Speaker 1:
Coming up on this episode of The Doctor’s Farmacy.
Dr. Misha Kogan::
So I have the three mantras with cannabis. Start low, go slow, and deliver it where it needs to go. That third one, I think, is unfortunately, not as commonly understood out there. So if you have a lesion on the skin, put of there.
Dr. Mark Hyman:
Welcome to The Doctor’s Farmacy, that’s farmacy with an F. A place for conversations that matter. And if you’re confused about this whole story of medical marijuana and the use of marijuana as a therapeutic agent in healing and medicine, you got to listen up because we have an expert today with us, my friend,
Dr. Misha Kogan:, who is my go-to guy in Washington DC for functional medicine. He is the medical director of George Washington University Center for Integrative Medicine. He’s associate professor of medicine at the George Washington University School of Medicine. And I have known him for a long time, and I work closely with him, with my patients.
Dr. Mark Hyman:
And he is one of the most important thinkers and doctors in America focused on functional medicine. And now he’s turned his wisdom and medical knowledge to the field of medical marijuana and has recommended it to thousands of patients in lectures on this to professional audiences all around the country. And now he’s written a book, which is awesome. So we can actually learn what he knows, because it is a very confusing area. Medical Marijuana: Dr. Kogan’s Evidence-Based Guide to the Health Benefits of Cannabis and CBD. You can go get it, get it now. It’s out.
Dr. Mark Hyman:
And I recommend highly, if you’re having any issues that we’re going to talk about on this podcast, that you think might benefit, learn about it. Learn how it could be helpful. We have, unfortunately, in this country, had a backlash against various kinds of substances, whether it’s psilocybin or marijuana, because of their particular qualities, that I think the culture wasn’t ready for in the ’60s and ’70s. But now there’s a sort of reawakening. And medical marijuana is legalized in most states. Marijuana is legalized for recreational use in many states. Psilocybin is now legalized or again, it is decriminalized in many other states. And I think we’re going to see more and more research pushing forward these therapeutic substances that come from nature, plant-based medicine, okay. So welcome, Misha.
Dr. Misha Kogan::
Thank you, thank you. So exciting to be here, Mark.
Dr. Mark Hyman:
Well, I want to pick your brain about this because I have my personal experience with marijuana and I want to share that at the beginning and how powerful it was. Not like you’re thinking, no, make fun of me, Misha. This is not actually what-
Dr. Misha Kogan::
No comments.
Dr. Mark Hyman:
No, this is not what I’m talking, you… Okay, forget that. Okay, I had medical marijuana experience, okay. I should have properly phrased [crosstalk 00:02:49]. So I got sick a number of years ago from mold. And you were helpful in getting me some things to treat that. And I really was so sick and ended up getting a C. Diff infection from an antibiotic that I took, which caused colitis. And it also, I had a broken arm and I took a bunch of anti-inflammatory drugs, like Advil, got gastritis. And all of a sudden I went from my digestion working to not working. I had severe epigastric stomach pain. I was nauseous 24/7. I had bloody diarrhea 10 to 20 times a day and colitis developed. I was a mess.
Dr. Mark Hyman:
And I had really smoked pot a few times in college, but I really wasn’t a big pot fan. I just felt it made me stupid. I like my brain, so I don’t like feeling stupid. I was like, “What was I saying? Huh? What?” And a friend of mine, I was telling her I was having all these problems. And she said, “Why don’t you try this?” And she gave me this jar of weed that her nephew had grown, illegally, full of seeds. And I’m like, “I’ll try anything.” So I started to smoke and I did it every evening in order to eat, because otherwise I couldn’t eat. And it helped me eat, it helped me sleep because I was in pain, and it helped with the nausea, where nothing else worked.
Dr. Mark Hyman:
I was trying Zofran, which is a chemo nausea drug. I was trying Ativan, all your drugs for nausea, nothing worked. So it was really a profound experience for me, going, “Wait a minute, this is really a profound medication or an herb, that that is not been properly integrated into healthcare.” And so what I love about your book and I’m going to sort of get into it now with you. What I love about your book is that it is so clear. It’s so driven by research. It’s so detailed in its explanation of all the different issues, and concerns, and methods, and routes of treatment, that it’s kind of a refreshing look at this field, that I haven’t seen. I’ve seen a lot of noise about it, but I haven’t really seen any clear medical authority, like you, talking about this. So it’s been used for thousands of years. It’s not been legal for most of our lives and now it’s being legalized. So how do we begin to navigate the world of medical marijuana and integrating it into healthcare?
Dr. Misha Kogan::
Right, right. Well, I think the timing is pretty good. We had cannabis around, especially if you’re in the West Coast, if you’re in California, the access was there for quite longer than on the East Coast in most of The States. But I think you’re right. I think there just hasn’t been any really good, clear, well wrapped around package of knowledge that most people can quickly digest. And so I think that was actually then one of the key incentives for the book. I felt like I often was repeating myself, saying the same thing because nobody knows the basics. So I had to start like cannabis101 for each patient. I said, “Well, okay. Well, if I write about this, maybe they can just read it. And so next time they come, it’s a little less work to do.” Practical reason. No, but seriously, I think we’re entering the era where it’s just going to be one of our common tools and pretty much for almost all the medicine.
Dr. Misha Kogan::
I have no doubt that, by the way, it will be an alternative plant medicine in, say a decade. It’ll just be another tool in a standard allopathic model. I mean, it’s already, if you look around now, it’s getting integrated, it’s way bigger than any of our branches of integrative or holistic medicine. I mean, most of the pain doctors are already aware of it, most of them have some kind of a flow that they can get patients to get the cannabis. Like I give example of my own pain clinic at GW five, six years ago, I told them, “Look, you guys have to look into this. I’m happy to come and give you grand rounds and we can review this in detail.” And guess what? I mean, there go, “oh, no, no, no, no, no, no. We have everybody signed contracts that they can’t use any substance.”
Dr. Misha Kogan::
I’m like, “That’s not any substance, that’s controlling your pains.” “No, no, no.” And then, as the evidence accumulated, so I’m giving them grand rounds in a couple of weeks, as an example. So I think there’s a rapid uptick in acceptance. What’s interesting, there’s still zero clarity on how are you going to teach the students about, right? How are we going to carefully educate the public? If you look around, most of the information out there, it’s actually not academic. Majority of information that people are getting, is from commercial sources. And some of them are good, like Leafly is a… Not that I’m trying to advocate for anything here. But there are lots of good resources, but they’re scattered, they’re not academically supported, or academically-
Dr. Mark Hyman:
Backed.
Dr. Misha Kogan::
… backed. Yeah, right. And I think that’s not a change. And then a lot of people are going to listen to them.
Dr. Mark Hyman:
So what is the research base for medical marijuana? I mean, it’s being used clinically a lot. It’s used recreationally a lot. Is there an evidence-based, we talk about evidence-based medicine, which has issues-
Dr. Misha Kogan::
There is, yeah.
Dr. Mark Hyman:
But is there good research, looking at the benefits and the risks of medical marijuana?
Dr. Misha Kogan::
Yeah. I mean, I think the evidence is a rapidly growing. We still have a problem. I’ll start from the other end. We still have a problem with the fact that it’s still a controlled substance, it’s still DEA schedule one substance. So the research is limited and it’s really hard to get federal dollars to study this. And although, actually, it has been changing. But still, the clinical research is lacking. But despite that, there’s actually a lot of evidence. So into 2017, I’m just going to speak to most independent evidence, in 2017 National Academies of Sciences and Medicine came out with a really important report. It was literally, it was called Medical Cannabis Report on Medical Cannabis Efficacy. And they concluded, I mean, they put a significant conclusion.
Dr. Misha Kogan::
They said that for chronic pain, in adults, medical cannabis gets grade A recommendation. If we look at all of our meds that we have, opioids, they’re not even grade B, they’re like grade COVID minus-
Dr. Mark Hyman:
Opioids?
Dr. Misha Kogan::
Yeah.
Dr. Mark Hyman:
Really?
Dr. Misha Kogan::
Yeah. Yeah, for pain. And like an Advil and Tylenol, I think, getting grade B. And here you had cannabis with grade A recommendation.
Dr. Mark Hyman:
That’s incredible.
Dr. Misha Kogan::
Well, it’s incredible, but it didn’t get too widely known. I mean, people in our own field, of course, everywhere I go, that’s one of the key slides because nobody’s going to argue with National Academies of Sciences’ conclusion, right?
Dr. Mark Hyman:
Yeah.
Dr. Misha Kogan::
But since there’s been a lot, even more data NIH actually routinely now, holds workshops on cannabis and sort of allowing the clinicians and researchers look to most updated evidence. So there’s definitely a rapid shift.
Dr. Mark Hyman:
So you’re saying there’s NIH research on this now?
Dr. Misha Kogan::
There’s a lot of NIH research, yeah. Most of it’s still bench research or preclinical, but there is a lot more money going into that because there’s been call, some, probably a year ago more, probably more than that already. There have been multiple calls for proposals for a basic understanding of endocannabinoid system. And I think that’s the part where, for our clinical evidence-based medicine, right? Before you can study something clinically, you have to say, “Look, there is a clear knowledge of understanding of mechanism of action,” right? And we can arguably say, we know all this already. But the science has to take its own steps.
Dr. Mark Hyman:
Interesting, so I want to get into some of what the research shows around the benefits. But one of the interesting things that you touched on was the endocannabinoid system. So for those listening, the reason medical marijuana works, is it’s tapping into a biological system that already exists in our bodies and brains. And it’s called the endocannabinoid system. So can you talk just a little bit about that, Misha? And what it does, what it’s for, and what the benefits of this system are to our health.
Dr. Misha Kogan::
Right, right. Well, I think that’s actually critical we talk about this because that’s the core understanding of how actual exogenous or cannabis from plant works, right? So we have-
Dr. Mark Hyman:
And by the way, this system was named after cannabis, right?
Dr. Misha Kogan::
That’s right, that’s right.
Dr. Mark Hyman:
So it’s like the doctors discovered it in a way, and they named it after the molecule that they realized was working on it, which isn’t the only reason it’s there.
Dr. Misha Kogan::
That’s right. Well, let’s talk about that first and then we’ll… Because I have one philosophical point that I think you’re going to have a great take on this. So just like we have an endorphin system, so that endogenous opiates, we have this endogenous cannabinoid system. It’s actually a lot older, and a lot more complicated, and a lot more important compared to endorphin system. Why? That’s not necessarily clear, but it appears that it’s just more rudimentary. And historically, it appeared in our evolution first. So it’s one of the oldest regulatory systems in our body. We have literally, so the tetrahydrocannabinoid, which everybody after recreationally, the THC, right? So we have molecules in our body that are very similar. An endomide is a good example, it’s probably one of the more common, it’s not the only one.
Dr. Misha Kogan::
We have multiple, similar molecules internally, and we make them. We literally make our own cannabis constantly, in our body. And then there are a set of receptors. The more commonly known ones are CB1 and CB2. So you can think of them like a, it’s a gross analogy. It’s not necessarily 100% accurate, but it’s a good one, key in a lock. So your key is our endogenous cannabis molecules or let’s say an endomide and the lock are the CB1 and CB2 receptors. So when you open the lock, something occurs, like your door opens and then you have a cascade of effects. So if you open CB1 receptor, then you have some kind of likely neurologic impact. So say pain control or some decrease in anxiety, better sleep, those kinds of things.
Dr. Misha Kogan::
If you open CB2 receptors, which are on the periphery, you can have immune upregulation, so stronger immune system. You can have metabolic improvement, like certain metabolic parameters can improve. You can have your bones lay down more bone, so that their bones are stronger. So the impact, the list of impacts that occurs when this happens is so long, we’ll sit here and we’ll have a whole lecture about it. Bottom line, it affects almost entire system, almost every cell in our body, except for one area, has the CB1, or CB2 receptors. Here where the sort of the most crazy amazing mystery comes in, except for one area, and that’s the brainstem. So turns out, in the brainstem, which controls our breathing, there’s not as many CB1 receptors. So no matter how much cannabis you take in, your breathing is not going to get suppressed, compared to if you take a lot of opioids and we know what’s going to happen, right.
Dr. Misha Kogan::
So why that happens, nobody knows. The second mystery, that’s what I really want to touch on. Think about this, we co-evolved with a plant, which is a weed, meaning it grows everywhere, right? Because weeds, there’s a reason why they call it the weed, right? So how come we co-evolved on this earth together with a plant that allows us to have this fascinating interaction with it? And we’re coming back to the plants been used for thousands of years. In fact, it may be the oldest documented medical tool we have on earth. If I go back to some of the original Chinese medicine works, it’s been listed there as one of the first Chinese medicine herbs. And it’s not discussed in a lot of circles. It’s kind of hard to appreciate, right? But it’s there and it’s there as one of the original herbs that they’ve used. And then over the centuries, it was used in different ways. And then it finally kind of ended up in more modern civilization. But it almost feels like we’re now rediscovering-
Dr. Mark Hyman:
Yeah. But here’s a question for you. So in the opioid system, we have receptors for the opioids, right? Narcotics, right?
Dr. Misha Kogan::
Right.
Dr. Mark Hyman:
Heroin, morphine, all that. And that’s because we have our own system of pain control called endorphins that bind to those receptors. Is there a similar set of molecules in the body that naturally occur, that’s almost our natural marijuana-
Dr. Misha Kogan::
Right, well, that’s exactly-
Dr. Mark Hyman:
… as the endorphins are natural opioids? So what are those molecules and what role do they play? And how do they interact?
Dr. Misha Kogan::
Well, I think for listeners an endomide is probably the most important one to remember. The long list of endomide. That’s probably, it’s one of the most common, it’s one of the best understood. What’s interesting that in addition to this sort of endocannabinoid system, through cannabis receptors and let’s call them what they are, CB1, CB2, there may be others too, by the way, there are lots of other impacts. So the plant has other active molecules, turpines, I’m sure we’ll talk about this. It has flavonoids and all of them also have some impact.
Dr. Misha Kogan::
In fact, there’s a lot of research now going into turpines because turns out that if you just isolate THC and you take it in, the effect is going to be limited. If you combine that impact with what turpines can do, suddenly you have a whole lot more complex interaction with the body. And that’s where I think the gold of cannabis will be. And that’s why I’m not worried much about sort of pharma taking all of it over because recreating some of this interactions, what we often call an entourage effect, is very difficult.
Dr. Mark Hyman:
Yeah. I mean, that’s the typical efforts of medicine, which is to find something that works, to reduce it to the one molecule and to isolate it, reproduce it, and distribute it, and market it, and patent it. And what you’re saying is really important to underscore, which is that it’s the complex interaction of all the plant molecules and phytochemicals in marijuana that make it work. So if you just take any one of them out, it may be synergistic effects that you can’t reproduce by just isolating it as a single drug.
Dr. Misha Kogan::
Right, right, right, right, right, right. The simple example is, so historically, we had this sativa and indica strains. We’re trying to sort of walk away from this because it’s actually more confusing than anything-
Dr. Mark Hyman:
Oh really? Why?
Dr. Misha Kogan::
Yeah. Well, it’s really based on turpine contents. And since most of the modern strains are now hybrids, or many of them, this separation of is this indica? Is it sativa? Is a two parts indica, one part sativa? It just confused as everything too. So you’re really going to, in the future, it’s going to be, you’re going to look at the label and you’re going to say, “Okay, well, there’s X amount of THC, and there’s this concentration, and then there’s this turpines.”
Dr. Misha Kogan::
So you’re going to have some kind of a key on a label that says it’s a predominantly relaxing turpines, like say linalool. And it will allow you to say, “Okay, well, that’s probably good for sleep or for anxiety because that’s what it’s going to help with. So, that’s the future. And that’s how we’re beginning to think. We’re looking at, okay, this turpine is going to mix this way and it’s going to have this kind of total entourage effect. Then that’s what we’re going to, clinically, use it for.
Dr. Mark Hyman:
I think you just said it a very important phrase, the entourage effect. If the entourage of all the molecules in the plant that has the benefit, not just an isolated component. So let’s get down into the details of this because I know I shared my story about its effect for me. But what are the most robust research findings on the therapeutic effects of cannabis?
Dr. Misha Kogan::
Yeah. So I mean, definitely the pain I mentioned already. I think in terms of-
Dr. Mark Hyman:
Pain you talked about.
Dr. Misha Kogan::
Yeah, I think in terms of overall evidence, I think there’s just most of it. And probably second closest is nausea, especially when nausea comes in settings of some kind of a cancer, whether it’s a nausea from chemotherapy or a nausea from cancer itself, doesn’t matter. But that seems like there’s really robust evidence. And the third, I think is multiple sclerosis related spasticity. So those are the three original big ones that were in National Academy’s or NAS report. I think there’s honestly underscoring and there’s tons of evidence for insomnia. I think it’s just not really, we have don’t have like a one large control study to say this, but if you kind of look at collective amount of evidence and more importantly, what we actually see in practice, we see that, in my opinion, efficacy of cannabis for sleep is way over 90%. I mean, I don’t have-
Dr. Mark Hyman:
It’s true and it’s way more effective than all the other sleep medications, which are addictive and-
Dr. Misha Kogan::
It’s so much more effective than all the meds, it’s unbelievable. And it’s so much safer. Well, you know me, I’m geriatrician, so half of my practice people are over 65. And insomnia, in my practice, used to be one of the hardest thing to deal with, because I know I don’t want to write for any new drugs for sleep and then cognitive behavioral therapy is not covered by insurance. If I send them for acupuncture, it’s also often not covered, even though it’s a great tool.
Dr. Misha Kogan::
So I didn’t have, my toolbox was sort of all non-pharmacological. I couldn’t give anything to people. And if I would give something, then like maybe Trazodone, I was always writing the script with shaking hands. I might be doing more harm than benefit. So suddenly, in 2011, ’12, I started seeing what cannabis can do. And it was just, it’s just torn my practice completely upside down in about two or three years. I just stopped talking about almost anything, if the patient is really suffering. I said, “Okay, we got to try cannabis first and we’ll see what happens.”
Dr. Mark Hyman:
So all your nursing home patients smoking pot [crosstalk 00:21:41] for bed.
Dr. Misha Kogan::
Well, I wish. No, not quite, that’s a whole separate… You just opened a can of worms, that if we go there, it’s not going to come out of it. Well actually, it’s interesting that it’s shifting. I wasn’t expecting the nursing homes and assisted living facilities will sort of start actually opening up. I thought it would be sort of like, “Forget it. We’re never going to talk about this.” No, actually, in The States, where it’s medically legal, there’s gradual shift, there’s was gradual movement. And some facilities are actually very, those who have really open minded medical directors, a couple of years ago, American Directors Association, it’s AMDA, A-M-D-A. So they are the kind of docs who run nursing homes organization.
Dr. Misha Kogan::
They actually put out extremely supportive comment, when I read it, I almost fell off the chair. It was one of the most supportive comments, saying, “Yeah, we have to assure that if in our state, cannabis is allowed, that any interested patient will have some safe access. Of course, considering the safety of others and the facility.” That’s the difficult part because A, if you’re going to light up in the nursing home, the fire hazard. If you’re not lighting up, what else? I mean, how do you store something which is schedule one?
Dr. Mark Hyman:
There’s a vape.
Dr. Misha Kogan::
Yeah. Well, I mean, unfortunately, in a lot of situations, cannabis problems come only to two things. The price, and logistics, and nothing else, and not the efficacy.
Dr. Mark Hyman:
Yeah. So in terms of the efficacy, a lot of people are reluctant to use it in practice, a lot of misinformation. Can you share a little bit about how people can learn about this in the right way? And what the most important thing you’ve seen clinically from this are. There’s sort of two separate questions in there.
Dr. Misha Kogan::
Yeah. Well, I mean, I think outside of insomnia, to be honest with you, it’s still not my first choice for a lot of things. So I think I’m assuming that the patient who’s coming to try it or thinking about trying, sort of either exhausted other things or simply they just feel like their symptoms are not controlled enough by other things. So I mean, I think, well first, the condition for which you’re going to use should be evidenced. There are lots of hype out there with CBD, that it treats pretty much everything under the sun. And I will actually tell you that in contrast, the evidence for THC, evidence for CBD is dramatically more limited. And maybe outside of anxiety and high doses for some forms of insomnia, there’s not just that much evidence. All of the evidence-
Dr. Mark Hyman:
For CBD?
Dr. Misha Kogan::
For CBD, yeah. But-
Dr. Mark Hyman:
And for THC.
Dr. Misha Kogan::
Yeah. I walked into Walmart to get something or was it, no Walgreens. I walked into Walgreens a couple of weeks ago, to get something. I’m walking along the lines to find, and there you have it, CBD of every kind, Walgreens. And it’s their brand.
Dr. Mark Hyman:
I know, it’s everywhere. You can buy it at the gas station.
Dr. Misha Kogan::
Right, right. Well, what happens is simple, certain things for which it tends to work. Let’s say you have one or two things. Let’s say you have a bruise and so putting CBD on a bruise can actually ease it up, or there’s a placebo effect. But next thing you know, now it’s getting translated all over the place. Anyway, so bottom line, you got to start with what’s evidenced. Next, you have to figure out logistics. Logistics sometimes where things bog down. So let’s say one of your listeners is not in a state where it’s legal. Well, that creates a significant challenge. If you still want to try it, you’re going to have to travel to a legal state and then cross the lines, which is actually a federal crime, to bring the cannabis from one state to another. A lot of people don’t want to get involved because it feels like you’re violating policies, even though, to be honest with you-
Dr. Mark Hyman:
But there’s medical marijuana that you can prescribe as a doctor, right?
Dr. Misha Kogan::
Right. Well, but again, it’s only for the residents of the given state. I mean, I can prescribe it to anybody. Let’s say the patient travels to my state and I feel appropriately to say, “You should be…” But there’s no way for me to recommend it. If I try to recommend, they’re not going to get it because they can’t obtain the card. So in every state, it’s not like if I write let’s say, I don’t know, oxycodone prescription. It goes straight to the pharmacy.
Dr. Misha Kogan::
Here, patient is separated from physician, completely. So you have to get a medical card, which is always authorized by a state. So you have to follow the state guidelines to get the card. If you’re not a resident, well, you’re out of luck. You can’t get it. So then, once you get a card, then you have to identify dispensary and go there. And if your doctor tells you, “Okay, get this, this, and that.” Okay, great. But most doctors don’t tell you that. They simply say, “Well, go and talk to the budtenders, we call them, right?
Dr. Mark Hyman:
Right.
Dr. Misha Kogan::
So go talk to them and-
Dr. Mark Hyman:
It’s like the lady in the vitamin store, who’s recommending your medical care.
Dr. Misha Kogan::
Exactly, and some of those ladies are really good.
Dr. Mark Hyman:
They know a lot.
Dr. Misha Kogan::
And they probably know more than some doctors. Well, not probably, for sure. But some of them are clueless. They’re like a high school student. Not that… I have one. No, point being, it’s a dramatic… There’s just no standardization across the field, it’s a maturing business. I think in the future, it’ll self-regulate better. And I think there’s already some states that it took really hard, like Connecticut and Maryland, for example, and others. So they took really hard. They say, “Look, you’ve got to have some kind of an educational directory.” In Connecticut, you actually have to have a pharmacist on staff in every dispensary.
Dr. Misha Kogan::
So it’s a pharmacist who’s going to sort of guide the products, guide the education of the dispensary. It sort of has to happen this way. If we’re saying that this is medical, it has to look medical, right? And it shouldn’t look like alcoholic beverages. Okay, so I’m going to say something and I hope somebody from district government is listening. So get a load of this. In district of Columbia, where my main license is, I don’t know who was the miracle worker who said, “Oh, why won’t we move cannabis into alcoholic beverages industry?”
Dr. Misha Kogan::
So literally, when patient applies for DC medical cannabis license, what they see is that this is Department of Alcoholic Beverages, not a Department of Health, Department of Alcoholic Beverages. Who in their right mind came up with this stupidity, is just sort of… So you have some states that are thinking about this right and you have some states where it’s a mess. And how do we get to some kind of standardization? I don’t know. All I can say, or all I can do is to say, we got to teach our own colleagues first. I think to me, it’s so important topic.
Dr. Mark Hyman:
So speaking of teaching our colleagues and figuring out how to educate people, let’s talk about what the top clinical indications, what are the top reasons you’re going to use it? What are the conditions you treat? And what are you seeing in your practice?
Dr. Misha Kogan::
Right. So we mentioned pain, nausea, insomnia, spasticity. It doesn’t have to be multiple sclerosis related spasticity, I think in your spasticity. Actually, quite often, when a person has a sudden locked in muscles, for example, let’s say a neck, you can actually apply topical. Sometimes it’s really effective. All kinds of skin conditions. Lately, I find things like psoriasis, even like literally herpes flares. Those zoster flares-
Dr. Mark Hyman:
You mean it helps reduce those skin lesions, or just prevents the symptoms?
Dr. Misha Kogan::
No, it actually treats underlying problems. And it’s more complex than just THC, CBD. We don’t actually, exactly know which molecule is more important. But I often even use it for typical eczema in older age. I often use it now as a first line, you can even start with just trying CBD creams, sometimes even those work. So all kinds of skin conditions, I actually think… well, the way I kind of-
Dr. Mark Hyman:
And you use it topically for the skin lesions?
Dr. Misha Kogan::
Topically, topically.
Dr. Mark Hyman:
And use you use THC, as well as CBD for the skin conditions?
Dr. Misha Kogan::
Yeah, so for psoriasis, I like to use mix. So I like to use more THC than CBD. For eczema, I start with just CBD. And sometimes that’s enough, sometimes you have to add THC. I had a longstanding kind of a crack in the lip, which was from just cold sore, from herpes. I had it for about two decades and it would flare in the winter, when I go skiing, especially when the lips get dry. And it took about three months, twice a day application of low concentration THC. And now it’s been what, five, six years? I don’t know, the problem completely went away.
Dr. Mark Hyman:
Amazing, incredible.
Dr. Misha Kogan::
So it has, definitely, THC has anti-viral properties. So you literally can use it on low grade topical infections at almost no risk. If it doesn’t work, you have time to try something else.
Dr. Mark Hyman:
What else?
Dr. Misha Kogan::
Lots of different gastrointestinal problems. IBS, preferably-
Dr. Mark Hyman:
Irritable bowel?
Dr. Misha Kogan::
Irritable bowel syndrome, yeah. Preferably in the form where it goes down. So swallowing form and edible form. Shockingly, in inflammatory bowel disease, so Crohn’s and ulcerative colitis. You can use it orally, but actually, if the disease is mostly in the rectal area, you can use suppositories. It’s a very effective method. The data for that is mixed, but there’s a lot of people who try, IBD can be very persistent and very poorly controlled, even with new biologic drugs. And biologic drugs have a lot of risks, and side effects, and high costs. So I had a good number of patients in whom IBD has been controlled, just using cannabis alone. It sounds crazy, but I think cancer is probably one of the most controversial topics, we can spend a whole hour talking about.
Dr. Mark Hyman:
Yeah. Well, let’s talk about that for a minute because I’m sort of in this world and one of the things that I’ve heard people say, is that it can be CBD and other concentration specific forms, specific plants can be effective in cancer. Is there any data about that or what do we know?
Dr. Misha Kogan::
There’s very little data. I think we have kind of an early data. We have a little bit of positive data in brain cancer. We have a lot of data in preclinical. So if you take a Petri dish and you put the cancer cells on, and then you put cannabinoids, literally, almost all cancers get killed off. Now, how does that translate into what’s happening in our bodies is very hard to figure out. I mean, unfortunately, cancer translation science is generally slow. But I will tell you, those of us who use cannabis heavy in the practice, it’s just the patients find us. And often, they will do things without our… they’ll just do things, right? And they’ll come in to check in with us. And I’ll tell you, the most crazy cures I’ve seen in my practice, they all-
Dr. Mark Hyman:
Of cancer?
Dr. Misha Kogan::
… had cannabis. Yeah, they all had cannabis. That wasn’t the only thing that the patients were using. Don’t get me wrong. It’s always other-
Dr. Mark Hyman:
So was is just CBD or a combination?
Dr. Misha Kogan::
No, it has to be some THC. The ratios are not very clear. I tend to think that it’s much more complex than just THC and CBD. We do know that acidic forms, which are called CBDA and THCA have anti-cancer property. And then even some of the newer molecules that we’re just beginning to grow in our practice, so like CBG, for example, cannabigerol with a G, like in Georgia. So even molecule like that one, has some clear anticancer properties. So nobody truly understands yet. I know they’re experts with way more knowledge than me, who do this much more in their practice. But I just don’t think that there’s evidence enough to sort of put that into mainstream. It’s happening, whether we want it or not.
Dr. Misha Kogan::
I think there has to be a research and it’s happening slowly. I use it for almost all cancer patients, but not for cancer itself. I simply use it because well, think of it this way, right? Most patients, they’re going to have some cancer related pain, they’re going to have some cancer related nausea. They may or may not have anxiety and insomnia. But think about this. If I were to recommend them medications for this, it’s at least four pills. And here I have one product that can control it all, the dosing can be precised. The route of administration can be variable. And according to the patient’s liking. And guess what? You know what the side effect is, right? Somewhat, slightly getting high. So in literature, it’s a side effect. I’m yet to see any cancer patients tell me, “Yeah, it’s a bad side effect.”
Dr. Misha Kogan::
It’s not. I mean, people who overdose occasionally, it happens all the time, by the way, when you forget to mix the bottle or you just take a little too much. It’s not like it’s going to kill you. It may be very unpleasant and people can’t function, once they get a hold of understanding what happened and this never happens again, it often turns out into funny stories. I have plenty of those. One of my favorite ones, I get a call from our emergency room attending, saying, Dr. Kogan, one of your favorite patient claims she’s dead and she wants to talk to you.” And I’m like, “If she’s dead, how can she talk to me?” She’s like, “Well, I’m telling you, talk to her, she’s dead.” So yeah, she was using a bottle very appropriately, but went on vacation. The bottle was standing, things drifted to the bottom and well, so she didn’t mix it very well. Took the same dose, but from the bottom got overdosed, so-
Dr. Mark Hyman:
So this is really a safe drug though is what you’re saying, what are the risks and the side effects?
Dr. Misha Kogan::
It’s extremely safe.
Dr. Mark Hyman:
Are there any downsides? Reading about kids who use regular pot having cognitive function, ADD, and behavioral issues. Is there any merit to that? The old kind of pot heads, who would sit around and do nothing and just goof off, and-
Dr. Misha Kogan::
Well, I mean, nothing has no side effects, even cucumbers, as we say in Russia, right? I mean, you can die from anything if you use it the wrong way. A long story short, I mean, there’s tons of side effects. I mean, you have to really understand the medicine of it pretty well to know some of them. Heavy, heavy use of THC in youth is bad news because the brain doesn’t mature right. We know that. There’s a long lists of data, that’s conclusive. That says if the teenager starts heavily using cannabis, the outcome is probably going to be quite not good, much higher risk of schizophrenia, higher risk of accidents, higher risk of the brain being sort of as you said, we think of it as a pot head.
Dr. Misha Kogan::
But actually, the way the brain on chronic cannabis looks, it’s very specific. It’s sort of like this downing impact, suppression of lots of normal cognitive function, which leads to this sort of appearance of pothead. So I mean, heavy users now, interestingly, all of that, this is critical point, all of that comes from THC. What happens when you start putting a lot of CBD in the mix? Let’s say you’re using only one to one THC of CBD ratio. Most of us think all the side effects go away. So part of the recreational future, I think, is going to be, if you use products that have some CBD, is that going to nullify some of this longterm negative brain THC impacts?
Dr. Mark Hyman:
But, Misha, kids who smoke pot are smoking pot. They’re smoking the whole plant. They’re not having just isolated THC, so they’re getting CBD.
Dr. Misha Kogan::
Well, most of the recreational products are almost pure THC. And the reason is simple. The more CBD there is, the more different the high is going to be. In fact, often, there will be no high. If you have certain ratio, that’s way towards CBD, let’s say 20 to one, you may have very little high or no high. You may still have high, if there’s a high dose enough of THC. So the question is, should we gradually transition entire recreational industry to have CBD? That’s a hard philosophical question. Good luck transitioning anything that makes a lot of money, right?
Dr. Mark Hyman:
Yeah, right.
Dr. Misha Kogan::
But in my mind, that’s the main long-term concern, is this kind of heavy use of THC, non-medically, recreationally. In terms of side effects in medical use-
Dr. Mark Hyman:
So we’re seeing these kids having other issues like personality disorders, or bipolar disease, or depression, anxiety-
Dr. Misha Kogan::
It’s a self-medicating, yeah. Yeah, I was just reviewing article from JAMA that came in, in June this year. That basically shows any regular use of cannabis dramatically increased suicidality by like 40% and suicidal ideation. And they looked at the whole data, but if you carefully go back and you look how they looked at this, it appears very simple, that we just have a rapid increase in suicidality in all of the population of The United States. And this predates the COVID by the way. So it’s like till between 2008, 2019. So the suicidality and depression is on the rise. So a lot of people try to self-medicate.
Dr. Misha Kogan::
In fact, I often see people who are chronic users coming to me, because they’ve been trying to follow the literature and they’re using it for depression, for PTSD, for anxiety. The problem, when it’s often non-medically guided use, they get fewer THC, recreationally. They often use products that are too strong and you can have a very beneficial impact with much lower doses, with much less side effects. So it’s a problem of lack of education. And it’s also a problem of lack of access, ease of access to the medical products. Instead, people turn off into recreational without good managed advices or good recommendations. And partially, I hope they read my book and it’ll have-
Dr. Mark Hyman:
Yeah, of course. Well, it was so comprehensive, Misha. And you address some things that are very confusing for people. I mean, you talk about the science behind it, you talk about the sort of social and political aspects. You talk about the medical benefits of it. But you also talk about sort of the landscape out there now. And I remember when I was in college, it was like, you get Maui Wowie, or Saint-Siméon, or whatever, like where it came from. And that was like your brand. And now you go into one of these legalized marijuana stores and it’s overwhelming.
Dr. Mark Hyman:
It’s like picking wine. Where does it come from? And what is it? So you want to inhale? Is it edible? Is it topical? Is it a vapor? Do you want a pre-roll? Do you want to stick it up your butt? And what’s the ratio of this and that? And does it make sense sleepy? Or is it indica CBD, or is it sleeping, or happy, or party? I mean, it’s overwhelming. And I mean, I’m no novice here, but I definitely find it overwhelming and I wondered how you guide people into which delivery mode you should use and which is the best for which thing. So can you talk about that?
Dr. Misha Kogan::
Right, and that’s overwhelming for you. Think of some of my patients, who are over 75, 85, or 95, and they’ve never tried it, or they tried it 30 years ago and they have no recollection. So yeah, I usually start most of the patients with a sublingual full extract, what we called FECO, full extract cannabis oils. They tend to be most easy to control. You can start with just a couple of drops under the tongue, absorption bypasses the liver. So you don’t have the problem of hyper activation of THC that edibles can give a lot of people, if they’re not experienced, a very strong high for a very long time. And that can be very unpleasant and can basically kind of psychologically prevent from trying something again. So I almost always start either with topical, rectal, or with sublingual. Sublingual is by far most common.
Dr. Mark Hyman:
Topical, oral, or sublingual-
Dr. Misha Kogan::
Topical, sublingual, or rectal. So I often, if the patient comes in with something pelvic, like a pelvic pain, like ulcerative colitis, we very often would try suppositories straight up, because cannabis’ systemic absorption of rectal has sort of always been in question. And I do think there is some, but it’s just not as much as with oral and sublingual. But if you have a localized problem, so I have the three mantras with cannabis. Start low, go slow, and deliver it where it needs to go. That third one, I think is unfortunately, not as commonly understood out there. So if you have a lesion on the skin, put up there. If you have a lesion in the pelvic area, okay, well, so you can put it vaginally or you can put it rectally, if-
Dr. Mark Hyman:
But what if you have like anxiety, or nausea, or pain, or sleep-
Dr. Misha Kogan::
Right, so anxiety, and nausea, pain, that sounds more like neurological issue, right? So we’ll put it under the tongue-
Dr. Mark Hyman:
So you put it in the brain.
Dr. Misha Kogan::
… right, put it under the tongue. Vaping or smoking, a lot of people do. I’m not opposing to them, but those tend to have a lot more side effects. We didn’t kind of actually discuss that, right?
Dr. Mark Hyman:
Yeah, I want to talk about that.
Dr. Misha Kogan::
So vaping, smoking, you’re taking in the smoke, high temperature, you’re probably going to have at least some damaging lung impacts, even if the evidence is not necessarily clear that you’re going to… Well, there’s no evidence that you’ll cause lung cancer, no matter how heavy you smoke cannabis. But you can cause chronic cough-
Dr. Mark Hyman:
Does it cause the same kind of problems as smoking, vaping tobacco? In other words, does it cause pneumonitis and so forth?
Dr. Misha Kogan::
No, right. To much, much lesser degree. It definitely can cause chronic cough and bronchitis, but it doesn’t seem to cause lung cancer or say like interstitial pneumonia. Although, right, we had this scare right at the onset of COVID, when we had people who were using black market cannabis. They had this sudden bad lung disease and some people died, young people. So this has nothing to do with cannabis, EVALI it’s called, I forgot what it stands for. It’s basically a long inhalation injury from probably vitamin E acetate, which is a preservant in the illegal cartridges.
Dr. Mark Hyman:
So we don’t know for sure about inhaled and what it does to the lungs, like we do for vaping, right?
Dr. Misha Kogan::
Well, it doesn’t matter actually, whether you vape or smoke, both generally can come at a high temperature. Although, there are vapes now that have much lower temperatures. So those are better.
Dr. Mark Hyman:
Oh, so we used to use bongs for it, remember?
Dr. Misha Kogan::
Right. Well, Volcano has been around forever, right? It’s like a complex vaporizer that can precisely control the temperature. That’s actually often used in research because it’s so precise. Volcano has been one of the most common vaporizers in research. So I mean the final thing is that most of the prior use, recreational use is coming from inhaled route. So a lot of the research simply coming from that area because you just have a lot more people doing it this way. But I think the future of cannabis is really not an inhaled products.
Dr. Misha Kogan::
I think the future is in sublingual, oral, capsules, topical, rectal. People will keep using inhaled, smoking, whole flower, vaping. There’s nothing wrong with that. And I just, especially in my practice, where a lot of people over 65, I have a hard time initiating somebody new on inhaled product. They find out that it’s going to cause cough and especially if they already have some lung disease, like asthma, it’s not necessarily first route. But for certain things, it’s got sound, let’s say you have a severe nausea and you really can’t put anything in the mouth, what else are you going to do? Well, you can smoke-
Dr. Mark Hyman:
That’s what happened to me. I couldn’t eat, I was throwing up all the time, yeah. Now in terms of the forms and the types, I mean, how do people know what to pick? I mean, not everybody has a doctor that’s informed like you and so how do you know when you go in? You can maybe look at the route of administration, but there’s all these different varieties. It’s overwhelming, it’s like flavors of bubble gum.
Dr. Misha Kogan::
Right. Well, so I think you have to learn a little bit first, before you go to the-
Dr. Mark Hyman:
Oh, tell us what would be the take homes for people? What are the things that people should know before they walk into a dispensary?
Dr. Misha Kogan::
Right. I think the first take home should be know what condition are you going to use it for. And get a basic sense for that condition, what the experts would recommend. So if you get my book and you look up your condition in my book, you can see what I would recommend. There’s tons of other great books. It’s not the only one, and there are lots of experts, who actually know a lot more than me. But start at least from some basics, because otherwise, if you go and you rely just on budtender, it’s probably not the smartest thing. I hope in the future, in 10 years, I can say, “Oh no, just go and there’s going to be an educator in the dispensary, who’s going to tell you exactly what you need.
Dr. Misha Kogan::
And there are some dispensaries that are starting to do that. So sometimes if I’m totally strapped for time and I know a few dispensers in my area that do that well, I would send the patient there. Unfortunately, even with those situations, often, we have issues because you’d have a sensitive patient and they will just start so much higher. But then after you get some core basics and you started trying, you have to be persistent. Often, just starting with one product is not going to work very well. You have to try two or three, until you find your own personal kind of… And not only one product, often people need between two to three. That’s pretty much-
Dr. Mark Hyman:
Two or three different products. And why would we need two or three products?
Dr. Misha Kogan::
Well, let’s talk about pain for a second. That’s an easy example. Let’s say you have some kind of a chronic pain, let’s say fibromyalgia. If you get a product that has turpines that are more activating and you take that past 5 o’clock at night, you’re going to stay up till midnight or past. So you don’t want to do that. You want to take that early in the day. But the opposite is true too.
Dr. Misha Kogan::
If you take a calming, more sedating strain in the morning, you’re not going to be able to function very well, you’ll be sleepy all day. So here’s a simple example. If your pain needs to be controlled more than once a day, which often the case, you want to take something activating in the morning, something sedating at night. That’s one simple statement. But more often, you also can use different routes of administration. For example, edibles can be great if you wake up late in the morning and can’t sleep, let’s say your insomnia goes at 3:00 AM. You just wake up and then you’re up and you can’t go back to sleep. The edibles will work great. But if you have both-
Dr. Mark Hyman:
It won’t make you too sleepy, like in the morning, when you wake up?
Dr. Misha Kogan::
Well, you have to dose appropriately, right? You have to titrate to dosing. So, that’s the principle. Start low, go slow. You’ll start with a very low dose. And I usually start with sublingual forms. There’s this idea of therapeutic widening of the window. So if you start sub therapeutically, for couple of days, three to five days, and then you start increasing, you’re running much, much lower risk of side effects. If you start and you very quickly titrate up, let’s say each next dose adds 20, 30%, which is commonly done for pain, you may actually end up overdosing quickly.
Dr. Mark Hyman:
And then be groggy in the morning.
Dr. Misha Kogan::
And be groggy in the morning. But if you do this carefully and you get to a point where it’s working, so you could actually use sublingual right at bedtime or a few minutes before, because it will kick in quick. And then you can also take an edible, that will kick in a lot later. So some people can do that. Often, it’s not even needed. You can just take the oral a little bit earlier. But it takes time to figure all this combinations.
Dr. Misha Kogan::
And you need to either have a very knowledgeable provider, who will be sort of like an advisor and say, “Look, okay. Well, this is what happened. This is why it didn’t work or this is why you had side effect.” Well, you have to try it on your own if you have no access. So the book is written, both to help people who are complete novices, but also people who’ve already tried something. Because it outlines some of those pitfalls. Sort of what happens if you overdose and you’re afraid of going back to it? How are you going to do that? And that’s why still, a lot of people take inhaled because the predictability of the effect is better.
Dr. Misha Kogan::
You take a drug and you know how it’s going to make you feel, especially if you found the strain that works for you. I have nothing against it, it just often, for medical reasoning, that may not be the best approach. But often I don’t, if the patient comes to me and says, “Look, I’ve been smoking my whole life. This is what I do. This is how it works for my pain.” I often don’t say anything because I find that not often easy to transition person from smokable product to something else. I would tell them what I think and then give it up sort of up to them to say if they want to try it. I had a number of people who switched over the years, yeah.
Dr. Mark Hyman:
So what would be the best sort of sleep recommendations? Because a lot of people have insomnia, 70 million people have sleep disorders in this country and sleep issues. It’s a lot of people. So I’m just wondering, what your sort of starting recommendations are for people and where they could kind of begin to think about using it.
Dr. Misha Kogan::
Right. So find the product, find the sublingual product, like an oil, a drops, or what we call FECO, full extract cannabis oil. I don’t like alcohol because alcohol can burn the mouth. There are some tinctures that are alcohol based. I tend to like oils more, whether it’s olive oil or MCT oil. So find a product oil like that. A lot of the products that are specifically designed for sleep, they’re going to have a couple of simple features. The indicas is again, outdated. But that’s the kind of original term. So you’re looking for indica products, right. But now that we’re going away from it, you can look for a couple other things. You can look for this molecule called CBN, C-B-N as Nancy-
Dr. Mark Hyman:
CBN, yeah.
Dr. Misha Kogan::
… instead of CBD. So products that have high CBN in mixed with THC, sometimes are really effective. And often, the products would have the turpines that are coming, inhibiting, like linalool is one, but there are others. And the products would often say that on a label, like sleep, or tranquility, or whatever. And frankly, those products often design specifically for sleep. The good news is that a lot of the times, budtenders would know that. So, if you come into the-
Dr. Mark Hyman:
They know that?
Dr. Misha Kogan::
They would know that, yeah. And even though there are a lot of edibles for sleep too. There are edibles specifically designed to have the same sedating impact. I always tell people, start with sublingual, you’re running less risk of the next morning grogginess. You don’t know your particular THC need. It’s actually very interesting, the THC needs for insomnia varies quite a bit.
Dr. Misha Kogan::
I would say somewhere between three milligrams is probably the lowest, all the way to maybe 10, 15, 20 milligrams. And most people fall somewhere between five to 10 milligrams, what I’ve been seeing. But again, my population on average is a little older, and sicker, and more frail, and more sensitive. So I may be seeing a bit of a lower spectrum in my clinic. So I understand there are probably people who work with other groups of patients, where the dosing may need to be higher. So for pain, we generally think-
Dr. Mark Hyman:
Start with sublingual for sleep.
Dr. Misha Kogan::
Start with sublingual.
Dr. Mark Hyman:
Maybe an edible.
Dr. Misha Kogan::
Maybe an edible.
Dr. Mark Hyman:
And it takes about an hour to set in?
Dr. Misha Kogan::
Edible will take at least an hour, maybe a little bit less. Sublingual can take 20, 30 minutes, sublingual will tend to work a little bit faster. So plan accordingly. If you need to fall asleep at 11:00 and you take it right at 11:00, you may with either form, stay up for a little bit longer than you want. So you may want to time it a little bit ahead of time. Again, that’s why people like smokable, right? Because it hits right in and there’s no lag time.
Dr. Mark Hyman:
Yeah, it’s very quick.
Dr. Misha Kogan::
Right. And again, as I said, in the literature out there, I often speak about non-inhaled forms, simply because they’re safer. But it doesn’t mean that if you have a problem that you feel needs to be addressed urgently, I think some amount of inhaled products is totally fine, if it’s limited and done in a smart way. And again, yeah. So the lower temperature of inhaled product, the better. So the vape, if you get a quality vape, is probably safer than burning a flower, if you can vape the flower. Now there’s devices that are literally, I’m not kidding, iPhone controlled or computer controlled, where we can pick precise temperature and the dosing. So that’s the next generation.
Dr. Mark Hyman:
Really?
Dr. Misha Kogan::
Yeah. There’s some devices where you can tell the vape you want to take 10 milligrams. And if you know the cartridge concentration, it will calculate it precisely. So when you inhale, it will dose it right for that dose. So that’s a future, it’s already here, actually. It’s not even a future.
Dr. Mark Hyman:
Is it commercially available?
Dr. Misha Kogan::
Yeah, yeah. They’re commercially available, you can buy them. The one system that I’m aware of, called, Pax, P-A-X. So they are doing that already. Of course, it’s not cheap. You can imagine. So it’s not a typical pen vape, can we be 10, $20. Those things can be hundreds of dollars, if not more. So they’re not cheap.
Dr. Mark Hyman:
And they’re controlled by your iPhone.
Dr. Misha Kogan::
They can be controlled by your phone, or most of the time it is phone because it’s most convenient, because you want to set up certain parameters on the device to be precisely delivered.
Dr. Mark Hyman:
Amazing. Now also, there’s been some noise about COVID and cannabis, especially for long haulers. What do we know? What do we not know? I mean, it can be that there’s not much research out now.
Dr. Misha Kogan::
Yeah. Well, so the big noise was, I think, about a year ago, when somebody, and there was a researcher in Canada that made a splash, saying, that cannabinoids could be used as anti-COVID. I honestly think that was just a hype. I looked at that study. It was very, very preclinical. And we know that THC has a very potent anti-viral effect, so there’s nothing surprising there. But translating that to the human, I think it went from, it was a preclinical study to the Facebook saying cannabis cures COVID everywhere. And I was like, “Oh my God.” Now it’s fascinating you brought up long COVID, I actually feel strongly that in the last year, I feel like a third, if not half of everything I do is geared in that direction, simply because we have an influx of patients. And there. Cannabis can be godsend for a lot of symptoms.
Dr. Misha Kogan::
A lot of people still have horrendous insomnia and fascinatingly, they have really bad cognitive problems, like the attention lack, brain fog. Actually, I have seen some patients do really well with a very low doses of THC and CBD. I don’t necessarily going to use it on everybody. It’s still evolving as to who should we pick for that? A lot of people have, they lose a lot of weight and then they have this kind of general fatigability, and they’re not eating well, and they don’t have an appetite. Definitely, cannabis can be occasionally helpful for that. I would say there’s actually, I didn’t mention that as one of the most evidence-based approach, everybody know that you smoke and next thing you know, you really want to eat. It turns out the evidence for that is very mixed. It’s not as clear as you would think.
Dr. Misha Kogan::
There are definitely people who benefit from it. When you look at the studies, the studies have never been conclusive in contrast to pain or things like nausea. So I still use it. I think that newer molecules like CBG, for example, have tremendous promise for that. But again, we need a lot more data to be conclusive. But definitely can use it. So it can be a very supportive, additional tool for everything we do. But of course, you know more than anybody that a lot of this patients with long COVID, they have chronic inflammatory response. They have a mitochondrial suppression and kind of just general low energy states, where you really want to boost the cellular function first. I don’t necessarily think of cannabis being their first line. In fact, I’d be cautious if somebody’s going to start smoking for some of the relief of their symptoms. Actually, energy can be drained to some degree.
Dr. Mark Hyman:
It’s true. I mean, we’ve done a bunch of podcasts on long COVID and I think there’s more to learn, for sure. But it’s for those who are listening and want to know about what to do about that, which now it seems to be between 10 and 30% of people who get COVID, which has been millions and millions, so we have-
Dr. Misha Kogan::
And now it seems like the Delta is also going to give us long-term post COVID kids at somewhere between five to 10% of kids. So it’s scary.
Dr. Mark Hyman:
Yeah. I mean, I think people are worried about COVID, but I’m more worried about long haul COVID. Because most people don’t die when they get COVID. But you think of 30% of 200 million people, we’re talking 60 million people are sick-
Dr. Misha Kogan::
We have more than 1,000 patients at GW on the waitlist in just one clinic, just on waitlist because we can’t get them in quick enough. Because it’s a complex process of intake.
Dr. Mark Hyman:
Yeah. I think it’s really a problem. But from a functional medicine perspective, there’s a lot people can do. And I think symptom management through medical marijuana can be part of it, but it’s not really the only thing.
Dr. Misha Kogan::
Exactly.
Dr. Mark Hyman:
So, Misha, when people are listening to this and they’re like, “Okay. Well, I’ve got some of these conditions. I have sleep issues. I have pain. I have digestive problems. I have MS, I have,” whatever it is that we’ve been talking about. How do they go about finding a good dispensary, a doctor who can guide them? Where do people start? It is a little overwhelming.
Dr. Misha Kogan::
Right, it is overwhelming. So there are some really good online resources. I think Leafly is one, Weedmaps is another. So a lot of this websites will have a list of practitioners in the area. If you’re in a state where it’s legal-
Dr. Mark Hyman:
Can you give the websites for both of those?
Dr. Misha Kogan::
Sure. Leafly, oh, spelling. You ask a Russian to spell something, I have to look it up. I think it’s L-E-A, leaf, F-L-Y. Yeah, I think that’s right. And it is an app also. So you can-
Dr. Mark Hyman:
I’ll put it in the show notes too.
Dr. Misha Kogan::
Yeah, uh-huh (affirmative). L-E-A-F-L-Y. That one, most of the states would have a list of the doctors, who are formally authorized to recommend. So if you’re in a state where it’s legal, the first step, go to the actual state website, that’s responsible for medical cannabis and there will be a website. And it’ll explain to you, typically, the process of how to do it. If you can’t figure it out, there are websites, other websites that will help you. I really like one called NORML, N-O-R, okay. I got to spell that too. Interestingly, most of my spelling efficacy is when I type things, because I remember what my hands are doing. N-O-R-M-L. So it’s a national organization for the reform of marijuana laws. So they have a list for each state. How you apply. Like what is the process? What are the pitfalls?
Dr. Misha Kogan::
Because you got to get a card first. So once you get a card, hopefully, you have way to access where the physicians, because to get a card, you have to get a medical recommendation. So you went to a physician or a healthcare practitioner, who is approved for this state, like nurse practitioner or naturopathic doctor, et cetera. So hopefully, they’re knowledgeable. Now, what if they are not knowledgeable? Well, then your next level is either you’re going to find someone who actually understands something and it doesn’t have to be a doctor. There’s a lot of people who call themselves now, Canna Coaches. Some of them are great. In fact, in the beginning, 10 years ago, one of my sort of most informative colleagues was one such person.
Dr. Misha Kogan::
I mean, basically, Beth, self-learned the topic because she was basically almost dead from all kinds of medical problems. She was taking 30 pills. Her bills were in thousands of dollars a month. And she said, “Screw, all this.” Went to Colorado, learned all this stuff, got herself off all the pills and said, “Look, I got to teach.” So some people, they have just, through their life knowledge, they became so interested and engaged, then that becomes their whole world. So people like that end up, usually, being the masters, I would say. And if you can find one of those, great. If you can’t, you’re going to have to rely on your budtender. So then the road can be split. If you get a good one, you’re in luck. You may hit a jackpot right away and you’ll be fine and it will work.
Dr. Misha Kogan::
And if it’s not and something happens. You have to kind of go back and again, look for a provider or a source of information that’s going to work. So I know it’s not a satisfactory answer, but the reason is, we have to teach our colleagues. So I kind of, the way I took it on myself, I’m not a researcher. There are experts in this field, who are way deeper than me, but I’m in the university, right? I’m a full-time faculty. So we said, “Look, we got to do something.” And instead of creating yet another attempt at forming academic program, that’s very expensive. We said, “Look, we got to establish some kind of a cohesive process, where we will create a set of competencies.”
Dr. Misha Kogan::
So medical education happens this way, you have to prove to the larger administrative body of medical education, that this topic has a set of competencies that can be followed as a standard. If you have a couple of schools here and there, and few students can learn, that’s fine. But the next step really have to be every medical student coming out of medical schools must know this topic. And they not just need to know, “Oh, there are potheads, and there are none, and there’s some little bit of evidence.” No, they have to know how to recommend it. They have to know a basics of laws in states where they practice. They have to understand basic clinical application, basics of toxicity and how to actually, practically recommend it.
Dr. Misha Kogan::
And if we create set of competencies and then try to go to American College of Graduate Medical Education and say, “Look, you got to approve this.” Then that’s the next step. So, that’s actually what we’re doing. We got a grant from industry to organize this. So we already started a process. It’ll probably take some months to get this, but we’re hopeful that we’ll go and try to publish this in a decent journal and then try to push this. But it has to start something like that, because we have to start pushing the future of cannabis to be away from the industry or not away from industry, you can’t do it. But also, towards more academia and more stigmatization. Otherwise, industry is going to standardize it, not necessarily the way we want to see it.
Dr. Mark Hyman:
Yeah. I mean, I think you have a very good point there, Misha, because people are using it recreationally. They’re using it for mild symptoms like you’d get a Tylenol over the counter or something like that. But there are more focused medical indications and there are more and more going to be discovered as we’re doing the research and as you found, patients with psoriasis, or MS, or things you wouldn’t necessarily think about. And so, as a physician, I like to know what I’m doing. I like to know the dose. I like to know the source. I like to know where it’s coming. I like the standardization.
Dr. Mark Hyman:
I mean, whether it’s a drug or a supplement, I’m very, very picky about what supplements I recommend, because I want to make sure that the raw ingredients were sourced from the right place. I’m not sure I want them to come from China. If they come in, I want the herbs to be tested. I want the purity, the potency, the active ingredients, the concentrations, the bioavailability, I’m sort of obsessive about it. In the same way, I feel like with medical marijuana, you don’t know what you’re getting. It’s kind of a free for all. It’s not medicalized. And I’m not saying they should be only medical, but that there should be a medical, like just there are professional grade brands of supplements or you can buy the crappy stuff at Costco-
Dr. Misha Kogan::
That’s actually a critical point. And that’s one of the passing the level of initial knowledge. So going away from who knows what, to a point, how do you assure quality here? That’s probably the second most important problem right now. Believe it or not, shockingly, it’s much lesser of a problem in medical cannabis area compared to the CBD and the hemp. Because there, there’s zero control. So unless it’s a trusted company, you have no clue what is happening. Just what I mentioned, is are you going to trust your Walgreens to produce quality CBD?
Dr. Misha Kogan::
I don’t know. I’m not saying anything. But I probably wouldn’t, right? So I would have my own list of brands that I would trust that I would go to. With medical cannabis, each state that passed the law is required to regulate it. And most of the states actually did a reasonable job to say, “Okay, we’re going to control the production. We’re going to assure there’s some kind of attempt at quality assessment and quality measures.” So if you’re getting medical cannabis, you can be assured, you’re probably getting nothing from China. It’s locally grown. That’s actually a legal requirement because of the state.
Dr. Mark Hyman:
I mean, is it organic? Should you be worrying about pesticides and stuff like that.
Dr. Misha Kogan::
No, right, right. So you have to still worry about things. But you have to worry less compared to what’s going on with hemp. The other problem with CBD and hemp is, think of it this way, in order to get CBD in concentrated amount from hemp, you’re going to have to grow way more plants than cannabis. And so, if God forbid you have mold in there, you brought up this mold problem, you’re going to concentrate that toxin down. And we already have seen issues where there was serious illnesses with people consuming mold in cannabinoid products, whether it’s hemp or cannabis. So you really don’t want to hyper concentrate extracts if there’s any possible toxin, right? Because you’re going to concentrate the toxin. Well actually, there is a belief there’s been some deaths related to mold or other toxins in a concentrated product.
Dr. Misha Kogan::
So definitely, I think there has to be more regulatory mechanisms in the future. I think when the whole nation moves away from this mix of mishmash of states to descheduling or rescheduling cannabis, we’re going to have some kind of national process. And I’m very hopeful. I think if you look at most of the decent industry partners, they’re doing their best. I mean, a lot of the times it’s hydroponically grown. So hydroponically, definitely, generally speaking, will probably be safer, contaminants-wise. We talked about the cannabis is weed, right? I mean, there’s reason why we’re calling it that.
Dr. Misha Kogan::
It’s grows really quickly. It’s a very robust plant, it mutates quickly. If you have a right conditions, it’s relatively easy to cultivate it. And I mean, it is an art. I mean the cultivation of cannabis is a profound art. But it’s a lot easier than some other plants. And it’s a lot easier than a lot of or most of the, I would say, medicinal plants. So I think because of that, making the future of boutique cultivation or quality cultivation, forget just boutique, I think is quite bright. And I feel strongly, we’re going to have some maturation of the industry, where bed partners over time is going to evaporate and we’re going to be left with some reasonable quality that everybody can have access to, yeah.
Dr. Mark Hyman:
So, Misha, as we wrap up, I wonder if you have any parting thoughts about what you’d like to share with the audience about your take homes around medical marijuana.
Dr. Misha Kogan::
I think there are two big take homes. So one is I see cannabis as this amazing example of integration of plant medicine into our health. It’s sort of like rediscovering. We’ve had it for thousands of years, we forgot about it. We made it illegal, for whatever the… And then now it’s kind of coming back, roaring because we’re realizing the potential here. So I think following this field is important, but I also want to say critical. It’s not the only tool. It just needs to be effectively integrated and used correctly in the mix of everything else we do. It’s sort of a great example of why integrative medicine or functional medicine is the future, because we have so many other tools.
Dr. Misha Kogan::
And when you learn how to effectively use them, that’s where the magic occurs. So don’t get, over-hyped, don’t think that CBD, THC is going to cure everything under the sun. Go into the resources that are balanced and deliver the knowledge in a evidence-based approach with some kind of neutrality in it. So there’s not a lot of commercial interest. Because unfortunately again, most of the data or information out there is coming from commercial sources just trying to make more money on. And I think that will change, it will change. So future is bright, use responsibly, find the way to understand it, and you have to do it yourself. You can’t just rely on some doctor tell you what you’re going to take. You have to learn the basics here, at least for now.
Dr. Mark Hyman:
Thank you, Misha. Well, thank you for spending the time, doing the homework, the hard work that summarizes what we need to know in your book, Medical Marijuana: Dr. Kogan’s Evidence-Based Guide to the Health Benefits of Cannabis and CBD. It is the book, as far as I’m concerned, about medical marijuana. And everybody who’s interested in using it, who’s tried it, who wants to learn more about it, who’s figured out that maybe they would benefit from it, should definitely get a copy.
Dr. Mark Hyman:
Because it’s the most coherent, straightforward, and clear, both academic and also lay person guide to medical marijuana. And I learned so much and I thought I knew a fair bit, but I was basically just scratching the surface. So for those of you listening and love this podcast, please share it with your friends and family on social media. Leave a comment, we’d love to hear from you. How has it benefited you to use medical marijuana? Subscribe wherever you get your podcasts, and we’ll see you next week on The Doctor’s Farmacy.
Speaker 1:
Hi, everyone. I hope you enjoyed this week’s episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you’re looking for help in your journey, seek out a qualified medical practitioner. If you’re looking for a functional medicine practitioner, you can visit ifm.org and search their find a practitioner database. It’s important that you have someone in your corner, who’s trained, who’s a licensed healthcare practitioner, and can help you make changes, especially when it comes to your health.
