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The Doctor is in the House & Prescribing Cannabis

Have you talked to your Doctor about cannabis yet?  Many people simply have not! We are here to help. We had the chance to sit down with Canada’s leading Cannabis Doctor Dr. Mike Hart and we sure did learn a few things!   

Dr. Michael Hart, M.D is one the world’s most foremost experts on medical cannabis. In 2014, Dr. Hart became the first physician in London, Ontario, Canada to open a “Cannabis Clinic”. In 2016 he founded Readytogo Medical clinic, where he currently acts as the lead physician and medical director.

Here is what he had to say to Can Can Buzz 

Can we start with your relationship with cannabis, how did you and cannabis meet?

Me and cannabis met in a couple of different ways, but talking about if from a physician’s perspective, I started a family medicine practice in 2013 and started prescribing medical cannabis in 2014. The reason why I started prescribing medical cannabis was because I knew that there was a lot of people out there who were using medicines that weren’t as effective as cannabis could be for a particular ailment. Particularly a lot of people who had a lot of insomnia issues. Poor sleep was a big one. A lot of people get some response from some of the medications at first and feel like they are dependent on them. Not only are they dependent on them, but they don’t even work. They need to just take the medicine not necessarily to take them to help them sleep. A lot of patients have found cannabis to be really effective for sleep. The other thing too is chronic pain. We have some medications that are good for chronic pain, but in general we don’t have the best pain medications yet. Meaning that a lot of the effect of pain medications particularly opioids come with a lot of side effects and a lot of addictive properties. So, it gives patients another option for excellent pain control. And in addition to getting excellent pain control they are not at risk of getting addicted like they are with opioids. For sure if you use too much THC cannabis, and you are smoking it all the time, you can develop an addiction, but for most patients who are using it medicinally it is not how they are using. They are not smoking high THC cannabis all the time, they are using more CBD. They are using more one to ones, and they are not getting addicted to the medicine. Because of that, it has been really easy for me, a no brainer you could say, to continue practicing medicine the way I do and to continue using medical cannabis.

What is the typical patients journey when they come to your clinic for cannabis treatment?

A typical patient is hard to define because you have new patients that have never used any cannabis before, and sometimes you have other patients who have used cannabis before. If someone has never used cannabis before, and they are coming to me, generally they are coming to me, not all the time, but generally they are coming to me as a last resort. They still see cannabis, not as a medicine and because they don’t see it as a medicine, they see it as something that is really alternative that may or may not work. Because of that, some of those patients because of the attitude that they present with, may not in fact get all of the benefit from cannabis. No matter what study you look at, the placebo effect always has an effect, always. By telling yourself the cannabis is going to help, that can be therapeutic in and of itself just right there. That is something to keep in mind if you are a new patient and you are considering using cannabis. If you come in with the attitude of this is not going to work, but  I am just doing this so that I can say that I tried it – it is not going to work. But, if you are saying that I have researched cannabis and there a lot of other people that have used it, and were in the exact same situation as I was, and they used and they got better, why can’t I. That is the attitude that you want to have.

What type of patients don’t do well with cannabis? 

There are patients that don’t do well with cannabis. I can’t say for certain why but I have a very good reason behind it. There have been some genes that have been identified that if you have these particular genes, you could in fact be more susceptible to THC psychosis, THC hallucinations, to THC paranoia. If you are one of those people, getting some genetic testing done can in fact be beneficial for you. It will determine whether or not you are one of those people who has those particular genes, and if you are one of those people who has those particular genes, then it is a good idea to stay away from medical cannabis. 

Can people have an allergy to cannabis and is there testing for that.

An allergy to cannabis is not something that I am an expert on, and it is not something that I have really researched thus far. You can have an allergy to almost anything so I am not saying that it is not possible. I think that we should be really careful about that because there is already a stigma against cannabis. Again, I am not saying that everyone is fabricating this, some people may have an allergy to cannabis, but I think that when people say they have an allergy to cannabis, most of the time it’s probably just because they may have used a little too much THC and they may have an issue with cannabis. Some pre-conceived notion of cannabis beforehand.

What do you treat most often with cannabis? 

Sleep, chronic pain, mental health, epilepsy, autism, behavioral disorders in kids. Those are the biggest ones. 

How do you determine dose? Does the patient’s size matter?

For sure.  I don’t like patients using pure THC. I think for one, it can cause side effects like paranoia and hallucinations, but secondly, and probably more importantly, it can deter them from using the medication. Meaning, that you can have some people who have had one bad experience using cannabis in their life, and from that one bad experience they say the are never going to use it again. That person doesn’t realize that cannabis may in fact be the best medicine for them, but they used it incorrectly the first time. It is important for those people to understand that just because you have one bad experience, or even if you had several bad experiences using cannabis, it doesn’t mean that you are going to have a bad experience if you go to a doctor and they tell you how to use it medically and you get it prescribed to you. 

So when you are prescribing do you prescribe strain, or consider terpene profiles when making a prescription?

Absolutely. And that is something that I have written about before as well with CBD oil and how to choose a CBD oil. What you want to do is to use a CBD oil during the day that has terpenes that are going to be more activated, that are going to keep you focused, and are going to keep you alert. Whereas at night time, you are going to want to use a CBD oil that has some terpenes that are more sedating.  They are going to help you sleep. Just as an example – in the daytime something like pinene. Pinene, when that is used, that is the main cannabinoid and most of the time the cannabis will get labeled as a sativa. So why is it a sativa? It is because it has pinene in it and pinene is a acetylcholinesterase inhibitor. Most medicines that are used for Alzheimer’s disease are acetylcholinesterase inhibitors. So what do they do? They help preserve memory. That is exactly what pinene does. When you have pinene on board with THC you may in fact negate some of the cognitive deficits or short term memory impairments that come along with THC. That is fantastic. Again I am talking about CBD right now, if you do want to have a strain where you get the benefits from CBD but you also want to get some energy or some focus to increase your short term memory, using a strain with pinene can be really effective during the daytime. But, say at night time, you want to us some CBD and you also want to relax a little bit more, using a CBD with myrcene in it, (myrcene is a very sedative terpene) can be very very effective. 

How long before CBD begins to work?

Generally speaking, it is no different than the THC. If you are going to be vaping or smoking it, it is going to come on within seconds to minutes where if you are using it in edibles, it is going to be more like 30 minutes at least but it could 60 minutes up to 2 hours. 

How long do you have to take CBD before you realize the wellness benefit?

I don’t even know if big pharma made this up with regards to antidepressants being that it takes 4-6 weeks to kick in. It kind of sounds like they are getting you hooked and dependent upon it. It is kind of something you say. I certainly don’t say that to my patients about CBD and THC. As soon as you take it you are going to notice a difference. You should notice something right away. Over time will things get better. So, if you have a ton of inflammation, and that inflammation is causing you some pain, using CBD acutely can take away some of the inflammation. Acutely it will take away some of that pain acutely, but if you are using it constantly every single day, over time maybe you will reduce it so that inflammation never even comes on. So, you can use it acutely as in a medicine to bring things down. Say if you have a migraine,  and migraines come on right away, you need something right away. When you use cannabis it kicks in right away and it it takes it away right away. But, if you have a chronic condition, say you have chronic pain, it can take away that acute pain that you have but it can also even reduce your base line pain because it also going to reduce your overall inflammation.

Inflammatory disease is on the rise and seems to be everywhere with a lot of people contributing that to industrialization. What are your thoughts on that maybe being related to an endocannabinoid deficiency?

In terms of endocannabinoid deficiency, I have chatted about this a lot. Dr Ethan Russo is the guy that came out with that term clinical endocannabinoid deficiency. He states there are three conditions that have been associated with it, IBS, migraines and fibromyalgia. I could see that list possibly expanding in the future, and I do feel that a lot of people that use cannabis for those particular conditions do get a ton of benefit. I could see that list possibly expanding in the future because of how people have responded so well to cannabis.

What would patients need to know about cannabis contradictions with other medications. Are there any, and should they be concerned about taking cannabis and maybe other pharmaceuticals? 

In terms of cannabis and other pharmaceuticals, the biggest thing you probably want to be concerned about is over sedating someone. Cannabis as we chatted about earlier, is a medicine because it does sedate you. Sometimes you want to be sedated like we chatted about when you are using it for sleep, that is the whole point. If it didn’t make you drowsy, and didn’t sedate you, it wouldn’t be effective for sleep. That is why we are using it. I think we need to be careful about demonizing the use of THC because it can be effective for sleep – especially for patients that have PTSD who have nightmares. THC is the cannabinoid not CBD that is more effective in those situations. That is what has been shown in the literature, and that is what I have seen in my practice. 

 So no issues with taking heart medications and taking cannabis?

I would say when you are taking cannabis you want to be careful about being sedated like I said. Also too, I have seen it in the literature, yet I have never seen it in my practice, serotonin syndrome. If you use a ton of different anti-depressents for example SSRIs, and you add a ton of CBD on top of that, there could be a potential interaction. Also, it has been shown to interact with a couple different anti-electic medications and it has been shown to change some of their levels as well, so you need to be very careful about that. I did see one study that said that they worked together in terms of the anti-electic and the CBDs, so there may in fact be an additive, or maybe even a synergistic relationship between those two. I think it was specifically clonazepam was the one that I saw in the study that had its levels effected by CBD. Hopefully we will have more research about cannabis interacting with other medicines in the future. For now, that is actually one of the safest things about cannabis is that there are very few drug interactions.

Do you in your practice combine cannabis treatments with pharmaceutical treatments then?

Yes absolutely. A lot of people who use cannabis think that everything natural is healthy and good and everything that is pharmaceutical is bad. I think we need to get away from that. We just want to use the most effective and safest medication whatever that is. If that is a pharmaceutical fine, if it is something natural then that is great too. What you want to do is you want to use the safest and most effective medication. I will say for the most part natural medications are safer, and that is why a lot of people are gravitating toward them these days. If you are in pain or you have some type of disease, and there is a pharmaceutical out there that can help you, and the risks outweigh the benefits, even if there are side effects, and the risks outweigh the benefits then I think it is good decision to take that. If you can take something and the benefits outweigh the risk I think it is good decision for you. 

How do doctors learn about cannabis treatments today?

Most of the ways that physicians learn is through self study – I think that is the biggest thing. There are also conferences that people go to, there is on line learning, and there are webinars. The one thing that we don’t have is it wasn’t built into the medical curriculum when I went to medical school, and I haven’t heard too much from other physicians or from other medical students that they have now built it in. Hopefully that will change in the near future and that way physicians will be less reluctant to prescribing medical cannabis. 

Are you doing anything specifically to address the doctor education around cannabis itself?

Specifically, I just try to use my social media platforms which is something that everyone can easily access. That is one of the biggest things I do. I do interviews like this, I do podcasts. I am just trying to leverage media and social media in general as much as I can. Whenever I am asked to speak at conferences -which I have done fairly recently I did one in Barbados- I will absolutely take advantage of those opportunities to do what I can there.

So what advice would you give doctors before prescribing cannabis?

I would say to do as much research as you can and I would say before prescribing it, think about why you are prescribing it, and think about is this the best medicine for this particular patient. In many instances it will be, and in some instances it may not be. If you had a patient that had a really bad experience with cannabis in the past, and no matter what they have done, and they have tried several different ways, high CBD low THC, and high THC low CBD all different ways, maybe they are not a good candidate for cannabis. But, if you have had other patients that have responded really well, I think that by supporting them, you can maybe not only treat their ailment, you can prevent them from using other medications that could potentially be harmful.

Does the source of CBD hemp vs cannabis matter?

So CBD is CBD – there is no difference in the molecule. When you talk about sourcing CBD from hemp vs sourcing cannabis, if you source it from hemp (so hemp is considered to be less than  0.3% THC) , you know that you are going to get something that is going to be extremely low in THC which a lot of people are looking for, and lot of people have found to be beneficial. Are you going to get all of the cannabinoids and terpenes? That is the big issue. You can get these whole spectrum hemp products, but a lot of people say that they are not as effective as a lot of full spectrum cannabis products. Why is that? Some people believe that it is because a lot of the products that are high CBD oils are from cannabis. They are never generally below 0.3% like it is with hemp. It is usually more like between 1-2% meaning that if you have 20mg of CBD, most of the products are going to have 1-2 mg of THC. There are a lot of people who believe that just that tiny bit amount of THC that you are getting when you are using cannabis products vs. hemp products, is really helping patients, and their symptoms. They think that the THC and the CBD are working synergistically together even though again, it is very small amounts where as when you have hemp products that is just less than .3% THC there is really not enough THC in there to get to benefit from the entourage effect.

Does organic matter?

I am someone who eats organic food, I eat organic everything, so to me organic always matters. I believe that we should try to make organic products but at the same time too, a lot of the LPs (licensed producers in Canada) they have to indicate whether or not a certain product has been irradiated, and I think that is really important. I did see one study that showed when you do irradiate the product, you can in fact lose some of the terpenes. Just something to keep in mind.

What is the number one myth of misconception about cannabis that you want to see squashed?

The number one myth that I would like to see squashed is that cannabis makes you lazy. Cannabis doesn’t make you lazy just being a lazy person makes you lazy.  I think that people who use cannabis and say that cannabis makes you lazy, they were like that before. They would have been like that with or without the pot. I think that we need to take away that blame because cannabis is not the thing that is making you lazy. That is just a personal decision that you have made, and people don’t like hearing that because the responsibility is placed on is them and not on the cannabis, and that is the message that I would like to send to people.

Is there one thing that you would like to see changed in the Canadian regulations?

There is no need for someone to have to try gabapentin and opioids before they can try cannabis. Cannabis should be a first line treatment for many things. So that is the thing that I would like to see changed.  Cannabis is a first line treatment not a last line treatment like it is in most guidelines.

What is the most interesting thing about cannabis as a medicine that you have learned in the last 5 years?

I am always surprised at different things that come up in my office. A lot of people will tell me that they start using cannabis say for chronic pain, but I can’t imagine how many people once they have used it for chronic pain, tell me that even though it helps my pain you wouldn’t believe what it has done for my diabetes. And, that probably again is one of the biggest things. A lot of cannabis users – it has been shown (there have been 9 different studies) now that have associated cannabis use with lower BMI. So, cannabis users in general are leaner than non-cannabis users. Again, 9 different studies have shown that. What I have seen in my practice is a lot of people have better control over their blood sugars. They sometimes even drop their diabetes medication. A lot of people are losing weight, so that’s probably the biggest surprise that I have seen, and obviously it is a very pleasant surprise for people.

Is CBD psychoactive?

CBD is psychoactive, but so is caffeine. Just because CBD  is psychoactive doesn’t mean that it makes you high or is a dirty word. Psychoactive just means that it is going to change your perceptions on how you feel. If I give you a ton of caffeine you are definitely going to feel that. If I give you some CBD you are definitely going to feel it – I mean I shouldn’t say definitely because some people in some instances don’t feel a ton from it – but most people when they use CBD do feel something from it, and that is why it is psychoactive. Just because something is psychoactive doesn’t mean that it is intoxicating.

Yes, you will definitely feel CBD in fact a lot of people feel it and go “whoa what was that”.

And the thing is too just on that note, that is the whole point. People come to me because they want to feel different. If you do nothing you are going to stay the same way you are now.

You should be much more afraid of staying the same way you are now then of change.

Dr. Mike Hart

If you stay the same way you are now, you are still going to be in pain, your are still not going to sleep, you are still going to miserable. It is a bad decision to stay where you are. You need to have something to change that. By using something psychoactive you are going to get that change. You should be asking for the change. You shouldn’t be rejecting change, or be afraid of the change, you should actually be asking for the change. I want to change. I want to get better. I don’t want to stay this way anymore. You should be afraid of staying where you are.

I have to ask this one because it is everywhere, if vaping cannabis safe?

Absolutely it is safe. We chatted earlier a little bit about the vaping scare recently. It is not people using good medical grade cannabis in a trusted medical vaporizing device. Vaporizing is an excellent way to use the medicine. It eliminates all the combustion, obviously. There has been studies that have shown if you vaporize over smoke, you are less likely to contract an upper respiratory tract infection or get the common cold.

How does somebody find a canna-doctor?

You know the best way would be to go to Google and to just search for your local cannabis doctor. I think that most larger centres now will probably have at least one physician, so it shouldn’t be too difficult to find a physician on line. 

Dr. Mike Hart is also the co-author of the Amazon Best Seller “Friendly Fire”: Why Vets Are Lighting Up and Ditching Pills to Treat PTSD. His outspoken stance has landed him on a variety of media outlets, including an appearance on the Joe Rogan Experience Podcast.  You can find out more about Dr. Hart by visiting his website: mikehartmd.com

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