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:
0:17
Hello, I'm Dr. Michael Koren.
Dr. Erich Schramm:
0:19
Hi, I'm Dr Erich Schramm.
Dr. Michael Koren:
0:21
And Erich and I have been having this fabulous conversation about cannabis. In our first session we talked about cannabis 101, just basic terms and understanding why, theoretically, it's effective, and then in our second section we talked about actual patients, where you make a difference. So that's pretty cool, yeah. So now in this session I want to really get into the practicality of it. Like how do you go from me referring a patient to you or a patient learning about your practice and presenting with a medical problem and that person actually walking out with the right product? So let's kind of walk through it step by step. So we gave many examples in the last session of people with anxiety or palpitations or irritable bowel, inflammatory bowel disease, and all those folks could benefit from your services and the products that you'll help them get. So how do they get them? So you make your decision, you know they need a balanced product and then explain exactly where you go from there.
Dr. Erich Schramm:
1:18
Okay, so the guidelines are set forth by the state, which is basically the legislature. So if somebody asked me and say, well, why do things go a certain way in this process? And I'll say the legislature made that determination.
Dr. Erich Schramm:
1:32
And then I remind them that the legislature is not stock full of scientists and physicians, so the way the process is designed is in that context. Now, I still think it's a pretty functional system, but it does the way that its structure is based on what the legislature has put forward. So when a patient determines or decides that they're going to do a certification, then I'll reach out to them and, as a new patient, they'll fill out a new patient.
Dr. Michael Koren:
2:01
So certification makes it legal for the patient to use cannabis in the state of Florida?
Dr. Erich Schramm:
2:20
And then a patient will then either bring the records or they'll sign a medical records release so that I can actually have those records, because you do want to have those records, and then they fill out the medical records from their physician.
Dr. Erich Schramm:
2:32
And then so they'll come in and we sit down and we have a great discussion about well, tell me about any of your previous experience with cannabis, because that can predict what kind of products that they may lean to, because if you have someone who's a seasoned cannabis person, those ratio one to one products may be low potency. But if it's a cannabis naive patient. Those are high potency. You have to understand their background in terms of what they've had in terms of cannabis.
Dr. Michael Koren:
2:58
And are there available products? One to one, two to one, three to one? Is everything out there, or tell me a little bit more about that.
Dr. Erich Schramm:
3:05
Yeah, and so out there in the dispensary world. So once you get certified and we talk about the medical card, a person can walk into any dispensary in the state and get product and there's 22 different businesses as dispensaries in the state, so you can get just about any product in any dispensary. So you, but not every dispensary is created equal. Some tend to gear a little bit more to the recreational users and then some tend to gear towards the medicinal user, so ratio products.
Dr. Michael Koren:
3:33
But the recreational users still need to be certified?
Dr. Erich Schramm:
3:39
Now, in this medical marijuana practice I'm seeing medical patients, and so the typically the first thing the medical patients come into say hey look, don't get me high.
Dr. Erich Schramm:
3:49
I'm looking for relief, so understanding where those dispensaries are and what those products are. So when a patient comes in, of course I want to know what their concerns are, what their problems are, what do they want to get out of that? What would be the ideal situation for them? Oh, you'd like to sleep through the night. Oh you'd like to get through your day without pain. Oh, you like to have less stress. You want a better quality of life.
Dr. Erich Schramm:
4:11
Okay so understanding what they want to get out of that. And then so I submit whatever necessary documentation you have to the state's assigned a seven month period for your certification. Okay, the card. So once I put in orders, say you have now access to your products, the state will send you out emails so you can get registered that you can get your card, which is good for a year.
Dr. Erich Schramm:
4:40
So your certification good for seven months, card good for a year, and once you get your card then you can go off to your dispensary and get your product. And now the state has it so that you can do your certification and you get your card registered on the same day, so people can be in the dispensary that night, and so it's a nice system that they just developed in the last two years.
Dr. Michael Koren:
5:00
So, in terms of your interface with the system, do you send an electronic prescription to the dispensary? Do you give patients a piece of paper? This is my recommendations, or how does that play out?
Dr. Erich Schramm:
5:12
Okay, as far as the process, your driver's license is linked to your medical marijuana certification. So when you punch in and people will put in, you have to submit your driver's license number, your social security number and based on that then it'll identify you through the driver's license database, which allows you that when you'd get your certification even though it may take two weeks to get your card you can use your driver's license on the same day because in the you're creating right.
Dr. Erich Schramm:
5:44
And it isn't that you're providing a certain specific prescription. You're just setting basic parameters in terms of how much edibles or orals or inhalants or flower or topical that you're assigning, and you can determine how that's going to be and then they can go.
Dr. Erich Schramm:
6:01
It's like you're putting money in a bank account and then they can go and draw out of that, depending on what kind of products they do. What I provide for the patient is a detailed written. I have basically different sheets which are the product outlines for all the different dispensaries here. So if I know a patient needs a certain type of product, I'm gonna say underline, highlight, I'll write the dosing recommended on that. So when they leave they have a sheet or two of paper that'll be specific. They go to the dispensary, they show the person the dispensary, because I tell patients I say the dispensary knows their products but they don't know you as a patient and I don't want them to be the person recommending your products.
Dr. Michael Koren:
6:45
So in your written recommendation for the patient you'll say if an oral versus an inhaled product is better, I assume, and give them information about ratios.
Dr. Erich Schramm:
6:57
Right, so what? I try to gauge for that, and so If you inhale cannabis, you get an immediate relief. So patients will utilize this, like people with migraine headaches where there's a compelling need to have immediate, more immediate relief.
Dr. Erich Schramm:
7:10
I saw a patient who is having like spasticity problems and does great having something that's more immediate. But when you inhale cannabis it's going to be good for two or three hours. If you do an edible, the onset for that's about an hour 45 minutes, sometimes two hours, which are going to get eight hours. So, understanding what type of relief you're trying to offer a patient tinctures give you about four hours relief. The oils under the tongue onset at about 30 minutes and then there's topicals, which are another option too. So when a patient goes into the dispensary for, say, a first time, a lot of times there's discounts being offered because those dispensaries know first time patient, hey, they're going to be trying a few things. So it's a great time. And right now I've seen the prices in the dispensaries because the insurance doesn't pay for it has actually come down in the last six months. So there's a great time for new patients coming into the system because they're getting discounts, they get a chance to try these different products.
Dr. Erich Schramm:
8:07
And then I schedule follow up at three or four weeks because you can't just let the patient say here, try this and get all see in seven months. So we get a three or four weeks to understand where those products are sitting. For that patient, make adjustments if they need to go somewhere else to get those products, but that's the way that I set up my practice.
Dr. Michael Koren:
8:26
So one of the concepts in standard medicine is that you like to try one thing at one dose for a period of time and see how the symptoms respond to that, or whatever the parameters you're tracking responds to that. Is that something similar to how you approach things?
Dr. Erich Schramm:
8:42
General guidance. Yes, and I'm conservative because everybody, especially cannabis naive patients, are going to start on the lowest dose, so maybe a quarter dropper or maybe a third of a gummy. So I try to be very specific on how we start a dose. But I will tell that patients as I look, because everybody's different in their sensitivity. They'll say well, if you've tried it at this dose for a few days, you can go into the next higher dose to half dropper or full or half, however that you feel that you're comfortable to utilize it. Here are the potential side effects you might be looking for. But I try to give them some guidance, if anything. When I do follow ups patients if there's one thing that they just could better optimized as their dosing because people are generally hesitant to go to higher doses- but, I try to reassure them.
Dr. Erich Schramm:
9:26
I say, look, you really are not going to get dependent on this, it's not going to be addicting, it's not going to cause mind altering effects. So we try to get them to feel more comfortable. After three or four weeks the patient realizes okay, I'm getting more comfortable with their products and they can start to be more comfortable.
Dr. Michael Koren:
9:43
You may have an increased desire to listen to Pink Floyd. Exactly right, right right right. I'm getting those old headphones out you know, but otherwise you should be pretty safe. So to that point, let's just talk about some of the pragmatic things. Can you drive when you're using cannabis products? What are the recommendations for that?
Dr. Erich Schramm:
10:01
Okay, that's a great question. And so what I tell a patient? I said, look, the whole premise of this practice and these recommendations and products is non-intoxication. Now, if it's a bedtime product and I'm trying to get you to sleep, then that's a different discussion, because your bedtime product, nighttime product, you know, I'd say, think of it like what if you were to go out to dinner and you decide you're going to have four glasses of wine.
Dr. Erich Schramm:
10:25
What do you think you might expect? Sure, sure and same thing. So when you're using a product you know as a potential for intoxication has to be used intelligently. Daytime products, by design, are intended to be non-intoxicating, so you know again. This is why I favor higher ratio products 20 to one, 15 to one, 30 to one as a daytime product.
Dr. Michael Koren:
10:46
CBD to THC Right.
Dr. Erich Schramm:
10:47
Right. So you're really pushing those kind of products and I tell a patient I say if in a doubt you know you can, if you're going to have a concern about the effects for a daytime product, take the product on a day you're not driving anywhere then, you can gauge that and so, but for most patients it really isn't going to become an issue.
Dr. Michael Koren:
11:03
Okay, how do police officers assess this? I don't think they have a blood level test that they do. Yeah, do you blow into something and find out what your cannabis level is?
Dr. Erich Schramm:
11:19
There may be something out there in the works for that, but I'm not aware of it. And, quite honestly, you know my experience is with because I've taken care of a lot of law enforcement patients not cannabis patients necessarily but they have zero interest. Zero interest in pursuing patients with medical cannabis card.
Dr. Erich Schramm:
11:39
Now, if they person is being pulled over for apparently driving under the influence, then yes, you can get arrested or get a ticket for driving under the influence, but they have zero interest in wanting to pursue patients with medical cards, and I think the last federal raid on a cannabis dispensary was in 2009. So the federal government has no interest in going after patients with medical cards.
Dr. Michael Koren:
12:08
So how about, like traveling to different states or different countries? How does that play out?
Dr. Erich Schramm:
12:13
Well, I tell a patient, you know so? The TSA came out and said we are not a drug enforcement agency, but if we come across your products we've got to do something with it. So what I tell a patient? I say, if you're going to go on a domestic flight, put it in your checked bag. Okay don't carry it on. And don't take it out of its original packaging.
Dr. Erich Schramm:
12:33
So if you're going to be driving from state to state, I said just make sure you leave it in your original packaging. Because most places don't again don't want to have anything to do with that. But if you take, you decide that you're going to put your gummies into a Ziploc bag somewhere and try to carry that around that could be a problem, but for the most part I tell them you know you really shouldn't run into any problems with this.
Dr. Michael Koren:
12:56
So you don't advise hanging them in a bag that drops down from your rear view mirror.
Dr. Erich Schramm:
13:03
Correct. That would be a bad idea, right. Theoretically, you really can't be out there using cannabis products in public. That's not the intent of law, so yeah they don't want to see that.
Dr. Michael Koren:
13:12
Okay, so final question for this session how long should patients anticipate needing to wait before seeing the effects of your recommendations?
Dr. Erich Schramm:
13:21
Oh, it should be pretty much right away. You know, the first couple of few weeks is really that initial period to see how sensitive patients are to THC. It comes down to it. But as far as you know, especially for like pain relief, it's pretty quick and, you know, as far as helping to get people to sleep. Likewise, it shouldn't be the case that you know three or four weeks down the road people are questioning whether it's working. If I get that question, then I have to consider that they're just underdosed and say, okay, well, this is why we do follow-up. So then I can say, okay, well, you need to consider how you know you're being dosed with the product.
Dr. Michael Koren:
13:59
Beautiful. Well, you answered all my questions, so we'll end this particular session, but I want to explore with you in the next session future research and what we can expect over the course of the next five years with regard to cannabinoid research, and how the government may change its policies.
Narrator:
14:16
Okay, thanks for joining the MedEvidence Podcast. To learn more, head over to MedEvidence. com or subscribe to our podcast on your favorite podcast platform.
