Continuing the discussion about medical cannabis with Dr. Khalsa and Dr. Rad! Learn why they feel passionate about giving specific patients access to this medication.
Continuing the discussion about medical cannabis with Dr. Khalsa and Dr. Rad! Learn why they feel passionate about giving specific patients access to this medication.
Join Dr. Khalsa and Dr. Rad for a candid talk about how and why they decided to help patients access medical cannabis!
Common Questions and Myths about Cannabis explained.
There are a lot of questions and myths surrounding cannabis as a medicine. We have answered some of the common questions to help people better understand cannabis.
Myth: People who use medical marijuana are often “stoned” and “high”
Patients do not necessarily get “stoned” or “high,” and reaching that level of experience is absolutely not a requirement of effective use. There are many different strains of cannabis, each with particular ratio of CBD and THC compounds.
Many patients who use cannabis for medical conditions are able to find the strains that will control their symptoms but not cause them to feel “stoned.”
Myth: Cannabis is a “gateway” drug
Many studies have shown that this is not the case. Cannabis does have some side effects but overall they tend to be mild if cannabis is used appropriately.
Medical cannabis may even help reduce overdose deaths from drugs. Dr. Marcus Bachhuber published a study in 2014 wherein he found, “There was about a 25 percent lower rate of prescription painkiller overdose deaths on average after implementation of a medical marijuana law.”
Cannabis actually has a better safety profile than many of the conventional medications we use!
This idea of cannabis posing a danger as medication came from a now disproven study, called “the monkey study,” conducted by Dr. Robert G. Heath, in the 1970’s. He was a researcher at Tulane University in New Orleans. His study stated that Cannabis killed brain cells, a conclusion which has since been disproven since then by more rigorous, modern research.
According to the National Academy of Sciences Institute of Medicine, marijuana possesses an estimated dependence liability of less than ten percent.
This percentage is approximately the same as anxiolytic drugs (like Xanax and Valium) and far lower than that of alcohol (15 percent) and tobacco (32 percent).
Myth: Medical marijuana doesn’t have enough scientific evidence behind it
Cannabis has been used medicinally for thousands of years by many, many cultures. Ours is one of the few cultures to ever bother banning it, and those bans are quickly being rescinded at the state level.
Despite the US government’s nearly century-long prohibition of the herb, Cannabis has continued to be studied in many different forms. A search on PubMed (the repository for all peer-reviewed scientific papers), using the term “marijuana” yields more than 21,000 scientific studies referencing the plant and/or its constituents, nearly half of which have been published within the past decade.
There are many avenues of research left to pursue, of course. One of the first steps is to start to talk more about it, then to get the laws changed federally so that patients can begin to see immediate relief and so that research institutions may lawfully conduct more studies.
There are quite a few studies that have shown its safety profile. It is fairly nontoxic, and almost impossible to have a lethal overdose with most side effects being temporary and mild.
Different disease processes have different amounts of evidence. For example, there is some good evidence for cannabis relieving chronic pain, improving appetite, and relieving painful spasms.
Myth: Cannabis causes schizophrenia
There is no evidence that cannabis actually causes schizophrenia. There is a known association between schizophrenia and cannabis; high doses of THC in people who already have schizophrenia can experience psychosis. There is no causal relationship between cannabis and schizophrenia, however.
The question still remains: does cannabis cause psychosis? Or are the people who are genetically predisposed to schizophrenia more likely to use cannabis? The latter seems much more likely at this time, and suggests that there is no fear of cannabis “causing’ schizophrenia or psychosis to develop.
Myth: Medical cannabis laws and/or dispensaries are associated with increased crime
This is not the case. They have actually done studies looking at this, and these studies have showed that there is no evidence of increased crime.
Myth: Cannabis smoke causes lung cancer
Cannabis smoke can irritate the lungs and long term use can cause chronic bronchitis, but studies indicate no evidence of cannabis smoke causing lung cancer or COPD like cigarettes do.
Myth: Cannabis kills brain cells
Again, this idea came for the now disproven “monkey study” in the 1970’s. Certain components of cannabis such as CBD have actually been shown to be neuroprotective.
It can however cause short term memory loss, especially with significant daily use, which is usually reversable with cessation of high doses.
The caveat to this is in adolescents where there is some concern that it may cause some long term cognitive damage. Once brains mature out of adolescence, the already minimal risk is further reduced.
UPDATE ON E-CIGARETTE AND VAPING RELATED LUNG INJURY: Vitamin E Acetate has been linked to e-cigarette and vaping lung injuries by the CDC investigation. This does NOT mean there are no other dangerous compounds present but this is certainly a breakthrough in furthering our understanding of EVALI. For now, we continue to advise our patients to avoid e-cigarettes and vaping products. Please talk to your cannabis physician about other options for ingestion of medical cannabis. #evali#vaping #cannabiscommunity #vapingcommunity #stayinformed #marijuana#marijuanacommunity @ Canna Therapy MD
Night shift worker? Stress keeping you up? Can’t get your mind to stop racing at the end of the day? Did you know that not getting 7-8 hours of sleep a night can increase your risk of obesity, diabetes and cardiovascular disease? Studies show more than a third of Americans are not getting enough sleep. Cannabis can help you get the sleep that your body needs! #cannabis #cannabiscommunity #medicalcannabis#medicalmarijuana #insomnia #cantsleep #medicalcannabiscard#insomniac #cannabishelps
Schedule an appointment today to talk with Dr. Rad or Dr. Khalsa about any sleep troubles you are experiencing!
Check out advice that Dr. Rad and Dr. Khalsa give on visiting a medical cannabis clinic! This was published in MO Greenway Magazine, which can be found at the following link: https://mogreenway.com
Dr. Rad recently got a chance to speak with senior writer Katie Heaney for The Cut, New York Magazine about vaping related lung illness.
Check out the article here for great information about the recent developments and advice on how to prevent this from happening to you.
For now, Canna Therapy MD feels all patients should avoid vaping and vaping related products for BOTH nicotine and THC until the CDC is able to complete their investigation into the underlying cause.
Please seek immediate emergency care and inform your emergency physician if you develop chest pain, shortness of breath, fever, abdominal pain, nausea, vomiting or diarrhea after vaping in the last 90 days.
The CDC also encourages patients to report their vaping related symptoms to: https://www.safetyreporting.hhs.gov/SRP2/en/Home.aspx?sid=a6939cbf-f782-4509-8544-0921663abefb
“24 year old female, found down. GCS 3, CPR in progress. ETA 5 min.”
The radio crackled off and I immediately started running towards the resuscitation bay to meet the EMS crew.
I methodically slid on the vibrant blue nitrile gloves, carefully placed my face shield on and prepared my intubation kit.
All codes are the same. The fundamentals of medicine kick in. Airway. Breathing. Circulation. A. B. C. In emergency medicine, we train to maintain composure in chaotic situations. I take a deep breath and prepare to take charge.
When EMS arrived, one crew member was performing chest compressions, sweat dripping down his face. The other crew members carefully transported her from their stretcher to our bed. The medic immediately briefed us, “No improvement, 1 round of Epi given, no shockable rhythm en route.”
“Ok everyone, continue chest compressions and administer the next round of Epi” I said.
Multiple rounds of chest compressions and medications were given. I placed an ultrasound over her chest during the pulse check. Her heart was still. The room was still. We all knew her fate.
“Time of death 1437.” I stripped off the face shield, removed the gloves and glanced at her family through the window.
Often times in the moment, emergency physicians are focused on the task at hand. What can I do to bring her pulse back? Is there a shockable rhythm? Is there a reversible cause for her death?
A lot of times, we can’t get them back, as hard as we might try. I once had an attending tell me, “They’re already dead. You can’t make them deader. Do your best to bring them back and be there for the people who are left behind.”
I walked over to the family and gave the speech I was used to giving over the years. I watched the color drain out of their faces; guttural moans filled the room with despair. The questions flooded of “Why her? Why this? Why now?”
I couldn’t answer those questions. As I covered her body with a bright clean white hospital sheet, I glanced at her arms. Scars from the needle sticks searching for a viable vein for the heroin. Evidence of the long battle she had been through.
Colleagues, friends and family have all questioned why Dr. Khalsa and I felt a need to advocate for medical cannabis. Anyone who has been affected by the opiate crisis has never asked us why we do it, they simply thank us.
When you have firsthand experience with the gruesome toll of opiates, it is easy to advocate for safer treatment options. Physicians agree at this point that opiates are not the answer. However, patients are left with no other alternatives. As physicians, we cannot simply ignore pain control or defer it to the next doctor to worry about.
We understand the hesitancy both in the medical community and general population. For many years, cannabis has been stigmatized with both physicians and patients abusing the system. In the medical community, cannabis physicians are sometimes viewed as lesser-trained doctors, who frequently did not become board-certified in a specialty. In other words, this was just a way to “make a quick buck.” Another barrier is that medical education certainly does not include a section on medical cannabis. Physicians have to go out of their way to gain additional training and expertise in this area.
Dr. Khalsa and I want to change this perception. We are board certified physicians in emergency medicine and still practice on a regular basis. After working for many years in Colorado, we saw the good and bad of cannabis legalization and we readily discuss these risks and benefits with our patients.
No medication is perfect and we encourage the medical community and our patients to always maintain a guarded perspective on any novel treatment. Just look at the drug commercials on TV that subtly try to list over fifty various life-threatening side effects. These are commonly followed by large lawsuit advertisements for the previously mentioned side effects. No medication is taken without risks and this includes medical cannabis.
Yet, medical cannabis does show promise. We continually review the most recent literature on cannabis. But, we also listen to our patients. A common theme that comes up is that patients enjoy having control over their own health. They appreciate having an active role in determining strains, dosing and frequency of this medication. With any chronic illness, control is something that disappears over time. They feel mainstream medicine only contributes to their lack of control and medical cannabis helps them regain some balance.
Patients tell us about how they were able to cut out opiates from their lives, how they head into their chemotherapy sessions without enduring weeks of nausea and vomiting, how they enjoy their lives again without having to worry about daily intractable seizures. We listen to their success stories.
Medical cannabis is not the right choice for everyone, but we are here to start the discussion about whom it can help.
Radhika Ratnabalasuriar MD
SOAP Note Diaries
“ER docs practicing in a cannabis world”
My Body has a Mind of Its Own: Sarah’s Story
As I walk into the room I try to focus completely on Sarah, a young woman who is presenting to the emergency room today for numbness and tingling.
She sits calmly, although I can tell she is nervous. She periodically jitters around in her hospital bed, laughs nervously and apologizes for coming to the emergency department.
“I just didn’t know where else to go. It seems no one can help me and I know something is wrong.”
To be honest, as an EM (emergency medicine) physician I don’t love the vague complaint of numbness and tingling. In my experience the causes are vast and with limited time and resources in the emergency room it seems impossible at times to find a diagnosis. But, I’m going to try my best for Sarah. I know she wouldn’t be here if it were not a last resort.
I ask her what’s been going on and she immediately loses her calm demeanor and bursts into frantic tears. “It’s just been so frustrating, I feel like I am going crazy and I am really scared”. She reveals to me that she has been plagued for months by random numbness and tingling in her arms and legs, and now even has a little bit of weakness in her left arm that comes and goes. Sometimes she feels her vision is going blurry. Other days, she has painful spasms that coarse throughout her back like electricity striking her every 5 minutes. She lowers her voice and sheepishly admits, “On top of all that, I noticed I don’t even have a sexual drive anymore with my husband.”
Many people, including doctors, including ourselves at times, may brush Sarah off. “You’re just stressed. You need more sleep. It’s all in your head.” I can tell she has heard all this before as she quickly assures me again that she “is not crazy.” I stop her. “I don’t think you’re crazy Sarah. Let’s get some further testing and see if we can figure out what is going on.” She smiles timidly, relieved that someone is taking her seriously. She just wants an answer.
Sarah’s MRI ended up showing characteristics concerning for multiple sclerosis. The diagnosis is certainly not always this simple, but we got lucky, if you can call it that.
I went back into the room to discuss this with her. You could sense her internal struggle between relief that something was wrong and she wasn’t “crazy” versus accepting that she now has to live with this new disease process.
Patients who deal with MS have various symptoms and challenges they face on a daily basis and we see them in the ER for many of these. Neuropathic pain, muscle spasms, spasticity, depression, anxiety, and insomnia just to name a few. It is difficult to see them keep coming back to the ER feeling hopeless about their quality of life.
Objective: We reviewed the literature to see how patients like Sarah could improve their quality of life with medical cannabis.
Interestingly, spasticity seen with MS is one of the few diagnoses that has significant evidence-based studies to support the use of cannabis in its treatment. This type of evidence is what the medical community considers a “good” study that they feel comfortable using to guide their practice.
Many of the studies that are done on cannabis are simple observational studies which do not meet this rigorous evidence-based criteria.
It seems cannabis can be used to treat a range of symptoms including spasticity, muscle spasms, issues with mood and cognition, bladder and bowel problems, neuropathy and insomnia.
Cannabis is a known powerful antioxidant and some researchers ask the question if this could help reduce oxidative damage and slow death of neurons. This would translate to slowing the overall process of multiple sclerosis.
Unfortunately, at this time there just isn’t enough research to know if this is possible. However, we find it an interesting area of future research.
Assessment and Plan: Medical cannabis has been shown to help with spasticity in people with MS.
With the correct guidance it could also potentially help with a number of other challenges people face with MS. Since research is limited, it is best to trial medical cannabis in very small doses first to see if there is a benefit to the patient.
It can take a bit of trial and error to achieve the correct combination of cannabis to obtain the desired effect. We suggest having the guidance of a Cannabis trained physician to accomplish your treatment goals.
As always, you should discuss your plan to use medical Cannabis with your neurologist and other specialists to make sure you achieve optimal treatment. We also want to ensure it does not interfere with any other ongoing treatment plans you may have for your MS.
We DO NOT currently recommend using cannabis to try and slow the progression of MS, but this is something to continue to watch going forward as more research is produced.
Sarah walked out of the emergency department that day feeling more empowered than she had in the last few months.
She knows it’s a long road ahead, but she tells me at least she has hope now. And hope is a pretty priceless emotion to keep when you’re battling chronic illness.
As she walked out of the room, I smiled and thought, “You got this Sarah. And we have your back.”
Recommended Reading and resources:
“Cannabis Pharmacy; the practical guide to medical marijuana” 2017 edition. By Michael backs with foreward by Andrew Weil, MD. Jack D McCjue MD medical editor.
“Cannabinoids in multiple sclerosis (CAMS) study: safety and efficacy data for 12 months follow up”
J Neurol Neurosurg Psychiatry. 2005 Dec; 76(12): 1664–1669.
“Effect of dronabinol on progression in progressive multiple sclerosis (CUPID): a randomised, placebo-controlled trial.”
Lancet Neurol. 2013 Sep;12(9):857-865. doi: 10.1016/S1474-4422(13)70159-5. Epub 2013 Jul 13.
The SOAP Note Diaries: “ER docs in a cannabis world”
Dr. Khalsa and I were initially nervous to take the leap and start specializing in medical cannabis. We knew some of our colleagues would look down on us. However a part of us always knew we were supposed to advocate for this patient population. People who could genuinely benefit from medical cannabis.
This blog became a way that Dr. Khalsa and I could share our stories with you from working in the emergency department. We encounter so many different people who are battling severe diseases and we feel they deserve access to medical cannabis without stigmatization.
They deserve to be treated as patients who are seeking medications that work best for them.
They deserve to be treated not as drug addicts or uneducated people but as patients who are looking for a different approach to their treatment plans, when nothing else seems to be working.
These are their stories and we hope we can do them justice.
Our hope is for this blog to bring a new perspective to the table. Thank you for keeping an open mind and for taking the time to read our stories.
What is a SOAP note?
A SOAP note is used by many physicians to document the patient’s encounter. It is a shorter simplified note made up of 3 parts.
“Subjective” explains why the patient is there. This part is told completely from the side of the patient. Why are they here today? What is bothering them? What makes it better? What makes it worse?
In our blog, this is where we tell the patient’s story. All names are fictional and specific details about the case have been changed to protect the patient’s privacy.
“Objective” is the physician’s evaluation of the patient, including a physical exam. It states the facts of what they have observed with the patient and their clinical findings.
In our blog, this is where we review the literature on medical cannabis related to a specific disease process. We talk about what the studies showed, any weaknesses in the literature and any future research that is pending.
“Assessment and Plan” is the part where a physician documents what he/she thinks the diagnosis may be and his/her plan for further evaluation or treatment.
In our blog, this is where we summarize our thoughts on the disease and the effectiveness of medical cannabis. They are our “take home points.”
‘Final Impression” is where the physician documents his/her final diagnosis and thoughts.
In our blog, this is where we express our final thoughts about the patient and topic at hand.
We always cite recommended resources and additional reading materials on the subject matter at the end of each blog post.
Thanks for reading!
Drs. Khalsa and Ratnabalasuriar