drug formulary requests typically have to be FDA approved of which marijuana is not yet. What if marijuana is legalized in your state? Well, this triggers another clause, which says that if a drug becomes available without a prescription, then it's removed from the healthcare plan drug formulary. And therefore the insurance company is not required to pay for it. So that's basically three strikes in your route for getting it paid for at this point by your health insurance plan, including Medicare, Medicaid, and your insurers. The one caveat may be workers' compensation cases. I give you an example of Watson versus 84 Lumber out of New Jersey. Basically an injured worker was getting therapeutic cannabis recommended for complex regional pain syndrome. And he wanted the workers' comp carrier to pay for it for the work injury. It went up to the sort of, I think the appeals court in the state and the injured petitioner, the injured worker got a physician to write a letter and testify about the importance of it. For whatever reason, the workers' comp carrier did not have an expert witness testify because they wouldn't agree to come to court. So therefore the judge in the case found for the petitioner and ordered that the workers' comp carrier had to pay for the medical marijuana use. So that was the only way to get it approved is to go through the court process. Anyway, that's my update. Feel free to reach out for any questions and stay well and thank you. So Mitch, back to you. Thank you all for a wonderful presentation. We have a few minutes left. So I'm gonna ask the panel a question. And the one question that I have is why should PM&R physicians integrate cannabis-based medicine into their practice based on your clinical experience? We'll start with you, Dr. Bierman. Okay, well, obviously Dr. Carter hit it out of the park when he talked about it's used for pain, it's used for treating muscle spasm and it's used for sleep. All of those things are beneficial. I think one of the most important reasons is that many of your patients are already using cannabis and it really helps solidify the doctor-patient relationship. Often patients come in and say, doc, this really helps for my sleep or this really helps for my anxiety. And if you take that seriously and don't roll your eyes and say, well, this is just a cocky pock, pock peacock and say, yeah, I understand. And this is the proper dose. I think that for solidifying the doctor-patient relationship and for treating some of the very important issues that you have to deal with, that it would be well-advised to integrate this into your practice. I do wanna say that the American Academy of Cannabinoid Medicine, for which Greg Carter is the president, has a lot of good standards and a lot of good information on our website. I also wanna encourage people to take a look at the whole Plant Expo, which will be going on until December 4th. So both our website and whole Plant Expo are worthwhile. Back to you. Great, thank you. Greg? Any comments? I wanna put it up along for David's book as well. I think it's very important for podiatrists to educate themselves and that's one of the most comprehensive books out there and fairly straightforward. I think, as Dr. Bierman said, you know, it really hits a lot of targets that are very critical and important to our practice as podiatrists. And as Dr. Prywas also mentioned, a lot of your patients may already be using it. So I think it's critical that you learn the pharmacology of cannabis. Okay, great. Just real briefly, and I think I would be remiss if I didn't ask this question, Greg, is did you have any personal experience during your cancer treatment? If you could share at all, just, you know, briefly, if that played a role at all. Oh, yes, absolutely. In fact, a former student of mine, Sunil Agarwal, who is a physiatrist in Seattle and has an integrative medicine clinic, he was one of my attending physicians. And I was able to get through really hard for chemotherapy and radiation with almost no opiates. And that's all thanks to cannabinoids. Wow, that's remarkable. Thank you. Thank you for sharing that. And thank you for being with us today. Stu, you have some comments. What's been your experience with integrating it into your PM&R practice? Sure thing. Well, you know, it's important because if you look at the list of diagnoses and conditions that are in almost all of the states that have a medical cannabis program, half of those diagnoses, if not more, fall into the kind of patients that we treat, whether it's spinal cord injury, brain injury, chronic pain. So this could be another tool you could utilize for patients who are not responding to other issues or want to try something different. Now, acknowledging that, you have to realize also, know the regulations in your state, find out if you have to actually, that is in some states, have enough continuing education and CME credits in order to certify patients, because some states require that. So that's important to understand. And also remember that for patients who are working, you need to have a discussion with your working patients about the fact that if you're recommending therapeutic cannabis for them and they get drug tested at their job, are they gonna have an issue to deal with? So there's, you know, and that's why the regulatory part of this does, you know, come into the real world for physiatrists because we're trying to help our patients improve their quality of life, pain issues, but how it impacts everything else around them is gonna be crucial. So I think that it's important to understand how your state regulations are set up. If you have questions about, you know, what forms to use, what to recommend, you know, we haven't even talked about the different types of strains and dosages and delivery systems. And so that's a whole other talk we could spend another hour on. But it really is crucial to know where you're practicing, what you do and how you're not gonna make it worse for your patient. Right, right. And you know, you're right. We've talked about having a symposium because there's so many elements to this. And I would encourage those who are watching this today, we're putting together something already for next year. If people have particular areas of interest that they wanna learn about, since we don't have the opportunity to do Q&A, I would encourage some of our academy members to write us and let us know what kinds of things they wanna hear discussed. We have about three minutes left. One of the concerns that people have, people have been asking me is, what if your state becomes one of those states you showed on the map that is completely recreational? What role do you still see the physician having in those states where people have access to it recreationally? I'll start with you, Stu, this time, since you're working on a lot of legislative issues. What do you think? Sure thing. Yep. So realize that any of those states where it's legalized, you have to be basically 21 years or older in order to use it legally. So all the pediatric patients who would, you know, possibly need therapeutic cannabis for treatment, a legalized cannabis system doesn't help them one bit because they're not old enough to actually access it. So you still need the medical aspect and the program for patients under the age of 21. So that's crucial to understand. The other aspect, of course, is that, you know, if it's legalized, where are you gonna get your recommendations from as far as, you know, what works? Certainly you leave it up, you know, to, you know, free will to decide if it's legalized, what to do. But as clinicians, we can help provide insight that I think patients will still need for that. I would echo that just to say that in my state, we have a pharmaceutical model. And so the, all of the dispensaries are treated like pharmacies. And so we have licensed pharmacists who are advising patients, whereas, you know, you don't have that in many states where, you know, you have bud tenders who are basically advising patients. And I still think when you're dealing with medical issues, like some of the things you outlined, we really need to have that medical input. And I'm sure Dr. Bierman, you would agree with that as well. I was just gonna jump right in and say that was probably one of the most important things that got said here today, is I think that this recreational is a way to undercut the credibility of the medical utility of cannabis. This is one of the most valuable tools in our medical toolbox. And people do require education from doctors. They do require supervision from physicians. And I remember I gave a grand rounds at one of our hospitals here. And one of the physicians who was in charge of education said, I can't tell you how many people have come in with hyperemesis. And you have people who are using it recreationally or using it inappropriately. And I think that Connecticut is doing it the right way. This is medicine. And I mean, if you wanna use it recreationally, we can do that with alcohol, but there are people who abuse alcohol in the same way that people who can abuse cannabis. Right, and just lastly, and this is another topic that we've discussed in the past, to be able to get a medical education, you made a point of that. We have to educate the doctors. And to that end, maybe the American Academy of Cannabinoid Medicine would be leading the way. I wanna thank all of our speakers for this. This has been a unique opportunity for us. I hope that everyone benefited from it. And I do hope that we get another opportunity to present an even longer session for our members. And I wanna thank you all again for joining us today. Thank you.

Medical Cannabis

Benefits

Misconceptions

Pain Management

Muscle Spasticity

Sleep Induction

Mood Enhancement

Endocannabinoid System

Proper Dosage