Meet The Doctor Trying To Bring Medical Marijuana Into The Mainstream
An increasing number of states in the U.S. are legalizing medical cannabis, which means millions of people have access to medical marijuana cards. These can be used to buy cannabis to manage pain, treat mental health conditions, and help sleep issues.
But a majority of U.S. medical schools offer no education about medical marijuana and its effects on the body. As a result, many physicians and medical professionals do not feel knowledgeable enough about cannabis to make recommendations to patients about what their options are: With so many methods of taking marijuana, and an endless combination of dosages and strains, many patients and doctors feel at a loss.
Dr. Mikhail Kogan is trying to change that. As the medical director for the George Washington University Center for Integrative Medicine in Washington, D.C., Dr. Kogan is one of the foremost experts on using medical cannabis to treat a variety of conditions. A majority of his patients are geriatric and suffer from conditions as wide-ranging as cancer and Alzheimer’s. Dr. Kogan traces his experience using marijuana as an alternative medicine in his book, Medical Marijuana: Dr. Kogan’s Evidence-Based Guide to the Health Benefits of Cannabis and CBD.
Ira chats with Dr. Kogan about why marijuana is successful as a treatment for so many medical conditions, and how interested patients should approach their physicians if they feel it could be right for them.
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Mikhail Kogan is medical director in the George Washington Center for Integrative Medicine in Washington, D.C.
IRA FLATOW: And now for the rest of the hour, we’re going to talk about the other side of the legal cannabis coin, medical marijuana. As you know, more states in the US are legalizing medical and recreational cannabis. And that means that millions of people have medical marijuana cards, which can be used to buy cannabis to manage pain, treat mental conditions, and help you sleep. There’s a lot that cannabis can do.
Yet, many physicians and medical professionals do not feel knowledgeable enough to make recommendations to patients about what kinds of cannabis to use or just how much to take. That’s because a majority of US medical schools offer no education about medical marijuana and its effects on the body.
Our next guest is trying to change that. As a doctor, he hopes to educate other medical practitioners about how medical marijuana can be an effective treatment for a wide variety of conditions. Dr. Mikhail Kogan is medical director of the George Washington Center for Integrative Medicine in Washington, DC. He’s the author of the book, Medical Marijuana, Dr. Kogan’s Evidence-Based Guide to the Health Benefits of Cannabis and CBD. Welcome to Science Friday.
MIKHAIL KOGAN: Thank you. So great to be here.
IRA FLATOW: Nice to have you. In your book, you discuss treating your patients with medical marijuana in many different circumstances. What are the typical medical conditions where you recommend medical marijuana?
MIKHAIL KOGAN: Well, Ira, you already mentioned probably the most common one, and that’s pain, of course, or all kinds of different pain syndromes, particularly chronic pain syndrome. But I use it at this point probably for over a dozen conditions, definitely sleep, chronic insomnia. In fact, in my practice, it’s becoming probably first choice to use medical cannabis. It’s just simply that effective, with much less side effects compared to standard medications, such as Ambien.
And also, the other methods that treat chronic insomnia is just more complicated and more expensive. Definitely, we’re using it a lot in cancer patients and not just for pain, but for nausea, for vomiting, for sleep as well as anxiety. And just, kind of, when patients go through chemotherapy, generally speaking, they develop a lot of different symptoms. And if we have to treat those symptoms with different medications, you would have a cocktail of two or three or four or even more medications. And cannabis often hits multiple targets at the same time. And frankly, the bigger issue is, it’s just often patients prefer it over other methods.
And since my practice is primarily more than 50% patients over 65, for older adults, cannabis is often a lot safer than other medication choices. So I’ve often, maybe not as a first line, but would start using cannabis for even conditions like Alzheimer’s disease, when patients get quite agitated. We know that if we try to use standard approaches like medications, they’re pretty risky. But the cannabis seems to have some evidence of the efficacy.
So we’re probably going to have cannabis in the future shown to be effective for a large percent of all ailments that afflict us. And the reason for that is that we have our own endocannabinoid system. So literally, Ira, we make our own pot. Our system constantly produces molecules that are similar to what we take from weed. And so we can learn. We don’t have enough current scientific data, but I’m pretty sure in the future, we’ll learn what are the ways for us to augment deficiencies of our own in the cannabinoid system with exogenous cannabinoids.
IRA FLATOW: So we have receptors in our brains.
MIKHAIL KOGAN: Exactly, and not just brains. We have receptors in almost every cell in our body. Actually, quiz, my favorite quiz– you ready for it?
IRA FLATOW: I’m ready.
MIKHAIL KOGAN: Which part of the body does not have cannabinoid receptors? And why is it so important?
IRA FLATOW: Which part does not–
MIKHAIL KOGAN: Correct.
IRA FLATOW: –have cannabinoids? I’ll say my toe.
I don’t know.
MIKHAIL KOGAN: Actually, no, no, no, your toes actually have tons of receptors, right? Because the skin and muscles are actually pretty rich in receptors. No, it’s actually your brain stem. And it’s kind of shocking. It’s not really clear evolutionally why. But brain stem is what controls are breathing. Brain stem is very heavy in opioid receptors, but why there’s no cannabinoid receptors, and that’s why you really can’t cause death by cannabis.
You can’t overdose cannabis to the point of stopping breathing. I mean, you can get so stoned and stupidly drive car into the tree, but you can’t directly die from respiratory suppression by cannabis. And again, it’s actually a little bit of a mystery. But it tells you this worry that basically our entire system is wired in the way that cannabinoid system basically and the cannabinoid system regulates almost most of our processes one way or another. And it seems to be evolutionary a lot older than endogenous opioid system. It’s also a very interesting factoid that–
IRA FLATOW: Interesting.
MIKHAIL KOGAN: –people don’t know, yeah.
IRA FLATOW: I think that most people think of cannabis as just being weed. I’m smoking it. I’m eating it just to get high. But you say medical marijuana, there’s no other drug that can treat as such a wide range of medical conditions. It’s a very complex drug. How many different forms or different– I don’t know the right way to call it– different varieties of cannabis is there?
MIKHAIL KOGAN: Right. Well, so you actually used perfect word. So we used to use the word, “strains.” We used to use words like “different species.” This is all seemingly botanically incorrect. Variety is really the right term. There seems to be over 20,000 by now that we know that we cataloged and probably going to have more. And they’re all one species.
We used to think there’s sativa, there’s indica, there’s ruderalis. The sort of most up to date information seems to point that it’s just the cannabis sativa as one plant, and the other categories are more just the broad varieties, but within them, each one of those, there are just so many thousands of different subvarieties, if you will, or just varieties.
And I think that’s partially explains why we have an explosion of commercial interest and growing interest in agricultural processes and growth because there’s so many different ways it can be grown. There are so many different extraction methods now. It just seems like we’re at this entry point into this field which probably will end up at some point be called endocannabinoid, just cannabinoid medicine as a whole section of the medicine, because as we learn more and as we understand more science clinically, we’re probably going to realize complexity of it is such that one particular physician, if they want to, they’ll have to specialize in it literally.
IRA FLATOW: This is Science Friday from WNYC Studios. Yeah, and there are so many different ways it can be ingested. Right? It can be a cream. It could be smoked. It can be eaten. It can be tincture. Is there a danger if people smoke cannabis to their lungs, like you’d be smoking cigarettes or tobacco?
MIKHAIL KOGAN: Right, so great question. So it looks like that cannabis does not cause increased risk of lung cancer, which is good news for those who prefer inhaled direction of intake. But it does cause significant amount of lung problems. Mostly, they are relatively benign, so chronic cough, bronchitis. But there has been some speculation that it could increase risk of chronic pulmonary lung disease. It’s not necessarily very clear.
But frankly, think of it this way. If you have multiple different ways of taking it in and if there’s even a slight risk of particular route causing side effects, why would you want to do it, right? If you look back, historically, 20, 30, whatever years ago, there was no topicals. And of course, nobody even thought of something like applying it directly or vaginally. So now we have methods that are not only safer in many ways, but they are more precise.
So let me give you an example. It’s my favorite mantra with cannabis. Start low, go slow, deliver it where it needs to go, and stop when you get there. So point being is, you start at the lowest dose because you just don’t want to overdose. You overdose, and the experience is not pleasant. Side effects are actually pretty common. We can talk about that some more.
But especially in my population of patients in older adults, if they overdose with the first intake, it could be quite unpleasant and actually could be risky. If you are dizzy, for example, and your chances of falling is high, you can break a hip, and it can be disastrous. So you have to start very slow.
When you’re gradually titrating up, there are a couple of things that happen. First of all, what we know for sure is that with most of the cannabinoids, there is something that’s called a J curve of efficacy. In the beginning, when you just start taking it, low doses don’t usually work perceivably. They’re doing something, but you’re not going to feel your pain getting better, for example.
But as you increase your dose, you’re going to get to a certain point of much better efficacy. But if you keep taking more and more, eventually, that efficacy will going to go away. So that, we call that a J curve. You have this kind of the best– your personal dose. Now, the problem here is that– and this is part of the clinical challenge with working with cannabis. That J curve is very individual. So for some person, the best dose would be, say, 5 milligrams of THC at that time for sleep, and for somebody, it could be 20.
And how do you know where your personal dose is? Well, we don’t know that yet. I mean, there may be genetics that involved. At some point, we’ll learn that. But in reality, it’s a trial and error almost always. So you have to start low, go slow. Then you really want to try to put the cannabis where you have a problem.
IRA FLATOW: This is Science Friday. I’m Ira Flatow. My guest, Dr. Mikael Kogan, medical director of the George Washington Center for Integrative Medicine in Washington, DC. He’s the author of the book, Medical Marijuana, Dr. Kogan’s Evidence-Based Guide to the Health Benefits of Cannabis and CBD. You mentioned that you work with elderly and frail people. And you mentioned that it’s safer, often more safe than prescription medications.
What about on the other end of the curve? What about younger people? Is there any danger? You talk in the book about problems with young people and their changing brains as they’re growing up. What is the danger there? And do we know enough about it?
MIKHAIL KOGAN: Yeah, we do. We know significant amount of data. Thank God for some of the existing infrastructure in science. We actually have been studying side effects and toxicity of cannabis for very thoroughly for a long time. So if I were to name sort of two or three major problems that cannabis users can run into, I would definitely say that the young crowds, teenagers, even young adults, 20 up to probably 25, very heavy use of continuous THC daily definitely is associated with a negative impact on brain. I don’t think there’s any doubt about it.
And what’s interesting that it’s CBD seems to ameliorate most of the dangers, although I would say the science is inconclusive as to, is that absolutely true, and what is the dose of CBD to remove those dangers? It’s not very clear. But definitely I would advise the young listeners, be careful. Stay with balanced strains if you have to use it, and best not to use it at all if you can avoid it.
The issue is, what do you do with patients who are young and for whom it’s effective for certain issues? I think it’s a pretty complicated topic. I think the other side effect that always gets brought up is the psychosis or risk of schizophrenia. It’s interesting that at low doses, THC can actually, or cannabis, can actually treat certain psychotic states and even be sort of beneficial in schizophrenia. But it also increases risk of early onset schizophrenia, although we think it’s because it simply moves the timeline forward. So if somebody would have developed schizophrenia anyway, but if they start using weed, then they’re going to develop schizophrenia earlier or faster.
IRA FLATOW: You’re using terms like think or not sure. To me, how do how do we get to be more sure about–
MIKHAIL KOGAN: Exactly.
IRA FLATOW: –these things? And don’t we need to, as physicians, to understand it more completely?
MIKHAIL KOGAN: Of course we do. And I hope some of the politicians are going to listen to this presentation. Well, the problem is, it’s still a Schedule I controlled substance, so we really can’t, on the federal level, research it easily. And there is a lot of physicians, a lot of researchers within academia who really want to study it. And unfortunately, it’s very difficult because when it’s a Schedule I controlled substance, you only have access to federally regulated products. So the federal government has authorized growers. And those are the only ones you can use.
The problem is that until very recently, their products had nothing to do with what’s sold in dispensaries. So I could study something that’s 30, 40 years outdated. And then it’s going to have zero clinical applications to what patients are actually buying from dispensaries nowadays. So we were still very slow. Now things are getting a little bit better. It was recently just the approval of expanding this program where more growers can apply, get licenses, and start making products that are closer matching what’s in dispensaries. But it’s not going to be a fast shift. We’re still years behind.
And unfortunately, there’s a whole history here. We got set back in science of cannabis by so many decades. And it’s unfortunate. I think back in 1937, American Medical Association was the only organization that stood up and said to the government, we should keep cannabis medical, and we should not tax it heavily. And we should allow patients to use it. But of course, most listeners know what happened, that nobody listened. And of course, now American Medical Association is against the use of cannabis, which I think it’s kind of ironic.
IRA FLATOW: But do you think that there are a lot of doctors, do you find among physicians, some are willing to suggest medical cannabis to patients, but they don’t know enough about it?
MIKHAIL KOGAN: Well, that’s absolutely true. And I actually find also that a lot of doctors are not willing to suggest. And they’re really afraid. There’s even misconceptions among doctors who are afraid that if I’m going to recommend cannabis, that my license can be taken away, which, by the way, legally, completely wrong. Nobody can take your license away if you’re just recommending cannabis for appropriate education.
And but there’s a massive lack of education. And thanks, Ira, for mentioning that we’re trying to change that. We recently got a grant. And we’re going to set up a process, called Delphi process, in which we will identify the competencies in medical education for medical cannabis. Medical education, as a conservative field, moves slowly. So in order for something to be uniformly adopted in every medical school, we have to have a set of standards. And there are no set of standards for cannabis education.
And that has to change first before we can go back to the Association of American Medical Colleges and say, look, you have to really push that every medical student graduating from US medical school has some basic knowledge. And that will gradually start the shift. Part of the problem right now in a lot of academic institutions, there is simply no mentors.
IRA FLATOW: Ah.
MIKHAIL KOGAN: The cannabis doctors who decided, look, we’re going to be enthusiastic about this field, we’re going to learn, many of them are on their own. And part of it is, they’ve been afraid being in large academic centers because leadership often has been against this topic. And it’s been difficult to move this field forward within large academic centers.
But it’s shifting. It’s definitely shifting. I gave grand rounds at George Washington University on this topic every year or so. And every year, I ask the same question. So how many of you here today are recommending cannabis? And every time, we get more hands. So it’s definitely, things are moving forward, they’re slowly shifting.
IRA FLATOW: Because I feel from my experience that it’s the bud tenders, the people who work in medical marijuana dispensaries, who seem to be at the forefront of advising people, who come back, time and time again, because these folks have been given good advice on cannabis formulations that work. But it’s these bud tenders who seem to be the practitioners here.
MIKHAIL KOGAN: Yeah, and it could be a blessing, it could be a curse. Not all of them are highly educated. The standards of what they’re supposed to know is quite different. Some states require every dispensary to have medical director. And it’s kind of going more that way or just a medical personnel. It doesn’t have to be a physician. It could be a nurse or somebody, a pharmacist. But some states don’t have that. And the quality of bud tenders is kind of all over the place, unfortunately.
We actually talk a little bit about this in the book. We also try to discuss how do you deal with this? Or even bigger issue, how do you deal with when your doctor says, oh, forget it. This is toxic for you. You shouldn’t be using it. Well, how do you engage this doctor in a productive conversation?
IRA FLATOW: Well, how do you?
MIKHAIL KOGAN: Well, I mean, you show them the evidence. Part of the way we wrote the book was that not just for the public, but because I’ve been as an educator in this for quite some time, and I see those pitfalls. And one of the best ways to convert the skeptic is just to show them the data and not walk away. It’s just continuously engage the person and saying, look, how about if you consider for this condition?
Why, OK, so for pain, for example, let’s try– I’ll give you a concrete example. In my own institution in anesthesia department, chronic pain center, there was a lot of resistance for a long time. And finally, after I treated some of their patients and they did really well, they finally said, OK, fine, come give us a talk. And now the doors is open.
So it’s basically education tends to trump the ignorance and misconceptions and the fear. I think there’s still a ton of fear about this, not just fear of legality and then prosecutions for possession and use, but also fears that it’s highly addictive, which, by the way, is a total misconception. It’s not totally not addictive, but it’s minimally addictive, definitely way less addictive than alcohol, for example.
And there are many others. I mean, there are misconceptions that you have to smoke it, which is totally in 2022. I hope that in the future, we’re going to have less and less inhaled products.
IRA FLATOW: But there’s an old saying that marijuana is a gateway drug. You know what I’m talking about, right?
MIKHAIL KOGAN: Right.
IRA FLATOW: To a more dangerous substance, but you write in the book that cannabis could actually be an exit drug. Tell us about that.
MIKHAIL KOGAN: Yeah, yeah, so we actually have a large number of studies pointing towards the fact that it seems to be an exit drug, at least an exit drug from two main categories of medications. One is the opioids, and the other one is hypnotics of sleeping aids. The opioid exit strategy seems to be evidence at the pretty high level. We’re talking about high quality studies published in leading medical journals in the last couple of years.
For sleep exit, it’s a little less clear. We have more of data collected from states that legalized medical cannabis. And in those states, the use of over-the-counter and prescription drugs drops by the degree of millions per day, so in each state. So we’re talking about massive decline. And in terms of the opioids exit strategy, it seems like we’re going to save upwards of 30% or 40% of all deaths from opioids if you institute cannabis in a particular area.
IRA FLATOW: That’s incredible.
MIKHAIL KOGAN: It’s incredible. And I personally find it a little baffling why is there no more talk about this on the high level of politics, because we’re in the middle of opioid crisis. And there are all kinds of interventions that have been tried. And yet, nobody at the level of politics talks about cannabis as one of the major strategy, which I just give you the numbers.
Those numbers are not random numbers. This is a serious research done from multiple different institutions in multiple different states. And it’s repeating itself over and over again. And it’s a little unclear why this is happening. I don’t want to speculate. And I hope it changes.
IRA FLATOW: Well, if there’s so much money involved in the drug industry, and especially in sleep medications, right, and a lot of lobbying goes on and politicians are lobbying not to do– you know what I’m talking about.
MIKHAIL KOGAN: You said it. You said it. [LAUGHS]
IRA FLATOW: But it’s true, right?
MIKHAIL KOGAN: Yeah, I don’t want to sound that there’s a conspiracy theory. I don’t think there’s any, but I think you’re completely right. I have a favorite expression to most of my patients. You’re going to a butcher, you’re not going to buy a salad. So we’re operating in this medical industrial complex something threatening a massive infrastructure of income. Of course, it’s going to delay the progress.
IRA FLATOW: So is it a good thing, then, that industry is getting more involved with cannabis? Because that may take some of the direction or move it in that direction. Or is it a bad thing–
MIKHAIL KOGAN: Well–
IRA FLATOW: –for business?
MIKHAIL KOGAN: –I have to give you a legal answer, maybe. It’s both, of course. I mean, I think the benefit is that when industry gets involved into anything, it expedites the process of expansion here. But of course, they’re going to also try to make money out of this. And there’s a lot of– talking about the other side, there are a lot of hype and wrong claims about cannabis. It’s kind of Wild, Wild West out there.
IRA FLATOW: Such as?
MIKHAIL KOGAN: Well, especially the newer products like Delta-8 THC, for example, which is completely another research. There’s basically no clinical evidence that Delta-8 does anything at all. And yet, you can buy it online and ship it to your house. And there are claims out there that it does exactly everything that THC does.
Where often industry tends to push the envelope way ahead of evidence, is it good? Sometimes it actually may be reasonably good because it does enforce researchers to move faster. But often, it’s just blandly making money out of nothing, out of thin air, and making wrong claims altogether and causing problems in the process.
IRA FLATOW: This is Science Friday from WNYC Studios. One last question for you.
MIKHAIL KOGAN: Sure.
IRA FLATOW: There’s speculation that cannabis may help COVID long haulers. What do we know about that. Is there any truth to that, any evidence-based data?
MIKHAIL KOGAN: Yeah, well, there’s definitely truth to that. Data, no, data is probably just– it’s going to take a bit longer for data to come out. But long haulers have a lot of symptoms that we already talk about. They have a lot of sleep disturbances. They have a lot of symptoms around pain, whether it’s empathic pain or other types of pain. They have a lot of anxieties and a lot of instability of their nervous system. So they’re triggered quite easily with very minor triggers.
And cannabis has a role to play in everything I just mentioned. So it’s basically as a help for symptoms, there is no doubt in my mind. And we’ve been already, at our clinic, we started a long haulers subsection and partnering with George Washington University. And we’re seeing a lot of patients benefit from cannabis because often, the, really, number of tools that the patients can use effectively is pretty limited. And the symptoms can linger for a long time.
IRA FLATOW: Very interesting. Thank you for the work that you do and for taking time to be with us today.
MIKHAIL KOGAN: Thank you so much. It’s a pleasure.
IRA FLATOW: Dr. Mikhail Kogan, medical director of the George Washington Center for Integrative Medicine in Washington, DC, author of the book, Medical Marijuana, Dr. Kogan’s Evidence-Based Guide to the Health Benefits of Cannabis and CBD.