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As the ecosystem of cannabis professionals grows often doctors are left out of the conversation. Many doctors are concerned about their reputation if they recommend cannabis and many don’t yet understand what conditions can help or how to prescribe it. That is why I’ve asked Dr. Gregory Smith on to CannaInsider today to help us understand how physicians are beginning to grapple with cannabis in traditional medicine practices. Dr. Smith welcome to CannaInsider.
Dr. Smith: Oh yeah thank you Matt. I’m glad to be here.
Matthew: To give us a sense of geography can you tell us where you are in the world today?
Dr. Smith: I am at the beach in St. Pete Beach, Florida.
Matthew: Oh great.
Dr. Smith: 80 degrees and sunny here.
Matthew: Now tell us a little bit about your background and how you got into cannabis?
Dr. Smith: Yeah. I’ve been a physician for about thirty years. Six of those years in the United States Army and about fifteen years ago when I was a California physician I took the course on how to prescribe medical marijuana and I’ve been using it as part of my practice since that time. I do primary care practice, family practice, and some public health. Several years on and off in public health as well.
Matthew: Okay and recently you’ve written a book about cannabis can you tell us about that?
Dr. Smith: Yes. So it’s called “Medical Cannabis, Basic Science, and Clinical Applications” and during these years I’ve been practicing there has been no textbook out there, no science based textbook at all to help a doctor give him a companion manual to go to as different conditions arise that may respond to cannabis. So over the years I gradually transitioned so now I’m full time in medical cannabis and about two and a half, three years I started writing a textbook working closely with a very prestigious Boston publisher and to make sure it’s a peer reviewed, high quality text and it just came out about a month ago.
Matthew: Okay. Do you see doctors hesitant to recommend cannabis to patients? Is there a stigma?
Dr. Smith: Those are two questions. That first one I’ll give you a couple numbers here in the states like Colorado and California where they’ve had medical cannabis for decades; two decades only 10% have ever prescribed it once and 1 1/2% have prescribed it with any regularity. So that gives you some idea of what a minority of the population. It’s something like 700 doctors in the whole country have ever prescribed medical cannabis out of about 700,000; so one in a thousand. So yes I would say there is a problem with doctors prescribing it and the stigma is half the problem.
Matthew: Yes. Now I notice when I go to the doctor if I bring up certain topics they kind of roll their eyes like uh oh we’ve got an internet doctor here in the building. He’s got just enough information to be dangerous but do doctors have the information in general to help their patients with cannabis? I mean is that changing? Where do you see it prescribed where it is prescribed that 1% of the time?
Dr. Smith: Oh okay so that goes to; it’s being prescribed 94% of the time in states like Colorado, Washington, California. 90% of the time is for chronic pain condition which is a very huge distribution. However it’s very easy to get a recommendation letter with an issue like chronic pain where there’s not a lot of objective things to go after like there is with multiple sclerosis, PTSD; there’s some very objective findings as to just saying you have chronic back pain. So traditionally or historically it’s been 94%. Also there is a stigma because I think a certain significant proportion of the patients over these past twenty years in California and Colorado were using the medical cannabis system to bypass prohibition against recreational use of marijuana. So that’s what was going on in California for many, many years and Colorado until recently so there is that always in the back of your mind that this is a drug seeker trying to get marijuana and not for a valid medical reason and that is how most of the medical community doctors and doctors groups have looked at medical marijuana until the last couple years.
Matthew: So let’s say there is a doctor listening and they’re curious or would like to begin incorporating cannabis into their practice. What’s a way they can start to integrate cannabis into their practice for their patients as one tool on their tool belt?
Dr. Smith: Okay without plugging my book alone; a book whose title I mentioned earlier; a medical cannabis book there is a wonderful treatest which was put out about three or four years ago by the Canadian Health System which is a couple hundred page summary. It’s a little obscure the way they cite the science. It’s not so easy to use in a day to day practice for a doctor and whereas my book is specifically targeted to make it easy for day to day use for different diagnoses and there is a JAMA Summary Journal that came out about July of last year that also gave some pretty good insight to what conditions; to gain insight into what conditions it can be used for effectively.
The only thing I can think of that can tell you how a doctor can use it for dosing, for managing a patient month to month and year to year is the book I wrote. I can’t think of another without being self-aggrandizing; I can’t think of another document that tells doctors how do I start the patient, how do I follow them, what tests do I do, when do I stop it, when do I increase the dose? So that has been missing.
Matthew: Now you mentioned that you were in the Army. Were you in the Army as a physician?
Dr. Smith: Correct yeah. It was a scholarship program where they paid for medical school and I did six years active duty and got out as a major and they shot at me too many times. I thought it was time to get out.
Matthew: Did you see any use of cannabis for PTSD?
Dr. Smith: Not in the slightest. In fact we could probably use our medical license to bring up the subject in the exam room with a patient. I could probably lose my medical license.
Matthew: Wow. That’s harsh. So let’s talk a little bit about a patient kind of bringing up the subject of cannabis with their doctor. What’s a way to do that so you maximize your chances of the doctor being open to it?
Dr. Smith: Very good question. I would say for your symptom or your diagnosis. You just have a symptom that you’re wondering if it may be helpful and you do your Google search and you print that up and you bring it in to the doctor and they especially if it’s got some interesting information because there’s not much real good research. There’s going to be anecdotal information. It’s going to be non clinical trial kind of information. People with case studies or some doctor that observed this or that after you used cannabis so but bring that into the doctor so that he knows there’s some foundation and you’re not just trying to get cannabis to get high and then if you have an open minded doc he’ll go out there and research it and get back with you. He may just refer you to a website and there are two websites which I hope you bring up eventually. Where to find a doctor that is already educated and willing to listen to your needs for medical cannabis.
Matthew: Where do you see cannabis having the best response to certain symptoms or conditions?
Dr. Smith: Another good question. I’d say it has moderate effects with pain. The best evidence has been showing it helps you cut your opioid use so these people; several million in this country that are on chronic, daily opioid use. You can cut your opioid use dramatically and maybe 10% can actually stop opioids altogether and substitute it just with cannabis. So pain is a big one and along those lines then we move to arthritis and inflammatory processes. Not acute pain or acute injury but chronic pain from arthritis, chronic inflammation from an inflammatory bowel disease. It’s very, very effective in these chronic, inflammatory, painful, achy, stiff conditions that the older population tend to have.
Matthew: Yes and I witnessed that in Colorado with the baby-boomers starting to age and getting different creams and stuff for arthritis and different tinctures and similar things to help them with inflammatory or autoimmune issues. Do you think as there’s more cannabis medications available such as oils and so forth that are maybe in tablet form or something like that doctors will feel more comfortable prescribing it?
Dr. Smith: That is a huge observation Matt and so other than the stigma the other half of the reason why doctors are not prescribing it is because it’s unlike any other medication. There’s nothing else in our armamentarium; a doctors bag where it’s a plant and then you send them to a dispensary and they go home and have to smoke or vaporize or eat a cookie there are no water soluble versions in a pill and there’s no injections of it. So 99% of all medicines are water soluble and you can make a pill or an injection but the cannabis is oil based and fat soluble and you can’t make a pill or a reasonable injection yet. So it’s a different substance. There’s very little advice to them on dosing and you can get high. You can go have a car accident if you give the patient too much. So those are barriers. Other than stigma there are these barriers and they are changing quickly with the advent of biosynthetic cannabinoids.
Matthew: You are involved with Marijuana Doctors is that site where people who want to connect with a physician that’s familiar with cannabis can find those doctors?
Dr. Smith: Yeah Matt just so you know my involvement is only to help those guys grow. I have absolutely no business connection or paperwork connection other than I love what they do.
Dr. Smith: And the gentleman behind it is a very bright young man probably in his thirties who has produced a wonderful website. So I’m helping him get specialists. He has a real need for specialists. 95% I’m going to guess that number of the docs in the country the 700 doctors are family practitioners or general practitioners who and generally much older doctors who are willing to prescribe medical cannabis and what we need is neurologists, pediatricians, oncologists working at medical centers willing to take a look at this as a medication. So I have been giving him free advice and recommendations on how to build up his specialist database.
Matthew: Let’s go over a hypothetical treatment that involves cannabis. Could you just maybe highlight one that you see used often so we can just kind of get a sense of what that would look like?
Dr. Smith: Yeah. Let’s go with Alzheimer’s one of my particular favorites at the time. I’m involved with some Stage II trials for a cannabis medication. So there are five FDA approved medications for Alzheimer’s right now. All of them work for about six to twelve months. They reduce symptoms and then they stop working. They do not reverse or stop the progression and just making the symptoms go away for six to twelve months and then they don’t do anything. Cannabis is amazing both CBD and THC are amazing medicine for this at a low dose once at bedtime for an elderly patient 2.5 mg of each of CBD and THC; sometimes 5 mg each. It can be any format you want to give to get those medicines into the body. They prefer an edible. The old population don’t like the idea of smoking. It’s a drug in a pipe but you can give them that kind of dose once at bedtime. It takes months to make sure it’s the right dose because the evidence that it’s working is that they don’t get worse.
So if they get worse that dose isn’t working and you have to bump up to the next dose. So it’s a slow process but very effective and it actually halts the progression as well as doing the same thing that the FDA approved drugs do that helps the symptoms but it also halts the progression. So if you find someone early on in their 60’s, 70’s with only a mild case you can actually stop it from becoming a condition that requires day care and those kind of things.
Matthew: Wow. Let’s clarify I haven’t really heard too much about Alzheimer’s and cannabis as a treatment for that. So you’re saying like a one to one ratio THC to CBD?
Dr. Smith: Correct and again a bedtime dose. It can be given an edible, it can be a tincture, they can vaporize four hits and get 2.5 mg and the nice side effect is a little anti anxiety and a little relaxation which is always helpful to Alzheimer’s patient to get rid of a little bit of the agitation and the anxiety that they have.
Matthew: Let’s talk about CBD a little bit for a second. Do you think that’s kind of a gateway for physicians because there’s really no associated high with CBD so that’s how they may start is recommending something that’s CBD primarily as they warm up to cannabis as an application and they start to round it out with THC?
Dr. Smith: Yes and that’s already happened. So CBD oil is the treatment for all these little kids with intractable epilepsy’s so the 17 states that don’t have medical marijuana that do have CBD is because of these kids with the intractable epilepsy’s. If you add the 24 states and the 17 we’re getting way up there and it’s the 40’s of the number of states where you can get CBD to use for medical purposes and so docs; unfortunately it’s just pediatric neurologists who are using it and it is over the counter. It is considered a nutritional supplement and it’s over the counter in all 50 states but it’s good to get a doctor’s advice on how to use it when you’re dealing with something like intractable epilepsy, multiple sclerosis, and things like that but you literally can buy it. In fact I bought some the other day at my vapor store.
Matthew: Okay and for people that aren’t familiar with CBD let’s back up a little bit. How do you describe it to patients that maybe have never heard of CBD before?
Dr. Smith: It’s a nutriceutical. So it’s a lot like all the other things at the GNC counter that have small doses; tablet size or capsule size doses that can have an impact on your health. So a small amount will have a nutritional and health benefit and its safe and doesn’t require a doctor to use it. It has very, very few side effects until you get way up in the 100s of mg so there’s essentially no side effects until you get up to the 100s of mg. So it’s a nutriceutical like you’re CoQ10 something or other oils. The fish oils and things like that. It’s that safe; literally as safe as fish oil.
Dr. Smith: In fact it’s safer than fish oil.
Matthew: So it’s a compound of the cannabis plant but you have some concerns about the stalk and the stem when extracting the CBD compound from a plant. Can you describe why that might be?
Dr. Smith: Yeah, yeah. You really know how to cut it right to the issues. So the CBD oil that is available in all 50 states has to originate from a hemp plant which is a cannabis sativa but it’s cannabis sativa that has less than .02% THC and so it’s essentially THC free but it also has to remain from either the stem or the stalk. You can’t take it from the bud of the hemp plant even though there is no THC in that either but the way the law is written so what happens is something called bioaccumulation. The stems and stalks accumulate pesticides, heavy metals, whatever is in the soil is multiplied by dozens of times in the stalk and stem material and not in the flowering bud at the top of the plant. So when you take that stem and stalk and hundreds of pounds of it to extract maybe one pound of CBD oil you’re getting a lot of contaminates that you really don’t want to put into what you think is a healthy elixir.
Matthew: Okay. So how do you remove impurities from CBD?
Dr. Smith: Multiple extraction processes. So most of the CBD oil that you can buy from these online websites or at your vapor store or wherever mini marts sometime have gone through three extraction techniques and so they’ve extracted with different methodologies and they’ve gotten to a liquid; a green smells like grass liquid that’s probably 70% CBD but the 30% is other things that we don’t know. So that’s what’s mostly available. There’s maybe two companies in the United States that use four extraction techniques and they end up with a 90 to 99% pure CBD oil and those companies their product would be called pharma grade and that’s a very important thing for any consumer when they’re buying CBD oil to look pharma grade. It means that it’s been certified that that’s what’s in there and 98 or 99% CBD oil and the contaminates are at a minimal level and you can get a consistent dose. So you know you’re consistently getting 5 mg when you take 2 cc or whatever it is it says on the jar. So that’s huge difference between the different CBD oil products that are out there.
Matthew: In general since The Affordable Care Act passed what kind of impact has that had on doctors in general? When you speak with other doctors over the water cooler how do they feel about it?
Dr. Smith: Well we have a lot more patients.
Dr. Smith: Which isn’t necessarily a good thing. It has facilitated the addition of mid level providers so nurse practitioners and physicians assistants to help us with the increased volume. So I’d say there’s pros and cons like anything. I don’t think it’s a perfect law and it was modified by politics heavily as we probably all know. So it’s not a perfect program and the results are not perfect but there are a lot more patients and we’re seeing a lot of people that would have been uninsured getting free preventative care and very inexpensive or less expensive care than they would have got without insurance.
Matthew: Okay. Now you’re working on a CBD oil would you like to tell us a little bit about that at all?
Dr. Smith: Oh okay yeah. So I’m working with a company and this company I am associated with called CBD Biotechnology’s and they are using yeast fermentation and enzymes to create biosynthetic CBD, THC, and other cannabinoids. So what they will have is a 99. something percent pure product that was never in a plant at a cost of about 1/6 per gram of material that comes from a plant so it’s much less expensive and much more pure and they’re well underway to having this kind of product. That product can then be made water soluble through some new nanotechnology and so you can now have tablets of THC, tablets of CBD, tablets of one to one. Also it’s a wonderful thing to have injectable CBD’s and THC’s. All sort of pharmaceutical grade 99.9% pure products will be coming along the pipeline that did not go through the plant growing process.
Dr. Smith: Very interesting.
Matthew: Now switching to a personal development question is there a book that you would recommend to listeners that’s had a big impact on your life?
Dr. Smith: Yeah I think it’s called “Cannabis Pharmacy.”
Dr. Smith: It’s been out several years. I’d say 2010, 2011. I think it’s targeted at the patient. So they’ve seen the doctor, they have the diagnosis; they went to the dispensary and now what do you do? Not only what do you do at the dispensary but what do you do when you get home from the dispensary. So it’s really much more targeted at the patient, end user and what to look for. Good science, bad science that sort of handbook for the patient called “Cannabis Pharmacy.”
Matthew: Okay great and as we close can you tell listeners how they can learn more about your work and your book and so forth?
Dr. Smith: Yes so the book title I gave you and it’s at Aylesbury Press and it’s www.aylesburypress.com and we have a newsletter which you’ll be directed at medical professionals not just doctors but nurses and caregivers called the Medical Cannabis Advisor and it’s coming out every quarter where we summarize all the new studies coming out of Israel, Europe, and some in the U.S along the way like the Alzheimer’s, Melanoma, Glioblastoma Cancer, Psoriasis but there’s so many interesting articles finally coming out now that we can do the research. The last three or four years we’ve been able to start doing these clinical trials that we hadn’t been able to do for forty years. So that’s coming out every quarter.
Matthew: Awesome. Well Dr. Greg thanks so much for coming on CannaInsider. We really appreciate your time in educating us.
Dr. Smith: Oh you’re welcome Matt. I appreciate the opportunity.
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Who better than a doctor than to help doctors understand the benefits of cannabis and then show them how to integrate cannabis into their traditional medicine practices. Dr. Gregory Smith walks us through how he is leading this change.
[1:42] – Dr. Smith’s background
[2:12] – Dr. Smith talks about his book
[4:09] – How often is cannabis prescribed
[5:42] – How doctors can integrate cannabis into their practice
[7:46] – How to bring up cannabis to your doctor
[8:59] – What symptoms or conditions have the best response to cannabis
[11:41] – What is the Marijuana Doctors site
[12:46] – Dr. Smith talks about using cannabis to treat Alzheimer’s
[16:29] – Dr. Smith describes what CBD is
[18:41] – How do you remove impurities from CBD
[21:07] – Dr. Smith talks about CBD oil
[22:33] – Dr. Smith’s book recommendation
[23:19] – Dr. Smith’s contact details
About our Guest:
Dr. Gregory Smith, MD, MPH earned his medical degree from Rush Medical School in Chicago, and a Masters of Public Health from Harvard University. He completed residency training in Preventive Medicine at Walter Reed Army Medical Center. Since leaving the US Army with the rank of Major, Doctor Smith has been in primary care practice in California, Georgia and Florida for the past 25 years. He first trained on use of medical cannabis in California in 2000, and has made medical cannabis and CBD oil part of his practice since that time. Dr. Smith is an avid writer, having published two medical textbooks, a novel called Malpractice, and articles with many magazines and over a dozen peer reviewed medical publications.
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What are the five trends that will disrupt the cannabis market in the next five years?Find out with your free guide at: https://www.cannainsider.com/trends