How To Talk About Medical Marijuana With Your Doctor

IRA FLATOW: This is Science Friday. I’m Ira Flatow. How many of you use medical marijuana, perhaps to cope with nausea from illness so you can eat or to help you sleep because you don’t want to take prescription meds with those long lists of side effects? And when you seek advice from your doctor for your aches, pains, and insomnia, do you ever ask what they know about using cannabis for treatments?

I’ve asked my doctors many times, and the usual answer is, I don’t know much about them. I should learn more. And it’s tough hearing that same answer, year after year, especially since 36 states and DC have legalized cannabis for medical use and about 5 and 1/2 million people in the US have medical marijuana cards. We asked our listeners to use our SciFri VoxPop app to tell us their experiences with using cannabis for medical purposes and if they talked to their doctor about it.

TIM: I mean, I think I could use it, but I don’t talk to my doctor about it because my doctor is the VA doctor.

MARGARITA: I don’t think there’s any shame in it. It’s pretty common these days to rely on marijuana for a number of medical issues. So yeah, I’m not really worried.

CRAIG: In 2003, I was diagnosed with HIV, and I began medication immediately. In the first three months, I lost a pound a week. So I switched over to real marijuana and began growing my own. But I was surprised that my doctor was reluctant to sign off on all the paperwork because he was afraid that he would get in trouble.

IRA FLATOW: I want to thank our listeners, Tim from Portland, Margarita from Pittsburgh, Craig from Oakland for sharing their experiences. Perhaps you have had the same experiences. Well, that’s what we’re going to be talking about. Cannabis and the medical establishment– are they on the same page yet?

Let me introduce my guest, Dr. Ziva Cooper, director of UCLA’s Cannabis Research Initiative in Los Angeles, California, Dr. Donald Abram, integrative oncologist and professor emeritus at University of California San Francisco’s Osher Center for Integrative Medicine. Welcome to Science Friday.

DONALD ABRAM: It’s good to be here.

ZIVA COOPER: Great to be here.

IRA FLATOW: Nice to have you both. Let’s get right into this. Let me ask you first. You heard our listeners. Dr. Cooper, does it sound familiar to?

ZIVA COOPER: No, absolutely. Having moved to Los Angeles fairly recently, what I hear a lot from patients– not my own patients, I’m not a physician– but patients of physicians that I know is that they’re frustrated. They’re seeking guidance from their physicians, and yet their physicians can’t really give them good information with respect to how to use cannabis and cannabis products for particular medical indications.

IRA FLATOW: And same with you, Dr. Abrams?

DONALD ABRAM: Yeah, as an oncologist, I think the most insightful study was from Ilana Braun at Harvard. She sent out a questionnaire to 400 oncologists across the country. 80% say that they discussed cannabis with their cancer patients. 78% of the time the patient initiates the conversation. Less than 50% of the oncologists said that they recommend cannabis, but only 30% said that they felt comfortable knowing anything about how to use it.

IRA FLATOW: Is that because they’re never trained in medical school or they just don’t keep up with the literature about what’s happening?

DONALD ABRAM: We live in the post-reefer madness post “just say no” era. And when I lecture about cannabis and the system in our body that contains the cannabinoid receptors and our own endogenous cannabinoids that we make, the endocannabinoids, I often would ask the audience, how many of you learned about this in medical school? And one of the advantages of Zoom lectures is I can now poll.

The CB1 receptor is the most densely populated receptor in the human brain. And in two different audiences of 40 and 70 physicians, 5% and 10% reported learning about it in medical school. So it shows you how much Reefer Madness is still with us.

IRA FLATOW: Let’s get into this, Dr. Cooper. Can you give us a quick overview for listeners who might be unfamiliar with this topic what cannabis does in the body that helps people with certain conditions like nausea, chronic pain, or whatever?

ZIVA COOPER: So this is a great question, Ira, that we’re still learning about and dovetailing on Dr. Abrams response that very few medical schools are offering the information related to how cannabis interacts with the body or the body’s own endocannabinoid system. There’s only about nine or 10 medical universities that offer a coursework with respect to understanding this. And in part, it’s because part of the science is in its infancy, and another aspect is that there are very limited FDA-approved medical uses of these constituents in the cannabis plant.

So how the cannabis constituents interact with the body to, potentially have therapeutic effects, this differs across what type of cannabis constituent we’re talking about and what the endpoint is. So these cannabis constituents can have an array of effects in the brain and the body that can potentially have therapeutic effects but may also have some adverse effects.

IRA FLATOW: And there are also strains, different strains of cannabis, and the ingredients in the plant itself. There’s CBD, THC. There’s indica for sedative sleep. There’s sativa. It’s not just a lump that people put together that they think of, oh, you’re going to take cannabis, you’re going to get high, right?

ZIVA COOPER: Exactly, and you raise an important point, Ira, in that when we talk about cannabis, we’re not talking about one thing. We’re talking about hundreds, if not millions, of different things because, in the cannabis plant, there is hundreds of chemicals that we think interact with the body. But the cannabis plant expresses these chemicals in different concentrations, and people use cannabis in many different ways. And each delivery mode of use is going to have a different effect as is the different types of chemicals in the product that they’re using.

IRA FLATOW: So Dr. Abrams, I know you’ve been a physician for decades, and you were an early adopter of recommending marijuana to patients even back during the AIDS crisis some 40 years ago. Why do you know this? And why do you recommend it? And can you recommend it when other doctors don’t?

DONALD ABRAM: Well, I did go to college in the ’60s, and I did inhale. So I have a little bit of a sense of what cannabis is and what cannabis isn’t. And I know that it really does not require a package insert, usually, for patients to understand how to benefit from using this 1,000 year old botanical that people have been using for millennia.

In fact, today, I just saw a 37-year-old woman with triple negative breast cancer. And going through her medication list in her electronic medical record, I finished, and I said, wait a minute. Didn’t you tell me that you were using cannabis? Because it’s not on the list even though we have, on the dropdown menu, medical cannabis can be added.

She said absolutely add it because it’s the only thing that helps me with my nausea. And it also allows me to sleep without, as I think one of the patients there said, the side effects of the sedatives that they wanted to prescribe. So I believe that patients really are quite capable of figuring out how to use cannabis therapeutically themselves.

IRA FLATOW: You know, I know people who work in the medical dispensaries, cannabis dispensaries, who are very knowledgeable in this from having worked there for years and knowing what mixture of this kind and that kind and how it works, who seem to know much more than the doctors do, Ziva.

ZIVA COOPER: So this is interesting because I think that, when Dr. Abrams talks about how people can use these products and they can glean information from their own experience, I think that we have to remember that what is available in dispensaries now– the industry is booming. And so when you go into a dispensary, we’re not talking about one simple plant type anymore.

We’re talking about many different products that a patient who hasn’t used cannabis or cannabis products before and they go into the dispensary, it can be quite overwhelming with respect to CBD and THC and all the other cannabinoids and the terpenes and the different chemicals that are being put into these products. And the truth is that the strength of a lot of these products, with respect to how much THC, how much of the intoxicating component are in these products, they are increasing in strength over time.

And so some people can actually have some pretty negative experiences if they are not experienced cannabis users and if they don’t know what to take. And I think that there is a conundrum here because, while the bud tenders can provide their expertise based off of what they’ve seen in their experience and some patients can feel things out for themselves over time, when we look at the scientific academic literature, there isn’t enough science to have caught up with the products.

IRA FLATOW: Why is that? That’s a good point, and I want to delve right into that. Why is there not enough science after all these years, decades, eons?

ZIVA COOPER: So I will say from the get-go that doing clinical trials is difficult to begin with. So you’re already dealing with that major obstacle. And then when you’re dealing with this plant that is federally illegal, that adds other regulatory obstacles and burdens that the researcher or the clinician has to navigate. On top of that, you have products that are available to patients that aren’t necessarily meeting the standards for the medications that we can give in a clinical trial. So we actually don’t have very many products that we can actually give patients in a rigorous trial, where, let’s say, we’re comparing that product, that THC or the CBD, to a placebo, to a sugar pill.

And lastly, one really important point is that all of this work requires funding. And so we, as researchers, work really hard to try and get funding to help support this research. So all of this is happening behind the doors of the University, where the industry is ramping up very quickly and people’s perceptions of how these products can be helpful is increasing at a very fast rate. And so, as scientists, we are really trying to scramble and keep up with the current trends so that we can be able to answer the most relevant questions from a public health perspective.

IRA FLATOW: Donald, chime in, please.

DONALD ABRAM: Well, I don’t know where to start. So with regards to the question of, why don’t the physicians tell the patients what to take? Well, I don’t know what’s available in my local dispensary. So it is a conundrum because I say go ask the bud tender what would work best for somebody with your condition.

A few years ago, I was approached by two doctor of pharmacy graduates from UCSF who asked me what I would think if they opened the dispensary. And I said, well, that would be a great idea. Well, they came back a year later and said, it costs $1 million down to open a dispensary in California. Instead, we’re going to do a concierge cannabis platform, where we’re going to discuss with patients what it is they’re trying to treat, what meds they take, and we’ll recommend to them an appropriate tincture. So that is something that I found very useful, particularly for my older cancer patients who are not very interested in visiting a dispensary.

With regards to the issue of why there’s no data, I think Dr. Cooper summarizes it quite well. It is a Schedule I substance, which the federal government thinks it has no accepted medical use and a high potential for abuse. And so you have to have many different regulations and procedures to jump through to be able to study cannabis. And the only legal source for cannabis to research has always been the National Institute on Drug Abuse, whose products are not entirely up to speed with what patients can get in the dispensaries.

IRA FLATOW: This is Science Friday from WNYC Studios. In case you’re just joining us, I’m talking with Dr. Donald Abrams and Dr. Ziva Cooper about cannabis and its use by doctors. Do you think, then, that the only way we would get enough research, the funding and the correct way of testing for the benefits or uses of cannabis would be if it’s legalized nationally?

ZIVA COOPER: So I’ll jump in here from my own personal experience in dealing with this issue, where having the federal Schedule I status is definitely a hindrance. But again, I will say it’s not the only hindrance. For example, we have CBD, now, cannabidiol. It’s a cannabis chemical. It’s a chemical in the cannabis plant. One out of seven US adults is using this chemical for some indication.

And yet it is no longer a Schedule I. But it is very hard to study simply because there are very few sources that I can get CBD from. So again, pointing to the importance of having a medication that really meets the FDA standards, so you need a medication that is free of metals, mold, pesticides. It has to be carefully produced so that it can be given to people in a clinical trial that the FDA oversees to some capacity.

So for me, the federal I status has definitely been a hindrance, but it’s not the only hindrance. We are just lacking the supply of these drugs that people are using right now to be able to study in people.

IRA FLATOW: Donald, do you think that doctors are going to catch up? I mean, cannabis laws state by state have changed so drastically over the past decade. Or so have you seen the perspectives of the medical establishment change over that time, also?

DONALD ABRAM: Well, I think if you look at surveys of physicians, physicians are highly supportive of medical cannabis. Over 2/3 in every study that’s been conducted and, for oncologists, it’s 82% in a study from about eight years ago are in favor of medical cannabis. The issue is that they feel that they don’t know enough to discuss it with their patients.

And this whole issue Dr. Cooper was talking about, the FDA and approval, the pharmaceuticalization of marijuana, I think, is incorrect. I think it’s a therapeutic botanical that’s been around for millennia. Patients should be able to access it like saw palmetto or echinacea, and it should be regulated like tobacco and alcohol.

It’s so much safer than alcohol. As a physician, over 40 years of my clinical experience, I have admitted one person to the hospital with a complication of cannabis that was dusted with PCP back in the 1970s. The number of people that I’ve admitted to the hospital with complications of alcohol, which is legal as a recreational substance, 100,000 people die in the United States every year from alcohol.

But the reason many physicians are also fearful is because it is a Schedule I substance. And especially people who have federal grants will not talk to their patients about cannabis for fear of having their federal grants retracted. I say, I have federal grants to study cannabis so that’s crazy. But we now have an administration where they’re asking young people who have used cannabis to get other jobs. So although people had high hopes, I fear that it’s not medicine. It’s the politics that needs to change.

IRA FLATOW: And we know how long that will take. Thank you both for taking time to be with us today.

DONALD ABRAM: Thanks.

ZIVA COOPER: This was great. Thank you so much for having us.

IRA FLATOW: Dr. Ziva Cooper, director for UCLA’s Cannabis Research Initiative in Los Angeles, Dr. Donald Abrams, integrative oncologist and professor emeritus at UC San Francisco’s Osher Center for Integrative Medicine.

Copyright © 2021 Science Friday Initiative. All rights reserved. Science Friday transcripts are produced on a tight deadline by 3Play Media. Fidelity to the original aired/published audio or video file might vary, and text might be updated or amended in the future. For the authoritative record of Science Friday’s programming, please visit the original aired/published recording. For terms of use and more information, visit our policies pages at http://www.sciencefriday.com/about/policies/