In this episode of What the Health, we explore the growing use of cannabis for medicinal purposes, especially among mature adults. John Salak welcomes guest, Dr. Leigh Vinocur from the Society of Cannabis Clinicians, to discuss the benefits and risks of cannabis use, the importance of professional guidance and the complexities of dosing and drug interactions. Dr. Vinocur also delves into the differences between recreational and medical cannabis, highlighting the need for personalized treatment and the potential impacts on older adults with chronic conditions. Tune in to gain insights on how to effectively and safely approach medicinal cannabis use.

00:00 Introduction to Cannabis as a Wonder Drug

01:17 The Risks of Self-Medicating with Cannabis

01:51 Expert Insights with Dr. Leigh Vinocur

02:59 Public Perception and Legalization Impact

04:04 Medical vs. Recreational Cannabis

05:29 Challenges in Cannabis Use and Monitoring

12:55 Cannabis Use Among Mature Adults

20:22 Understanding the Endocannabinoid System

22:49 Therapeutic Uses of Cannabis

25:26 Navigating Medicinal Cannabis

30:07 Conclusion and Final Thoughts

Don't miss an episode of What The Health. Subscribe now on your favorite podcast app to get the latest news and insights on health and wellness issues delivered right to your device.

Connect with WellWell USA:

• Website: https://wellwellusa.com/ 
• Join WellWell-Being: https://wellwellusa.com/register/ 
• All Things WellWell USA: https://linkin.bio/wellwellusa

Learn More about the Society of Cannabis Clinicians:

• Website: https://www.cannabisclinicians.org/ 

Connect with Dr. Legh Vinocur:

• Website: https://drleigh.com/ 
• LinkedIn: https://www.linkedin.com/in/leigh-vinocur-md-ms-facep-75305410/

Now cannabis products have been used and licensed for medicinal purposes for years to relieve anxiety and pain, ease nausea, and improve sleep among other applications. In fact, a sizable percentage of mature adults have increasingly turned to these products for help through both licensed medicinal centers and recreational cannabis outlets.

The legalization of cannabis, however, has encouraged users to skip professional guidance and self-medicate. This is always risky, but may present a particular challenge for mature adults who may be on other medications that may not mix well with the type or amount of recreational cannabis they're consuming.

Our upcoming guest is here to clear the air on cannabis use for mature adults effectively, laying out how to avoid risks and how to more effectively deal with cannabis products.

All right, we are at the best part of our podcast as we always say is when we get to dive into subjects with an expert and authority, someone who knows a heck of a lot more about the subjects that are important to you guys than we do and today we're talking about medical cannabis and particularly its applications, uses, considerations for mature adults, and we can't have a better guest to speak about that than Dr. Leigh Vinocur. This is with the Society of Cannabis Clinicians. So, Dr. Leigh, thank you very much for joining us on What the Health.

[00:02:25] John Salak: All right. And just so everyone knows, Dr. Leigh is in Maryland, near Baltimore, so you can't see it, but I understand Dr. Leigh has like 15 acres of woodlands that are filled with bears and tigers and deer and other animals.

So, if anything comes in during our broadcast, you can, you'll understand that. Cannabis, it is a wide open subject both for recreational and medicinal uses. Given deregulation use all sorts of things that the market has grown What are we looking at now?

[00:03:04] Guest: Well, I think that there is this perception now as acceptance and some of the stigma has gone away. And some rightly so, when you look at other substances like alcohol and things. Tobacco which probably causes more deaths and alcohol too than cannabis. But I think there is this perception that it's completely safe.

And that's not true of any medicine or any substance, right? There's always a risk benefit. I mean, I think it was the 16th century Swiss physician, Paris Celsus, who said the dose makes the poison. So, you can take in too much water and it can kill you. So, I think. That is a perception that as certainly as a a physician who does recommend medical cannabis and I've seen the benefits.

I take it seriously and treat it like a medication. So there's nothing that's 100 percent safe.

[00:04:10] Guest: Now we call recreational adult use, most states before that was passed that legalization. They started with medical programs, my same state in Maryland included. And I think there was a Pew research survey that said right now, Americans largely favor the legalization 57 percent said it should be legal for both medical and recreational, but I don't know that there is that distinction. Certainly as a physician, I have that distinction. And think about it too, as I recommend it to patients. And I do worry in a lot of these states that once legalization came about that people, might start to self medicate and not talk to a medical professional before trying to use cannabis in that way.

I mean, there are certainly people that just use it as a recreation. Is it more dangerous than alcohol? It's got different issues when you look at it comparing to alcohol.

[00:05:29] Guest: I think if we look to Colorado, which was one of the first states, they passed it in 2012 the market opened in 2014, they did see a slight decrease in their medical registration because, there's a cost to medical registration and follow up with physicians and such. And then the medication costs something too.

So I think there's went down from like. back then 110 to like 111,000 registered medical patients to 81, 000 personally as a physician. Then I know the patients I'm seeing, I used to weed them out when they started in Maryland to see, were they just trying to get a medical license? Because they wanted to use cannabis recreationally, every young person that worked in one of our medical dispensaries had, some kind of medical problem and somehow got a license.

I w I was very picky in who I recommended to get a license. And I mostly get referrals now from physicians and most of my patients are ill and need it. But We monitor in this state because there are registered patients and every state knows who's medically registered. But certainly there are a group of patients that self medicate.

And as a physician, that's a little worrisome for me. I think there was a state study that came out that said 54 percent of customers that come into dispensaries will ask the dispensary staff medical questions on selecting products, how to use it while only 3 percent of those patients had talked to their physician and got input from medical professional.

So I, I think that's worrisome. but part of it is the onus on us as medical physicians. We don't do training that much in medical cannabis, even to this day. An older study from the American Association of Medical Colleges said only nine to 10 percent of colleges are teaching the endocannabinoid system.

I'm teaching about cannabis and two thirds of medical students were saying they felt unprepared to deal with patients when they come out. So we need to do a lot more education within the medical community so that they understand therapeutic medical cannabis science and the therapeutics that can provide.

Am I going to some guy in Washington Square Park and saying, give me a couple of joints? I know that I'm not trying to make light of that, but I don't think people, if they haven't been involved in that really understand the process.

adult use and medical. But at the time, you go, you register, you find a provider that's registered. And, sometimes primary care providers will recommend and certify patients if they're familiar with it. But a lot of them will say, you have to go to the website, find a provider.

The Society for Cannabis Clinicians has lists in each state of providers that are doing it. And then you go and apply for a card and register. And in Maryland, we did it a little bit different. So there were already all these medical dispensaries that had been certified and, under some strict stringent rules about dosing and packaging, which are really critical and important if you're going to use it therapeutically.

And then when we passed, and it was a referendum that The public voted on so the public wanted it for adult use rather than scramble like some states have had, just these adult use recreational dispensaries, all the dispensaries suddenly could sell to, regular consumers for adult use.

However, precedents still took for the medical patients. There were certain times that only medical patients could be served in dispensaries, different lines and things, but, as a physician, too, I do worry that perhaps the products being made, especially dispensaries that have three verticals that have growing and processing and a dispensary that they're going to start to cater more for, To adult use and using cannabis for recreation, because, I'm a, firm believer in, the dose makes the poison, right? We're seeing higher and higher percentages of THC and cannabis and such, and not some of the other ingredients that can kind of temporize like cannabidiol, some of the mitigate, some of the intoxicating effects and some of the other physiologic effects.

[00:11:00] Guest: You bring up a great point that is an issue sort of around the country. Maryland did have a law with all the dispensaries and there's no distinction now between them. I think they're opening a few more licenses, but the dispensaries that were approved during medical, they do have to have a clinical advisor on staff, and usually that is a pharmacist who has some understanding and training in medical cannabis science and therapeutics.

After all, the University of Maryland School of Pharmacy, where I got my master's degree and I was in the inaugural class, one of the first in the country to have an actual master's in medical cannabis science and therapeutics. So in Maryland, I think we have a little bit more safety measures there because these are the same dispensary.

So if somebody was coming in and wanted to purchase it but hadn't seen a doctor and been approved, they could ask to talk to the clinical advisor there at the, and answer some of the questions for themselves. Again adult use patients can't even get as high. Levels of THC as perhaps medical patients can, and there are some differences in what the products are that they can buy and the amount that they can buy, because medical cannabis patients that are registered that might need a certain amount for the month, they can have higher quantities, but.

In our state, I'm proud to say that all the dispensaries have to have a lot of times they're farm D's or pharmacists, but you're right. And I wouldn't expect to see it anytime soon in a Walgreens yet. This whole idea of rescheduling, descheduling that happened with the last administration, I think was an executive order, which as we know, those can change rapidly.

So I'm not sure what's going to happen now with all of that.

[00:13:10] Guest: yeah, you raise a good point again. It is increasing in people 65 and older. We know that. I think there was one study that said from 2009. it had tripled from 11 percent to 32 percent by 2019. so within that decade and now, I think the number of older Americans is like tripled. The last statistic I saw was maybe from 2021, 35 percent noted that with a demographic between 60 and 64, almost half reporting cannabis use, so it kind of has taken off.

That generation might have been the generation of you. Using it in college, but it is different, I like to tell people it's not your grandmother's cannabis, your baby boomer grandmother's cannabis, right? Because we're seeing higher levels of THC in it. So people do have to be aware .

But the point is, they may be more saying, Okay, this is the grass, this is the marijuana, this is the Mary Jane that I remember, and it's going to be fine. But you're saying it's significantly different.

Just the highest levels, what does it mean in practical terms, the differences?

[00:14:46] John Salak: Mm

I mean, there are certain things, depending on and whatever, where you might. Like to use a little different ratios. And obviously either a young person or anyone just using it the way they say is a drink after work, alcohol, is fine but they have to be aware of that and physicians and family members should be aware of, overuse and the incidence of cannabis use disorder, you know, we will see substance use go up. Is it more dangerous than alcohol? I don't know. I, I'm not a drinker. And now. Coming to light is all this. You shouldn't even have one drink a day. They used to talk about moderate alcohol good for your health. Now they're saying one drink a day increases your risk for cancer. I'm a cannabis physician. I does have some great therapeutic and beneficial effects, but you really should be under the guidance of the physician and monitoring it and things like that.

[00:16:42] Guest: yeah, as I said, it is one of the fastest growing demographics as we cited, supposedly 35 percent of people over 65 were using it, turning to it for issues like chronic pain. 74 percent of older Americans complain of chronic pain. That's probably the number one reason people look to cannabis, especially in face of the opioid crisis and the worry about that and addiction, which as a physician, unwittingly, we were all part of that because we were told short term use of opiates are not addictive, but that's not in fact true. And I would hate to see with the new types of cannabis coming out, having this being led down the same road. So we do have to be careful, but there are considerations.

I think I wrote an article. Somebody asked that question for green state about what seniors taking cannabis and what are the considerations? And number one, 70 percent of seniors today are mature adults, probably have at least two or more chronic illnesses. Unfortunately, we are a society of chronic illnesses, right?

And so, almost 40 percent of them sometimes are on five or more prescriptions. So that polypharmacy, that's an issue when you add any other medication and cannabis is like that, you know, Oral, ingestion of cannabis tinctures or gummies, because it goes through the liver, our P4 50 system.

And when it's metabolized there, we only have so much enzyme at a time to metabolize. So if you're taking a big, Bunch of other drugs with it. Either you're gonna get subtherapeutic levels of some of those drugs or super therapeutic above. So, drug interactions are a big issue that, I think mature adults need to think about.

And one of the reasons why, nothing's a hundred percent safe. The other thing that happens as we age, there's a lot of changes that occur in our body that are related to metabolism. For example, usually our stomach acid level decreases. So the oral absorption of any medicine is affected that way.

We lose lean body mass, which has a lot of water in it as we age and muscle mass. And that affects the distribution of any drug cannabis included in the body. So we start to metabolize it differently. We have decreased blood flow to our liver and our kidney. And, What happens then is we become less efficient at metabolizing the drug and excreting it.

And then of course, any drug that has intoxicating effects as we get older, right? There could be over intoxication with it. I'm very careful when I start, older. And I have to tell you, I've seen patients come to me in their 80s, with their family member and, I tell them they can only try it if someone's going to stay in the house with them at night.

So they're not getting up so much with somebody there if they get up because over intoxication can lead to falls and falls and trauma injury is one of the leading causes of death. in people over 65. So, I always tell there's this adage with medical cannabis physicians start low, very very low doses, and then slowly increase as you see it. And it is a very individualized, personalized type of medication.

[00:20:16] Guest: Well, pain's probably, as the number one reason that people turn to it, but it also depends on the chronic illness. I don't know if your listeners understand, but, and this is how I started to get interested in cannabis. Way back before 2008 I was on faculty at the University of Maryland and a colleague was showing me a paper of his that just got and he had said the title of the paper is the level of endocannabinoids in stressed rats.

And I was like, what? Wait a minute. What were endocannabinoids? They just floored me. I said, you mean like endorphins? We have internal cannabinoids and we do. And that's part of the problem. I never heard that word through medical school training. I've been practicing almost 20 years. by now, and I hadn't even been reading a lot about it. Now some of it is we didn't discover the endocannabinoid system until like the late eighties and early nineties. Not to date myself, I had already graduated medical school then, but I was in training, but I was just floored. So, We have this endogenous system in our body and this is why we respond to it.

Phyto cannabinoids, the ones that come from plants because we have this system called the endo cannabinoid system and it is a mechanism that is, it's so ingrained in our evolution that like sea squirts have cannabinoid receptors, right? Anything with, a nervous, system has this system in place to sort of dampen and maintain homeostasis within our nervous system and it's in our immune cells.

It's in our brain. It's everywhere. So we have these receptors and our own body makes these internal cannabinoids. And we know in certain situations in the body after seizures, things like that, and our body makes on demand, these cannabinoids to help dampen the immune system, do these things. So that is why we respond to external cannabinoids. Famous, researcher Ethan Russo, he sort of coined this frame endocannabinoid deficiency syndrome and he looked at conditions that are very hard to treat, that might be a dysfunction of our endocannabinoid system.

Things like fibromyalgia, which is that chronic pain syndrome, autism in children and people aren't with these conditions, they do respond to cannabinoids. So that's why there, there is this judicious therapeutic use in certain conditions. So people that have MS, for example, sometimes turn to cannabis if we're talking about different reasons because of the spasticity, the pain the pain, because the cannabinoids have anti inflammatory effects. They have antioxidants effects, analgesic effects, because it interacts with our internal cannabinoid receptors that are all through the brain, the peripheral nervous system our GI tract, all these things.

I think an article I just published, Someone asked me about ulcerative colitis and cannabis, which is kind of like this autoimmune disease. It can dampen the immune response. So there's a whole host of medical problems that people turn to that are, we're still don't have a great grasp on managing them.

[00:23:47] Guest: DeMarzo is another researcher who said it helps us sleep, eat, forget. It can stimulate your appetite. That's why people used to take cannabis and they developed a synthetic. molecule called Maranol, was the brand name, which by the way, is a schedule three and it is THC.

It's just like an isomer, a backwards molecule that they had tried to use for years to get people to eat. But, chemotherapy damaged nerve pain, which is very hard to deal with, whether it's diabetes, chemotherapy, it's been shown to be effective in seizures. GW Pharmaceuticals in England developed the first ever, that was approved here in the U. S. It's FDA approved Epidiolex which is a CBD cannabidiol product, not a synthetic. It comes from the plant, to treat resistant seizures in very specific, genetic conditions.

But we know cannabidiol is very effective. It dampens the nervous system. So when you have a seizure, you have just this continuous flow of the, neurons firing, firing, firing. And in the normal body, when things are functioning, we make our own endocannabinoids that actually go backwards and dampen that nerve expression. But sometimes it doesn't work enough. So taking something like cannabidiol also has anticonvulsant properties by dampening that constant, signaling of the nerves from things like seizures.

[00:25:36] Guest: Well, I mean, I think being guided by a physician who's knowledgeable in it, and there are a lot of primary care docs that aren't comfortable, I think more and more are coming to believe there are, there's more and more research out there that it is useful conditions. The biggest problem with research, one, it's federally illegal, so that, Creating problem with research and two, there's no standardization anymore.

When you test a certain drug from one state to the other, because it's legal state to state, it's a patchwork of standardization and that makes it a problem too. I mean, there was a JAMA study that came out not long ago saying, cancer patients. did well with cannabis and used less opioids, but there was no dose recommendation.

There was no ratio of cannabinoids in there because there's no standard to it. And that's the biggest problem standing in the way of medicinal cannabis. And it all is because of the federal illegality of it. So there's no national standards like there are for Pharmaceuticals over the counter drugs, but, I think having somebody guide you and start with the dosing and it's complicated to, I prefer tinctures because control the dosing better, but it requires calculations of milligrams per ml, even the way the tincture bottles come, they give the full dose of cannabis in the bottle and you have to figure out how many milligrams per ml it is.

So I do those calculations with my patients and then they try it and I tell them, look, you have to keep a log so that when we talk again, you can tell me this is how many milligrams per ml, this is how it helped or it didn't help. And then we can go up. Same thing with gummies, you might get a package that tells you the whole dose of THC in there, but it's like six gummies and you have to divide it into pieces and they have to be equal.

And so these are the things that are standing a little bit in the way and why you need a good provider who understands it if you want medicinal cannabis.

[00:27:49] Guest: Right. They probably don't get a full medical history. They just, you know, the person's just asking him, I get migraines. What should I use kind of thing, but yeah.

[00:28:14] Guest: You can, you certainly can. Some primary cares might be, discouraging. I would hope that a lot of them, I, spend a lot of time going around the state talking at grand round conferences about medical cannabis, that they're open to it, but they don't feel comfortable. Recommending it or certifying somebody for it.

So, some state agency that is controlling licensing for dispensaries if they separate them or dispensaries and sometimes they are controlling the licensing for the medical cards that patients get so you can ask them if they have a list of physicians.

[00:28:56] Guest: No, never. And , it is expensive because of that. That's why I'm very cognizant of that. Even though I spend sometimes over an hour with my patients, it's not, I don't. Charged them for the time like that. You just couldn't because I know they're gonna have to buy the medication and it's expensive.

Look, we all know, now after what's happening. And I can tell you as a physician, insurance for regular medicines is, an issue. If you want to take the brand name thyroid nobody's going to let you have it. And we know, that what's interesting is, generic meds can have a 10 percent difference in efficacy. especially with like hormones, where tinkering a little bit matters. Insurance companies are fighting tooth and nail to cover any meds. So, cannabis, federally illegal, not even a question today.

[00:29:48] Guest: I don't know, as we said, the idea of rescheduling or de scheduling that was brought up last year was really related, I think, to an executive order, which I'm sure will be turned over. Nobody's been talking about it yet, but we're going to have some interesting things happening with hSS anyway. So,

[00:30:30] Guest: Yes, I, totally believe that.

[00:30:40] Guest: Well, We talked about that. No medicine is completely safe, right? 100 percent safe. So, but I don't know, misconception or challenge for mature adults because it is a very personalized therapy. One of the biggest issue I have is you have to have patience. You have to have someone to walk through with you to evaluate the types of products, the combination of cannabinoids, We want something maybe in the daytime that's more CBD dominant because it has less of the intoxicating effects and maybe at night, if sleep is an issue, you can change the ratios So the ratios of the cannabinoids, what cannabinoids? It can be difficult for anyone, especially maybe mature adults. There's no one size pill fits all the way that you take a pill. This is the dose. The FDA says, and this is it. So correct dosing makes it challenging and you really need a partner to go through it with you so that you can maintain consistency. And that's the other thing.

If you're using something, it's a plant, not a factory, right? I mean, all medicine started as plant medicine. If you think of it, foxglove became digitalis, willow bark was aspirin. Why did it switch to synthetics and whatever? Because there's more Standardization. You can be precise. And I have people tell me they'll use one product.

And even though it's supposedly the same product, The next time, maybe the effects are not exactly that good because these are plants, the littlest thing. can change how it's grown. The light, maybe something happened to one of the lights one day and, and the plant before they processed it, didn't have quite this mixture of cannabinoids.

And that, makes it challenging to plant medicine is challenging and cannabis has over 500 different compounds. But there is this thing in cannabis, we call the entourage effect where all the different cannabinoids and terpenes kind of work in synergistically to give that more natural, and satisfying effect of it medically, but it's all those little nuances that make it a challenge as a medicine too.

[00:33:28] Guest: Yes. And thank you for having me. I appreciate it.

Signing up is easy and free. Just visit us at wellwellusa.com go to Milton's discounts on the top menu bar and the signup form will appear. Signing up will take just seconds, but the benefits can last for years. So cannabis has undeniable medicinal benefits for mature adults. This, however, doesn't mean that consumption doesn't present risks and concerns for all adults, but particularly older ones.

It is important, for example, to seek qualified guidance when consuming cannabis products for medicinal purposes. This goes beyond simply relying on the in-house pharmaceutical expert that. May be available at a recreational cannabis outlet. And remember, not all cannabis products or their applications are the same, meaning they can affect people differently and if products differ, so do people and their existing medical conditions, which means users can react differently to the same product.

Finally, it may be fine to use a recreational outlet for cannabis, but for medicinal purposes, it is important to find outlets that can address your specific needs. Well, that's it for this issue of what the health. We'd like to thank Dr. Leigh Vinocur of the Society of Cannabis Clinicians for her insights and guidance.

If you'd like to learn more about cannabis use and Dr. Vinegar's work, you can visit the Society's website at cannabisclinicians.org, or you can visit Dr Vinocur's personal website at drleigh.com. That's D-R-L-E-I-G-H.com. Finally, thanks again for listening and we hope you'll join us again soon on what the Health.