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 and Erich and I had a fabulous session where we went over Cannabis 101. And I learned a lot.
Dr. Erich Schramm:
0:28
You passed the test. You got them all right.
Dr. Michael Koren:
0:30
That's right. I don't want to say my exact score on the quiz after the test, but I did pass.
Dr. Erich Schramm:
0:34
You might have cheated, I'm not sure, but you got it all right. It was all good.
Dr. Michael Koren:
0:38
So let's now look at this more from a clinical perspective. So you've now dedicated your practice to be focused completely on cannabis, is my understanding. You're not doing family medicine anymore and you're now basically a doctor that helps people use cannabis effectively. So tell us a little bit about your practice and then after that, let's delve into some patients that might benefit from the type of practice that you do.
Dr. Erich Schramm:
1:02
Right. So what inspired me to consider getting into the cannabis realm was so many patients that were looking for alternatives to traditional medications, primarily as in terms of maybe wanting to try to avoid certain side effects or just wanting a more natural approach to their health. And as a family physician, I consider myself to have a holistic approach to health and say, well, it isn't exclusively one side of medicine versus another. I think we can all peacefully coexist. But a lot of that, a lot of my incentive, evolved around being able to help patients outside of the traditional prescription realm and to that end. So this has brought a number of patients that come in looking for relief. Typically, the things that they're looking for treat a lot of sleep conditions. Meditating is very common anxiety, depression, so mood issues tend to be a big chunk of that practice. So it's an advantage to me is that I am no longer confined in terms of traditional medicine practice in which I have time to sit down and really talk with patients initial certification that I'll do an hour with the patient, providing them a lot of information about and a lot of education about the cannabis products and cannabis plans. So that's what has gotten me into this space.
Dr. Michael Koren:
2:31
Beautiful. So let's break it down very fundamentally for people. So I'm a cardiologist and I have a 60-year-old, moderately overweight woman that I'm treating for hypertension has mild coronary disease, but not necessarily symptomatic, and of course, in the course of my discussion with her she mentions that she can't sleep and that's really her biggest problem. So you should just tell her why don't you go out and smoke a couple of doobies and that should care of it.
Dr. Erich Schramm:
3:06
Yeah, yeah, I would refer to it as the smokable form of medical marijuana, and that is a possibility. People can get certified.
Dr. Michael Koren:
3:17
So take this case and tell me why I shouldn't just tell her to smoke a couple of joints and then go to you and I assume a more scientific approach. Okay, so go ahead.
Dr. Erich Schramm:
3:26
Right, and this is a pretty common patient actually. And what I tell a patient? Because that patient may come in and say, look, I don't want to smoke anything, I've never smoked my whole life and I don't want to start now and I say, well, terrific, we can accommodate non-smokable forms of marijuana. And to that end, they'll say, okay, what options there? And I'll say, well, a lot of people like to do edibles like gummies or tinctures, drops. There's a lot of different ways we can get and deliver a medical marijuana product that doesn't require smoking. The other thing is cannabis naive patients. Okay, and that's something that is important, because everybody that I see has a different level of experience, from none to frequent or regular use, and so for a cannabis naive patient, you have to consider that their sensitivity to the THC and those types of products is going to be potentially greater. And so you really have to direct them to not only like, say, a specific type of, say, an indica type strain which is your more evening relaxing, restful sleep, but you're also going to look at things that help to, things like terpenes and CBD that help to buffer some of the effects or the potential effects of THC for that patient, because too much of a good thing for a patient in terms of THC could be excessive THC could be heart rate palpitations, anxiety, bad dreams, so you don't want them to have that experience. So you have to consider products, especially balanced products, which ratio products, which means that they have both CBD and THC in it, because if you just give people a straight THC gummy, then you're going to have less than optimal effects. So I guide those patients to an edible and we could talk a little bit more about the different forms of canvas that are out there but I typically guide them towards an edible at a low dose to start with, and I would put a plug in to say that and I had seen a couple of patients this week who had this issue that I'd recommend also that you can get a good, high-quality CBD product at the dispensaries, because CBD helps to offset the negative effects. Negative potential effects for THC Interesting.
Dr. Michael Koren:
5:40
So you brought up a lot of things, so I'm going to unpack that a little bit in different ways. So you mentioned, for example, people that get palpitations, which, of course, is something I deal with all the time. So second case to throw out at you I have a 50-year-old person, again having sleep problems, but maybe related to sleep apnea, has a lot of palpitations and atypical chest pain, meaning it's chest pain that isn't something that is specifically related to coronary artery disease. I've treated them for coronary disease. We've worked them up. They have mild coronary disease, not zero. So I can't completely rule out coronary disease. But my sense is that more of their issues are related to anxiety and this sense of palpitations that are not specifically associated with a cardiac arrhythmia. So how would you process that person, given what you just told us?
Dr. Erich Schramm:
6:30
Okay, great, and very similar actually to a patient I was talking to earlier this week. And so, as far as palpitations, the heart has CB1 and CB2 receptors, and CB1 receptors are what part of that regulating that heart rate. And so if somebody tells me that two hours after dosing that they're getting rapid heart rate, then I know that's a THC effect. Now the good thing is for a patient with sleep apnea and I see a ton of patients with sleep apnea the great news for cannabis is it does not affect the brainstem breathing center, so you cannot. This is why you cannot kill people on cannabis, because you cannot sedate them to the point where they stop breathing. So cannabis is a great option for people who have sleep apnea because a lot of people, as you know, struggle with being comfortable with it. So to this patient, what I suggested to earlier this week, I would say, okay, back to considering. Okay, if you're going to do your bedtime gummy or a tincture, which tinctures last about half as long as a gummy about four hours. Gummies, edibles go about six to eight hours then I might say we might want to do a tincture. But again, it's important to have CBD in the picture here because it keeps the THC in check, which is good, and it's also has an anti-anxiety effect. So during the daytime for this patient who's going to tell you that they don't want to be impaired and they don't want to risk intoxication, then you would necessarily want to choose and I can talk about ratio products. But this is somebody that I'm going to be looking for a daytime high ratio, CBD, low THC, option 20 or 30 to one where they won't have any potential for intoxication, and then you know I can. Whether they need something a little bit more for stress relief, I can give them that. But in the cannabis world, less THC is better for anxiety. I see a lot of times people's anxieties can be made worse is really. THC is very dose dependent and so understanding how to initiate dosing in these patients is really important.
Dr. Michael Koren:
8:35
Interesting, interesting. So I'm going to give you a third case in getting into a little bit of this balancing concept. So now we have again these are all people that I would potentially see in my practice. So now we have, say, late 40s female who has a very strong family history of coronary disease and has familial hypercholesterolemia. So I'm treating their cholesterol. But we know that even women that have this issue are likely to get some degree of heart disease by the time they're 50. So she's a little bit anxious about that, but she's not symptomatic and we work her up. Fortunately she doesn't have any major cardiac issues, but she does definitely wants to stick with me because we're going to be very aggressive at preventing atherosclerosis through risk factor reduction. But she also is telling me about her irritable bowel syndrome and she also is very weight conscious and we know that weight has an effect on cardiovascular risk factors. So tell me a little bit how you balance all these things.
Dr. Erich Schramm:
9:48
Right, and so it all comes down to understanding what might be the optimal product. And I'm going to go back to talking again about ratio products because it's super important and, in this case, somebody who has having digestive complaints and cannabis is great for that. It's indicated for Crohn's and ulcerative colitis. It has great potential benefit for people with inflammatory bowel disease because of the anti-inflammatory effects and there are certainly understanding and the terpenoids that are involved and maybe helpful for her, and so that may select certain products that favor those kind of terpenoids. But at the end of the day, this would be a patient. How I would treat this patient is with a one-to-one. So I'm going to get a CBD to THC ratio product and the ratio is important because if you're worried about, hey, I don't want this person to get the munchies right, I don't want this person to come back and gain 10 pounds over a year, then I would be looking for a one-to-one ratio daytime product, maybe a hybrid something that or a sativa leaning product, because the other thing that a lot of these people don't have is energy, and so to consider how they can not just help their bowel symptoms, but how they can get through their day better with a little more energy. So a lot of times when I get people in the zone in terms of treatment, their energies are going to be improving. They get out, they start exercising, they get walking. So you're treating the initial problem, the main problem, but you're going to see a lot of benefits occurring in the periphery. So this is what I tell patients all the time. I say, look, I'm going to manage your stress, but we're going to get your sleep better. Or I'm going to help your pain, but you're going to sleep better. Or I'm going to help you with your digestive issues, but you're going to sleep better. Or you're going to have better daytime energy, but it's really going to come down to understanding how to deliver or recommend to them products that help to buffer the potential for weight gain.
Dr. Michael Koren:
11:45
No, those are some compelling situations where it sounds like you're able to help people. So let's get into the pragmatic just very briefly, and then we'll cover this in the next session in more detail. You write a prescription and they go to a dispensary, so what's the next step?
Dr. Erich Schramm:
12:00
Okay, so that's a great point. You cannot prescribe a scheduled one drug. How about that? So when people ask me, I'd say, well, I recommend those products. If I'm talking to a physician, I'll say we recommend those products because you can't legally prescribe a schedule one, and we can talk about that a little bit later. But the process is that patients will be often referred to their doctor, though you don't have to have a referral from your doctor. They'll come in and there's a certification usually takes about an hour. I get the records before they come in and we talk about the conditions that they may qualify. Some are unconditional. The state has 10 unconditional qualifying conditions and then there are other conditional conditions like insomnia, anxiety and certain pain issues that require we call it the same kind or class documentation where the providers put have submit scientific evidence that these are treatable conditions.
Dr. Michael Koren:
12:58
So we're going to take our deep dive into that specific area and in our next session I want you to walk me through the actual experience of somebody that comes into your office and has to go through this process.
Narrator:
13:09
Thanks, for joining the MedEvidence podcast. To learn more, head over to MeEevidence. com or subscribe to our podcast on your favorite podcast platform.
