Narrator:
0:01
Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased evidence, proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.
Dr. Michael Koren:
0:16
Hello, I'm Dr. Michael Koren.
Dr. Erich Schramm:
0:19
Hi, I'm Dr. Erich Schramm.
Dr. Michael Koren:
0:20
And Eric and I have been having this fabulous conversation about cannabis and we've had three previous sessions where we covered a lot of the nuts and bolts, and so now we want to talk about the future, and I'm a clinical trial guy, I'm a research guy, you're a research guy, and so we always like to let our audience know what's going to happen in the future and also what's the evidence for the information that we're providing them.
Dr. Michael Koren:
0:47
So we alluded to the fact that the endocannabinoid system has been studied in clinical trials and we've learned a lot, that you have a lot of clinical experience and certainly you have helped a lot of people, and the question is how we take all this information and standardize it. So we know that this works more often than not for this type of patient. So I want to get into that with you. And, of course, part and parcel of that is the government and how they're regulating this, and that probably, at this point, just makes it more difficult to look at this from a scientific standpoint. But it is what it is and I'm very curious to see how that might change in what's on the horizon for this type of research. So why don't you start us off by explaining this concept of why cannabis was illegal previously and why you can use it now, and those concepts about drugs that are scheduled.
Dr. Erich Schramm:
1:44
Right, so first of all, scheduled. One drug is a drug that has no recognized medical use and a high index or potential for abuse and, in that context, an example of that like LSD, heroin, mushrooms, psychedelics, so those are your classic scheduled one drugs.
Dr. Erich Schramm:
2:05
That was the Control Substance Act of 1970, which a lot of people are familiar with. And so what that did? It basically puts those products, those drugs, those compounds into a sort of prohibition and out of that it makes it, from a research perspective very challenging, because it's to be able to do meaningful, quality research on cannabis or any scheduled one, there are a lot, a lot of hoops to have to jump through, and that includes the DEA, the FDA, et cetera, et cetera. And so research, a lot of that research has gone overseas. So there are, when we see the research papers they are forthcoming, a lot of that has moved to be overseas. The government had for a long time, very interesting one single farm in Mississippi where all the investigational marijuana joints were produced.
Dr. Michael Koren:
3:05
Really, then they had a special license by the government?
Dr. Erich Schramm:
3:06
Yes, absolutely. So they carved out and they're still there. It's in Mississippi, so that's the government's version of this and so this gives you an idea of kind of the culture. And so it's certainly been a big has hampered a lot of issues to keep people getting in and doing this research. Not to mention that when people get into doing the scheduled one or scheduled two space because people say, well, hey, isn't all these cannabis places they must be making a killing right? Money, hand over fist and then I'll say, well, the trouble is, if you're going to do business in schedule one and schedule two, you don't get any tax breaks.
Dr. Michael Koren:
3:48
So just explain to people what schedule two is versus schedule one.
Dr. Erich Schramm:
3:51
So as you get less scheduled, then it's more accessible and so less restricted, and schedule two are going to be your. Cocaine would be schedule two. Cocaine is schedule one.
Dr. Michael Koren:
4:00
Well, cocaine is used medically.
Dr. Erich Schramm:
4:02
Well, but historically, most of the common schedule twos are going to be your narcotics and stimulants. In fact, it means like your Adderall derivatives and things like that.
Dr. Michael Koren:
4:12
Because there is a medical indication for cocaine, right. Yeah, bleeding noses, right, things like that, ironically so but the problem.
Dr. Erich Schramm:
4:21
So if you're the high tax burden on companies that do business with schedule one or schedule two, so the cannabis companies aren't necessarily making a killing on this and so, if you can, if they were no longer scheduled one, then it opens up the potential for people who are considering investing.
Dr. Michael Koren:
4:39
It opens up to banking and opens up to, Just for the audience, schedule three. What type of drugs are those?
Dr. Erich Schramm:
4:46
Schedule three is going to be along the lines of ketamine, testosterone, tylenol with coding eubrenorphine, and that was the big news over the summer was that the administration had sent an application to the DEA for rescheduling cannabis from one to three. And would be very possible in the next 12 months that that might occur. Schedule four Xanax sleeping pills.
Dr. Michael Koren:
5:13
Okay. Along those lines and there's a schedule five as well, if I'm not mistaken. Yeah, I'm not sure what those are Okay.
Dr. Erich Schramm:
5:18
Is it just everything else? Anything?
Dr. Michael Koren:
5:20
else those are? Say what drugs that don't need any special consideration? Right, Is that right?
Dr. Erich Schramm:
5:24
Right and I think, a lot of the but the trouble is, I think, with people look at that and say, well, look, you can't kill people on cannabis, so you put it down as a schedule three and you know, and so you know what gives there, you know. So it's just it's. It is not currently likely that cannabis was going to be de-scheduled, in which people would hope that it'd be quote, you know decriminalized and you know, then it would just be, you know, adult use or what have.
Dr. Michael Koren:
5:49
Right Right Now, there are cannabis products that are on the market that are manufactured by pharmaceutical companies, as I understand it, for cancer, pain and things. Any comment about that?
Dr. Erich Schramm:
6:02
Right, you know. So you know. These products have been out there, merinol, and they're all derivatives. They've been around forever but, they're primarily being used for nausea and vomiting or anorexia associated with.
Dr. Michael Koren:
6:14
And they're scheduled to, I assume, similar to narcotics.
Dr. Erich Schramm:
6:18
Not sure how they're scheduled on that. Probably something along those lines.
Dr. Michael Koren:
6:22
Okay, we'll look that up and put it in a show note.
Dr. Erich Schramm:
6:26
So yeah, and and Sativax and some of the other products that are being derived are being developed on the are cannabis based and they're more recently being that.
Dr. Michael Koren:
6:38
But Right, so talk about the research. What, what do you predict? What's going to happen over the next five years?
Dr. Erich Schramm:
6:44
That's a great question, and one of the things that I've looked at is and I mentioned how you know, the big pharmaceutical companies have invested a lot, and they you know, the top five patents in terms of cannabis is amongst the big pharmaceutical companies, and I mentioned Pfizer's purchase of a.
Dr. Erich Schramm:
7:06
They bought Arena Pharmaceutical of 2021. And they're very much interested in their product. So, you know, if the tax burden is lifted and the regulatory burdens are lifted because they're no longer having to be comply with schedule one and schedule two requirements, then this seems that this would be an ideal opportunity for whether it's going to be big pharma or, you know, you know big investors, big investors to come in and and and get into the space. But it seems that it's going to be an opportune time because, as you know, we, we both know that, if you know, it's one thing to do a study anybody can do a study but if you really want to do a good quality study, a large, you know, randomized, placebo, controlled study, you know it takes a lot of resources for that to happen. So that seems like that could definitely be on the horizon, right.
Dr. Michael Koren:
8:01
And and for all of the controversy about big pharma in terms of of high drug prices, you have to give them credit for spending a lot of money to learn things. So we're all fortunate that big pharma is willing to invest a lot of money so that we actually understand evidence, we understand the truth behind the data, and so we use that in our day-to-day decision making for our patients.
Dr. Michael Koren:
8:26
And the fact that pharmaceutical companies are getting into the space should allow us to know a lot more about how cannabinoids work, how they can be deployed most effectively and safely. So I think we have to at least tip our hat to a big pharma for that.
Dr. Erich Schramm:
8:40
Yeah, no, I think, I think any, I think. Once that space opens up, I think we're all going to get a lot out of that.
Dr. Erich Schramm:
8:47
I think the challenges have been you know, historically in research that you know a compound is developed as, and it has an action at, a single receptor. So we're looking, single compound and a single receptor and you know marijuana really doesn't fit that model. It's multiple components. And so how to navigate products, how to get into that space that accounts for all the different components of that, the terpenes and the different cannabinoids that are out there, not just CBD but CBG, cbn, all the different variations of cannabinoids that are out there. It's a great space in terms of the science because there's so much to learn from that Right.
Dr. Michael Koren:
9:33
That's a really interesting point. So I've had conversations in the past, especially in the old days, when I was a single guy and meeting somebody at a bar and I would ask her if she would want a beer or wine or a hard drink, and she might say, well, I only drink vodka because otherwise I get a headache, and I would always be skeptical about that, saying, well, alcohol is alcohol. If you get a headache from alcohol, it shouldn't really matter what you're drinking. That was the scientific thinking and maybe that's not necessarily true. Maybe there are other components of these things that are more holistic but that could also be studied. So we can certainly do studies where we look at one strain of marijuana versus another strain of marijuana and see whether or not one is better than the other, for whatever the particular diagnosis is. So this gets in the concept of what you're mentioning in terms of a receptor and a chemical receptor versus the interaction of all the different ingredients for products.
Dr. Erich Schramm:
10:29
Right, and that's actually called the entourage effect. So if you read much in the cannabis space, you often hear that talked about the entourage effect. And that is true because the benefit, the efficacy of the plant is much greater from its total rather than just the individual components.
Dr. Michael Koren:
10:48
But ultimately that could be studied as well, based on the study design. Absolutely.
Narrator:
10:51
Yeah.
Dr. Michael Koren:
10:54
So what are your predictions in terms of where your particular niche develops? Is this going to become something that family physicians become more comfortable with, more involved with, or do you think it's going to remain a more established subspecial to?
Dr. Erich Schramm:
11:11
Okay, that's a great question.
Dr. Michael Koren:
11:13
And.
Dr. Erich Schramm:
11:13
I've given that a lot of thought. My answer to that question is going to be that, if it is rescheduled, that there's going to be greater access and that's the reason why they're doing it and then be able to actually prescribe cannabis. Now my experience, having spent a lot of time doing physician outreach and talking to physicians, is that most physicians really don't know very much about the endocannabinoid system, and I graduated med school in 2000,. Didn't learn anything about it, even though in the 1990s they were really understanding a lot of the endocannabinoid system. But I didn't learn it, and so I think it'll take if it ends up scheduled three, then it means that it could be tested on the boards and that will compel then.
Dr. Erich Schramm:
11:58
For we look at our teaching institutions, okay, well, look, now we have to incorporate cannabis as part of that medical education. So I mean and I saw a few other confirmsors doing that went in that MYT watching website or I heard, but that's going to take probably another five years, 10 years, I don't know. So eventually, yes, I think it'll get to a point where patients will be getting prescriptions, but at least, upfront, I perceive it as still being. I mean, I consider myself as a little bit of a specialist, and so there's, I think a lot of physicians that I speak to and work with see it in that fashion. So I think, more immediate, yeah, I think it's going to be looking more like a specialty, but eventually I'd hope that would open up to broader Interesting.
Dr. Michael Koren:
12:39
And my other question is do you predict that the dispensaries will be more regulated in terms of having to disclose exactly what's in their products? So here, for example, one of the standards of the pharmaceutical industry, both over the counter and prescription, is that there is an accurate list of ingredients. So if you buy cold medicine, it could have more or less hand to histamine, more or less ibuprofen or cinnamon, et cetera, but it's a law that requires that this product has this proportion of things and it's sold as that product. Now my understanding is that the dispensaries aren't quite there yet with that. Or am I wrong about that? Or is that regulated, or will it become regulated?
Dr. Erich Schramm:
13:22
In this state, every product that is sold into dispensary has to go through a certificate of analysis.
Dr. Erich Schramm:
13:28
And that is rigorous. So they're testing at least probably for 50 different things, including contaminants, insecticides, and then they test the integrity of the product. So is the product have what it says it has? And is it the THC level? And they do. Are there terpenes present? So when patients ask me about the safety of products, let's say somebody says what about vaping? Is a vape safe? And I'd say, well, if it's coming from a medical dispensary, I'd feel much more comfortable to say, okay, that's a reasonably safe product because it's been tested. But it's things on the street. Same with CBD. I'll say, well, look, if you're getting something on the street or at the gas station, hey, you're on your own because that stuff isn't being tested.
Dr. Erich Schramm:
14:16
So I feel very comfortable with the products that people are getting through this day, the dispensary. That's why, when patients come in because I would, and I joke a little bit with some of my patients and say, let's say, getting back to the old school days, right, and I said, okay, remember when you were a kid or in high school or whatever you know, the strength of the marijuana back in the day in the 60s, 70s and 80s is about a single digit five, seven percent THC. And so I'll tell a patient now I say, look, if you go in and buy a marijuana joint, that percentage is gonna be 18, 25%, especially for my older patients. Let's say, look, this isn't like the good old days. So really it does not take much.
Dr. Erich Schramm:
15:02
And these products, especially related to the purity of the products and the potency of the products, can't be. You don't wanna underestimate that. So I always tell patients let's say, well, look, this is why you gotta really start off with low dose. But yes, the products of this Florida Dispensies are vetted and a lot of this is grown in greenhouses. They go to a lot of great lengths because if one of the products has a problem they're gonna have to pull all the products off the shelf and that cost them a million dollars. So it's rigorous quality control from that standpoint here.
Dr. Michael Koren:
15:37
Erich, I so much appreciate the education. I've learned it an incredible amount and hopefully our listeners and viewers will get the same out of it. And good luck with your cannabis practice and keep it the great work and keep on providing evidence so that we can help our patients.
Dr. Erich Schramm:
15:53
Thank you, mike, for everything you do and allow me the opportunity to be here, and I'm happy to come back anytime you wanna talk any more about this. Good work, my friend, yes.
Narrator:
16:04
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