The Benefits Of Medical Cannabis
Listen as Dr. Mikhail Kogan discusses the benefits of prescribing medical cannabis.
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Learn more about Mikhail Kogan, MD
Mikhail Kogan, MD
Mikhail Kogan, MD, is a geriatrician with The GW Medical Faculty Associates and an assistant professor of Medicine at The George Washington University School of Medicine & Health Sciences and is affiliated with The George Washington University Hospital. Dr Kogan obtained his medical degree from the Drexel University College of Medicine in Philadelphia, Pennsylvania. He completed his residency in Internal Medicine at Montefiore Medical Center in New York City and a fellowship in Geriatric Medicine at The George Washington University Medical Center.Learn more about Mikhail Kogan, MD
Dr. Mike Smith (Host): Radiosurgery is surgery using radiation. It's the destruction of precisely selected areas of tissue using ionized radiation rather than excision with a blade. Welcome to The GW HealthCast. I'm Dr. Mike Smith, and today's topic, Advances in Radiosurgery. My guest is Dr. Sharad Goyal. Dr. Goyal is Chief of The GW Radiation Oncology Division at The GW Cancer Center and Professor of Radiology at The George Washington School of Medicine and Health Sciences and is affiliated with The George Washington University Hospital. Dr. Goyal, welcome to the show.
Dr. Sharad Goyal (Guest): Thank you for having me.
Host: In my little teaser there, I gave a little definition — you can find that anywhere on Google, a basic definition of Radiosurgery — but let's have the expert, yourself here, help the audience understand just what is radiosurgery.
Dr. Goyal: Okay. Just to give you a little bit of background, the concept of radiosurgery was first described by a Neurosurgeon named Lars Leksell in the 1950s. He proposed radiosurgery as an alternative to open brain surgery. He proposed it to avoid doing brain surgery in patients that may be too sick to get brain surgery. Over time, radiosurgery has emerged as a unique discipline involving surgeons, radiation oncologists, and physicists.
The basic concept of radiosurgery relies on the principle of precisely delivering high doses of radiation therapy to a target, and that target is typically some form of cancer located either in the brain or the body.
Host: Let me ask you something with that. I know my listening audience, the minute they hear high-dose radiation they get a little nervous. What does that really mean? Can you tell us what does that mean to them as a patient? Is the high dose controlled? When you say "precise" what does that really mean? How is that high dose controlled?
Dr. Goyal: Okay, so that's a very good question. When we talk about high doses of radiation, I'd just like to — when I talk about this with a patient I like to give them the alternative. The alternative is having your brain cut into and having the risk of infection, having the risk of having permanent weakness or paralysis from brain surgery. Radiosurgery is an outpatient procedure. This procedure typically takes between 30 and 60 minutes, and patients who drive in can drive home. There is no downtime. They can go back to work immediately, and they typically feel quite well.
Getting to your point about high doses of radiation and what that means for the patient. Basically, patients who are undergoing this treatment do not feel anything during the radiation. They are awake. They are conscious, and what they see or experience is a machine that moves around them delivering them the treatment.
The concept of radiosurgery stems from radiation therapy, and radiation therapy typically is a treatment where we deliver radiation therapy on a daily basis over the course of six, seven, eight, or even nine weeks time. We give a little bit of radiation each day, and the damage that the radiation does on a daily basis to the cancer builds up over time. By the end of the six or nine weeks, the cancer is effectively eliminated.
Host: Right.
Dr. Goyal: Radiosurgery is kind of a shift in that concept where instead of giving low-dose radiation over the course of many weeks, we're giving high-dose radiation over the course of one day or up to five days.
Host: Ah, got you.
Dr. Goyal: A decision of one to five days is based upon the location of the tumor, the type of tumor, et cetera, et cetera.
Host: Does that mean — with those cases where high-dose can be used for one to five days — does that mean — is one of the innovations here the ability to be much more precise in targeting, say, a tumor?
Dr. Goyal: Correct. Again, the concept of radiosurgery has evolved over time. Currently, in 2019, with the types of imaging that we are able to offer patients, we have sub-millimeter accuracy when we deliver the radiation treatment.
Host: Wow.
Dr. Goyal: And those are innovations in imaging and innovations in the delivery of the radiation therapy.
Host: And Dr. Goyal, how has that — in general, how has radiosurgery, in your opinion then, how has it affected or changed cancer treatment or cancer outcomes?
Dr. Goyal: Okay. When we are able to offer patients radiosurgery, we're not trying to detract or take away from a patient that needs surgery. My thought is, and what I tell every single patient, is that nothing can beat a great surgery. But if the surgery is going to leave the patient with permanent paralysis or deficits like oxygen-dependence, then they may not want to have surgery or surgery may not be indicated. Our treatment is an adjunct to surgery.
There are many studies that have been done. These are large studies taking hundreds or thousands of patients and giving half of them open surgery, whether it's in the lungs or prostate, or brain, and then the other half gets radiosurgery. In those studies, the patients getting radiosurgery have the same outcomes as patients getting open surgery. There are many benefits to open surgery, but in patients that either don't want open surgery or can't get open surgery, we have a treatment option available to them.
Host: Well, that's interesting, Dr. Goyal. Do you ever — with those kinds of studies, and I know that probably more needs to be done, more definite conclusions probably need to be drawn, and I get that — but with those kinds of results, when you look at how high-dose radiosurgery, in particular, can be one to five days, you're not cutting into anybody, there's less risk of infection and all that kind of stuff. If the outcomes are just as good as that traditional surgery, do you ever see in the future radiosurgery being the first place to go?
Dr. Goyal: Oh, that's a very difficult question. I may make it seem like radiosurgery is the best thing since sliced bread, but there are side-effects of radiation, and we typically do not offer radiosurgery, or we tend to push patients towards open surgery in a variety of situations. Number one, if they're young. The reason for that is radiation therapy can cause cancer. Even though we're using radiation to kill cancer, 10, 20, 30 years down the road, there may be a 1 or 2 percent risk of that patient developing a second cancer. If that young patient has a long life-expectancy, we will be pushing them to undergo an open surgery.
Host: Got you.
Dr. Goyal: That's one example. Each patient is different. I do feel that radiosurgery does have a place in the battle against cancer. It will never replace surgery.
Host: Got you. Speaking of the future of radiosurgery, where do you see this type of treatment going? What's on the horizon in terms of innovation?
Dr. Goyal: Okay, that's a very good question. There are several things that are here or will be coming down the pike. One is a machine that uses an MRI to help guide radiation therapy. You can use this for standard radiation treatment, or you can use it for radiosurgery. Imagine if you can get a very high-quality MRI image that helps you target the tumor, and then on the day of the treatment we can take another MRI, and we can better assess where that tumor is at that day, whether it's grown, or whether it's moved, or if it's close to another organ, we can change our radiation delivery to either maximize dose to the tumor and minimize radiation to the surrounding organs.
Other advents in radiosurgery include basically modifications on existing systems to help the radiation be more accurate.
Host: And that's really interesting, Dr. Goyal, it seems a lot of this is coming down to really controlling where that radiation is going, right? If we can more and more improve that precision, that seems to be where the power of radiosurgery lies, right? If I can give a higher dose, and it's not hitting any other surrounding organs, that means I have a better chance of killing that cancer, less chance of damage to organs and maybe those future cancers, right? Is that really — it's becoming precise — is that where you think most of the research is heading towards?
Dr. Goyal: Yes, okay. There is another angle to radiosurgery, and that's the concept of targeting a tumor in one part of your body and then seeing a response in other tumors in other parts of your body that were not treated with radiation, okay? That is a concept that has to deal with how radiation modulates the immune response in a patient. Basically, if I target tumor in a patient's lung, that will help stimulate their immune system to ramp up, and their immune system will help target any cancer cells that may be in other parts of the body. Something that many investigators are looking at nationally and internationally is combining radiation therapy with combinations of immunotherapy. Immunotherapy is drugs that also help ramp up your immune system.
Host: Right. That's very, very interesting isn't it, Dr. Goyal? It's that concept, that idea that a little bit of stress is actually good in some ways, right? It's a whole class of study called hormesis, and that's a very interesting maybe future, positive benefit of radiosurgery. You know, Dr. Goyal, this has been a fascinating conversation. Just to kind of summarize for the audience, what would you like them to know about radiosurgery?
Dr. Goyal: Radiosurgery is a cancer treatment where we are able to deliver high doses of radiation in one to five treatments. This treatment is equivalent to open surgery whether it's brain surgery or lung surgery for many different types of cancers. It is a non-invasive, outpatient procedure, typically taking 30 to 60 minutes a day. We offer it to patients in conjunction with surgeons and medical oncologists. We typically make decisions as a multidisciplinary group, and we try to offer patients the most tailored approach to their treatment.
Host: Right. Fantastic summary, Dr. Goyal. I want to thank you for the work that you're doing, and also, thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Goyal or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.
Dr. Sharad Goyal (Guest): Thank you for having me.
Host: In my little teaser there, I gave a little definition — you can find that anywhere on Google, a basic definition of Radiosurgery — but let's have the expert, yourself here, help the audience understand just what is radiosurgery.
Dr. Goyal: Okay. Just to give you a little bit of background, the concept of radiosurgery was first described by a Neurosurgeon named Lars Leksell in the 1950s. He proposed radiosurgery as an alternative to open brain surgery. He proposed it to avoid doing brain surgery in patients that may be too sick to get brain surgery. Over time, radiosurgery has emerged as a unique discipline involving surgeons, radiation oncologists, and physicists.
The basic concept of radiosurgery relies on the principle of precisely delivering high doses of radiation therapy to a target, and that target is typically some form of cancer located either in the brain or the body.
Host: Let me ask you something with that. I know my listening audience, the minute they hear high-dose radiation they get a little nervous. What does that really mean? Can you tell us what does that mean to them as a patient? Is the high dose controlled? When you say "precise" what does that really mean? How is that high dose controlled?
Dr. Goyal: Okay, so that's a very good question. When we talk about high doses of radiation, I'd just like to — when I talk about this with a patient I like to give them the alternative. The alternative is having your brain cut into and having the risk of infection, having the risk of having permanent weakness or paralysis from brain surgery. Radiosurgery is an outpatient procedure. This procedure typically takes between 30 and 60 minutes, and patients who drive in can drive home. There is no downtime. They can go back to work immediately, and they typically feel quite well.
Getting to your point about high doses of radiation and what that means for the patient. Basically, patients who are undergoing this treatment do not feel anything during the radiation. They are awake. They are conscious, and what they see or experience is a machine that moves around them delivering them the treatment.
The concept of radiosurgery stems from radiation therapy, and radiation therapy typically is a treatment where we deliver radiation therapy on a daily basis over the course of six, seven, eight, or even nine weeks time. We give a little bit of radiation each day, and the damage that the radiation does on a daily basis to the cancer builds up over time. By the end of the six or nine weeks, the cancer is effectively eliminated.
Host: Right.
Dr. Goyal: Radiosurgery is kind of a shift in that concept where instead of giving low-dose radiation over the course of many weeks, we're giving high-dose radiation over the course of one day or up to five days.
Host: Ah, got you.
Dr. Goyal: A decision of one to five days is based upon the location of the tumor, the type of tumor, et cetera, et cetera.
Host: Does that mean — with those cases where high-dose can be used for one to five days — does that mean — is one of the innovations here the ability to be much more precise in targeting, say, a tumor?
Dr. Goyal: Correct. Again, the concept of radiosurgery has evolved over time. Currently, in 2019, with the types of imaging that we are able to offer patients, we have sub-millimeter accuracy when we deliver the radiation treatment.
Host: Wow.
Dr. Goyal: And those are innovations in imaging and innovations in the delivery of the radiation therapy.
Host: And Dr. Goyal, how has that — in general, how has radiosurgery, in your opinion then, how has it affected or changed cancer treatment or cancer outcomes?
Dr. Goyal: Okay. When we are able to offer patients radiosurgery, we're not trying to detract or take away from a patient that needs surgery. My thought is, and what I tell every single patient, is that nothing can beat a great surgery. But if the surgery is going to leave the patient with permanent paralysis or deficits like oxygen-dependence, then they may not want to have surgery or surgery may not be indicated. Our treatment is an adjunct to surgery.
There are many studies that have been done. These are large studies taking hundreds or thousands of patients and giving half of them open surgery, whether it's in the lungs or prostate, or brain, and then the other half gets radiosurgery. In those studies, the patients getting radiosurgery have the same outcomes as patients getting open surgery. There are many benefits to open surgery, but in patients that either don't want open surgery or can't get open surgery, we have a treatment option available to them.
Host: Well, that's interesting, Dr. Goyal. Do you ever — with those kinds of studies, and I know that probably more needs to be done, more definite conclusions probably need to be drawn, and I get that — but with those kinds of results, when you look at how high-dose radiosurgery, in particular, can be one to five days, you're not cutting into anybody, there's less risk of infection and all that kind of stuff. If the outcomes are just as good as that traditional surgery, do you ever see in the future radiosurgery being the first place to go?
Dr. Goyal: Oh, that's a very difficult question. I may make it seem like radiosurgery is the best thing since sliced bread, but there are side-effects of radiation, and we typically do not offer radiosurgery, or we tend to push patients towards open surgery in a variety of situations. Number one, if they're young. The reason for that is radiation therapy can cause cancer. Even though we're using radiation to kill cancer, 10, 20, 30 years down the road, there may be a 1 or 2 percent risk of that patient developing a second cancer. If that young patient has a long life-expectancy, we will be pushing them to undergo an open surgery.
Host: Got you.
Dr. Goyal: That's one example. Each patient is different. I do feel that radiosurgery does have a place in the battle against cancer. It will never replace surgery.
Host: Got you. Speaking of the future of radiosurgery, where do you see this type of treatment going? What's on the horizon in terms of innovation?
Dr. Goyal: Okay, that's a very good question. There are several things that are here or will be coming down the pike. One is a machine that uses an MRI to help guide radiation therapy. You can use this for standard radiation treatment, or you can use it for radiosurgery. Imagine if you can get a very high-quality MRI image that helps you target the tumor, and then on the day of the treatment we can take another MRI, and we can better assess where that tumor is at that day, whether it's grown, or whether it's moved, or if it's close to another organ, we can change our radiation delivery to either maximize dose to the tumor and minimize radiation to the surrounding organs.
Other advents in radiosurgery include basically modifications on existing systems to help the radiation be more accurate.
Host: And that's really interesting, Dr. Goyal, it seems a lot of this is coming down to really controlling where that radiation is going, right? If we can more and more improve that precision, that seems to be where the power of radiosurgery lies, right? If I can give a higher dose, and it's not hitting any other surrounding organs, that means I have a better chance of killing that cancer, less chance of damage to organs and maybe those future cancers, right? Is that really — it's becoming precise — is that where you think most of the research is heading towards?
Dr. Goyal: Yes, okay. There is another angle to radiosurgery, and that's the concept of targeting a tumor in one part of your body and then seeing a response in other tumors in other parts of your body that were not treated with radiation, okay? That is a concept that has to deal with how radiation modulates the immune response in a patient. Basically, if I target tumor in a patient's lung, that will help stimulate their immune system to ramp up, and their immune system will help target any cancer cells that may be in other parts of the body. Something that many investigators are looking at nationally and internationally is combining radiation therapy with combinations of immunotherapy. Immunotherapy is drugs that also help ramp up your immune system.
Host: Right. That's very, very interesting isn't it, Dr. Goyal? It's that concept, that idea that a little bit of stress is actually good in some ways, right? It's a whole class of study called hormesis, and that's a very interesting maybe future, positive benefit of radiosurgery. You know, Dr. Goyal, this has been a fascinating conversation. Just to kind of summarize for the audience, what would you like them to know about radiosurgery?
Dr. Goyal: Radiosurgery is a cancer treatment where we are able to deliver high doses of radiation in one to five treatments. This treatment is equivalent to open surgery whether it's brain surgery or lung surgery for many different types of cancers. It is a non-invasive, outpatient procedure, typically taking 30 to 60 minutes a day. We offer it to patients in conjunction with surgeons and medical oncologists. We typically make decisions as a multidisciplinary group, and we try to offer patients the most tailored approach to their treatment.
Host: Right. Fantastic summary, Dr. Goyal. I want to thank you for the work that you're doing, and also, thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Goyal or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.
Transcription:
The Benefits Of Medical Cannabis
Dr. Mike Smith. (Host): There are few subjects that can stir up stronger emotions among doctors, scientists, researchers, policymakers, and the public than medical cannabis. Welcome to The GW HealthCast. I’m Dr. Mike Smith, and today's topic, The Benefits of Medical Cannabis. My guest is Dr. Mikhail Kogan. Dr. Kogan is the Medical Director at the George Washington Center for Integrative Medicine and Assistant Professor of Medicine at the George Washington University School of Medicine and Health Sciences and is affiliated with The George Washington University Hospital. Dr. Kogan, welcome to the show.
Dr. Mikhail Kogan (Guest): Thank you. I'm happy to be here.
Host: So, this is a big topic, right? There's a lot of debate about the role of medical cannabis, and even some confusion about what is medical cannabis versus every day, casual smoking of cannabis. Maybe you can help to kind of clear the confusion for us first. First of all, what's the difference between medical cannabis and what people smoke every day for leisure?
Dr. Kogan: Right. I think that's a really important question to start out with. Traditionally, there are two ingredients that are most commonly prevalent in the cannabis plant, and that's the THC or tetrahydrocannabinol, which is what everybody's looking for when they're trying to get psychoactive or recreational use. That's what makes people high. Typically, when you buy a product on the street or in the recreational dispensary, you're going to get a product that has a very high percent of THC. Now, it's even more confusing to say that THC does have a number of medicinal properties, but since we're just answering this first question, THC is primarily for recreational use.
When you're talking about the medical use THC is probably going to be there, but you're starting to look at other cannabinoids, and the second most common one is what's called CBD or cannabidiol. Typically, for medical use, we will have some combination of several ingredients, and the two most prominent ones are THC and CBD. Once you start having CBD percent or a ratio of CBD to THC — which is how we often will talk about medical use — is going up. Once the ratio reaches a certain — say, maybe 2:1 or 4:1, no matter how much THC you take it's very unlikely you're going to have any psychoactive or any high. In that sense, that's the most important separation.
Host: Right.
Dr. Kogan: There are also routes of administration. Usually, people smoke cannabis to get high versus when we use it medically, we use it topically; we can use it rectally. We can use it as a sublingual drop, as edibles also. And to some degree, of course, as well inhalation form, but less smoking and more vaporizing.
Host: Right, right. Just to kind of summarize for the audience, the medical cannabis is going to have a higher amount of the CBD versus the THC versus if you smoke it leisurely, you're going to get more of that THC. Medical cannabis has higher amounts of CBD. Why is that? What is it about CBD? What have we learned recently in the research that makes us think that this is a medicinal compound?
Dr. Kogan: Well, I think — let me clarify a couple of things here. It is very confusing, actually, because as I said, THC does have quite a substantial amount of medical utilization as well. It's really the intent of the use. And while yes, generally speaking, you need some CBD to kind of offset the THC high, but again, THC compounds alone are used. CBD itself is a pretty potent anti-inflammatory substance. In fact, it recently — I would probably say a month ago — has been FDA-approved as a medication for seizure disorder for certain populations in complex seizure conditions. So, there's already official medical use for CBD for at least one condition.
We use it a lot for — again, it's obviously off-label — but we use it for anxiety; we use it for sleep, and even topically, for pain. I think if I start carefully going through the possible list of indications, the list will be very long.
Host: Right.
Dr. Kogan: I think it's important to mention also that typically, most of us who have some experience in this field will probably utilize multiple cannabinoids at the same time. We will not use just CBD. We will combine CBD with THC or other ingredients. And also, there's this idea of Entourage Effect when you add components that are originally in cannabis. It's a small amount, but when they combine with the main ingredient, there's somehow a potentiation of the effect. That's called the Entourage Effect, and you can have a whole extract of the cannabis plant, and it's actually going to be more efficacious than if you just apply let's say only CBD alone or just THC alone.
Host: Just one, right.
Dr. Kogan: I think this is an unusual scenario where both medicinal plant medicine, as well as medication, will coexist.
Host: Dr. Kogan, I think maybe the listening audience might appreciate a little education on the cannabinoids themselves. I think a lot of listeners are familiar with the sympathetic nervous system, the parasympathetic nervous system, cortisol, and the stress response. We hear about all of that a lot, but there's another system in the body called the endocannabinoid system. Can you teach us a little bit about that, and why is that of such interest to physicians like yourself?
Dr. Kogan: Right, well, it's the oldest system we have. Actually, it's a lot older and a lot more prevalent compared to let's say the endorphin system, which is what we use things like morphine. The system is quite robust. It's present in every cell of our body. There are a couple of different receptors, primarily CB1 and CB2 receptors that we're talking. CB1 receptors are present in the central nervous system and CB2 in lots of other places. Most importantly, actually, it's a very strong regulator of the immune system and also, inflammatory responses. We know that cannabinoids — endogenous cannabinoids, and the most common one is anandamide — have regulatory mechanisms to control inflammation, to control and balance our immune system, and you also mentioned the hormonal system.
What's fascinating — and I don't know why that's made this way — is that we have almost no receptors in the brain stem. That's what’s responsible for a very high level of safety. Cannabis — in fact, it hasn't ever been described that anyone has died from using cannabis at any dose. That's probably because we don't have any breathing suppression no matter how much cannabis you use.
Host: Oh, okay.
Dr. Kogan: The THC, which is the psychoactive ingredient, is very similar to our endogenous anandamide. We have an exogenous molecule from plants that can induce a very similar effect that our own anandamide can. Of course, you can take a lot more of it exogenously to induce the high, which normally we don't get from our own endogenous system. And then CBD interestingly does not directly affect the receptor. It does, but it doesn't really have a potent effect. It rather modulates or changes the effect of THC and exudes its efficacy in some indirect way. And actually, it's not really fully elucidated. I would say the science of the endocannabinoid system is fascinating. It's very rapidly changing. We're learning a lot, and yet, we still don't have a lot of clinical answers.
That's a cautionary tale. There's a lot of hype. People use all kinds of products for all kinds of reasons. There's a lot of different hemp products with the CBD, and there are claims on the internet on anything from cancer cures and all kinds of condition cures. There may be cases, but unfortunately, the actual clinical data is lagging. That's really unfortunate because I think the potential here is really big. I hope that our politics are changing, so at least providers can start doing clinical studies.
Host: Right, right. And you believe based on what we see in the preclinical and some of these anecdotal stories that there's real potential for medical cannabis to be a powerful treatment tool for probably several different types of disorders? Just to kind of summarize here, of all the different benefits that you believe medical cannabis is potentially helpful for, what's maybe the top benefit that you think really we need to start studying and developing clinical trials for?
Dr. Kogan: Well, let me first give you just a quick summary of what's already proven, and then let's go into what I feel would be the next level of research and where I think the cannabinoids can have a really strong impact. I think chronic pain — and this is more specifically for things like fibromyalgia, chronic fatigue syndrome, neuropathic pain, those types of hard to treat pains — I don't think there's any more research needed. We need research to figure out the dosing, but the current data is very clear. In 2017, reports put out by National Academies of Sciences had been conclusive. They give a Grade A recommendation use in chorionic pain, which literally — they're saying that we should be using it as a prescriber almost as a first line.
I would also say that cancer symptoms — nausea, vomiting, appetite — that's also a very important role. It's quite conclusive, as well. And a third would be spasticity from different conditions like Multiple Sclerosis, certain bowel disorders that present with a high amount of spasticity and spasm, so something like irritable bowel syndrome.
And the next level of clinical research I hope will be in a couple of directions, and they're primarily all inflammatory conditions, so maybe IBD, inflammatory bowel disease, maybe neurodegenerative conditions such as Alzheimer's and Parkinson's. Of course, there's a very large amount of interest among the public in using cannabis as a disease-modifying approach for cancer. That's very controversial. There's a lot of potential because if you look at the preclinical animal studies and in vitro studies — Petri dishes — there seems to be a very strong anti-cancer effect. Will that translate to the clinical data in humans? It's hard to say, and I would definitely slow down the hype out there to say you really can't use something yet. Hopefully soon, once we have trials going and have results.
Host: Right. Well, what a fascinating topic, Dr. Kogan. I want to thank you for the work that you're doing, and also, thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Kogan or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment. I'm Dr. Mike Smith. Thanks for listening.
The Benefits Of Medical Cannabis
Dr. Mike Smith. (Host): There are few subjects that can stir up stronger emotions among doctors, scientists, researchers, policymakers, and the public than medical cannabis. Welcome to The GW HealthCast. I’m Dr. Mike Smith, and today's topic, The Benefits of Medical Cannabis. My guest is Dr. Mikhail Kogan. Dr. Kogan is the Medical Director at the George Washington Center for Integrative Medicine and Assistant Professor of Medicine at the George Washington University School of Medicine and Health Sciences and is affiliated with The George Washington University Hospital. Dr. Kogan, welcome to the show.
Dr. Mikhail Kogan (Guest): Thank you. I'm happy to be here.
Host: So, this is a big topic, right? There's a lot of debate about the role of medical cannabis, and even some confusion about what is medical cannabis versus every day, casual smoking of cannabis. Maybe you can help to kind of clear the confusion for us first. First of all, what's the difference between medical cannabis and what people smoke every day for leisure?
Dr. Kogan: Right. I think that's a really important question to start out with. Traditionally, there are two ingredients that are most commonly prevalent in the cannabis plant, and that's the THC or tetrahydrocannabinol, which is what everybody's looking for when they're trying to get psychoactive or recreational use. That's what makes people high. Typically, when you buy a product on the street or in the recreational dispensary, you're going to get a product that has a very high percent of THC. Now, it's even more confusing to say that THC does have a number of medicinal properties, but since we're just answering this first question, THC is primarily for recreational use.
When you're talking about the medical use THC is probably going to be there, but you're starting to look at other cannabinoids, and the second most common one is what's called CBD or cannabidiol. Typically, for medical use, we will have some combination of several ingredients, and the two most prominent ones are THC and CBD. Once you start having CBD percent or a ratio of CBD to THC — which is how we often will talk about medical use — is going up. Once the ratio reaches a certain — say, maybe 2:1 or 4:1, no matter how much THC you take it's very unlikely you're going to have any psychoactive or any high. In that sense, that's the most important separation.
Host: Right.
Dr. Kogan: There are also routes of administration. Usually, people smoke cannabis to get high versus when we use it medically, we use it topically; we can use it rectally. We can use it as a sublingual drop, as edibles also. And to some degree, of course, as well inhalation form, but less smoking and more vaporizing.
Host: Right, right. Just to kind of summarize for the audience, the medical cannabis is going to have a higher amount of the CBD versus the THC versus if you smoke it leisurely, you're going to get more of that THC. Medical cannabis has higher amounts of CBD. Why is that? What is it about CBD? What have we learned recently in the research that makes us think that this is a medicinal compound?
Dr. Kogan: Well, I think — let me clarify a couple of things here. It is very confusing, actually, because as I said, THC does have quite a substantial amount of medical utilization as well. It's really the intent of the use. And while yes, generally speaking, you need some CBD to kind of offset the THC high, but again, THC compounds alone are used. CBD itself is a pretty potent anti-inflammatory substance. In fact, it recently — I would probably say a month ago — has been FDA-approved as a medication for seizure disorder for certain populations in complex seizure conditions. So, there's already official medical use for CBD for at least one condition.
We use it a lot for — again, it's obviously off-label — but we use it for anxiety; we use it for sleep, and even topically, for pain. I think if I start carefully going through the possible list of indications, the list will be very long.
Host: Right.
Dr. Kogan: I think it's important to mention also that typically, most of us who have some experience in this field will probably utilize multiple cannabinoids at the same time. We will not use just CBD. We will combine CBD with THC or other ingredients. And also, there's this idea of Entourage Effect when you add components that are originally in cannabis. It's a small amount, but when they combine with the main ingredient, there's somehow a potentiation of the effect. That's called the Entourage Effect, and you can have a whole extract of the cannabis plant, and it's actually going to be more efficacious than if you just apply let's say only CBD alone or just THC alone.
Host: Just one, right.
Dr. Kogan: I think this is an unusual scenario where both medicinal plant medicine, as well as medication, will coexist.
Host: Dr. Kogan, I think maybe the listening audience might appreciate a little education on the cannabinoids themselves. I think a lot of listeners are familiar with the sympathetic nervous system, the parasympathetic nervous system, cortisol, and the stress response. We hear about all of that a lot, but there's another system in the body called the endocannabinoid system. Can you teach us a little bit about that, and why is that of such interest to physicians like yourself?
Dr. Kogan: Right, well, it's the oldest system we have. Actually, it's a lot older and a lot more prevalent compared to let's say the endorphin system, which is what we use things like morphine. The system is quite robust. It's present in every cell of our body. There are a couple of different receptors, primarily CB1 and CB2 receptors that we're talking. CB1 receptors are present in the central nervous system and CB2 in lots of other places. Most importantly, actually, it's a very strong regulator of the immune system and also, inflammatory responses. We know that cannabinoids — endogenous cannabinoids, and the most common one is anandamide — have regulatory mechanisms to control inflammation, to control and balance our immune system, and you also mentioned the hormonal system.
What's fascinating — and I don't know why that's made this way — is that we have almost no receptors in the brain stem. That's what’s responsible for a very high level of safety. Cannabis — in fact, it hasn't ever been described that anyone has died from using cannabis at any dose. That's probably because we don't have any breathing suppression no matter how much cannabis you use.
Host: Oh, okay.
Dr. Kogan: The THC, which is the psychoactive ingredient, is very similar to our endogenous anandamide. We have an exogenous molecule from plants that can induce a very similar effect that our own anandamide can. Of course, you can take a lot more of it exogenously to induce the high, which normally we don't get from our own endogenous system. And then CBD interestingly does not directly affect the receptor. It does, but it doesn't really have a potent effect. It rather modulates or changes the effect of THC and exudes its efficacy in some indirect way. And actually, it's not really fully elucidated. I would say the science of the endocannabinoid system is fascinating. It's very rapidly changing. We're learning a lot, and yet, we still don't have a lot of clinical answers.
That's a cautionary tale. There's a lot of hype. People use all kinds of products for all kinds of reasons. There's a lot of different hemp products with the CBD, and there are claims on the internet on anything from cancer cures and all kinds of condition cures. There may be cases, but unfortunately, the actual clinical data is lagging. That's really unfortunate because I think the potential here is really big. I hope that our politics are changing, so at least providers can start doing clinical studies.
Host: Right, right. And you believe based on what we see in the preclinical and some of these anecdotal stories that there's real potential for medical cannabis to be a powerful treatment tool for probably several different types of disorders? Just to kind of summarize here, of all the different benefits that you believe medical cannabis is potentially helpful for, what's maybe the top benefit that you think really we need to start studying and developing clinical trials for?
Dr. Kogan: Well, let me first give you just a quick summary of what's already proven, and then let's go into what I feel would be the next level of research and where I think the cannabinoids can have a really strong impact. I think chronic pain — and this is more specifically for things like fibromyalgia, chronic fatigue syndrome, neuropathic pain, those types of hard to treat pains — I don't think there's any more research needed. We need research to figure out the dosing, but the current data is very clear. In 2017, reports put out by National Academies of Sciences had been conclusive. They give a Grade A recommendation use in chorionic pain, which literally — they're saying that we should be using it as a prescriber almost as a first line.
I would also say that cancer symptoms — nausea, vomiting, appetite — that's also a very important role. It's quite conclusive, as well. And a third would be spasticity from different conditions like Multiple Sclerosis, certain bowel disorders that present with a high amount of spasticity and spasm, so something like irritable bowel syndrome.
And the next level of clinical research I hope will be in a couple of directions, and they're primarily all inflammatory conditions, so maybe IBD, inflammatory bowel disease, maybe neurodegenerative conditions such as Alzheimer's and Parkinson's. Of course, there's a very large amount of interest among the public in using cannabis as a disease-modifying approach for cancer. That's very controversial. There's a lot of potential because if you look at the preclinical animal studies and in vitro studies — Petri dishes — there seems to be a very strong anti-cancer effect. Will that translate to the clinical data in humans? It's hard to say, and I would definitely slow down the hype out there to say you really can't use something yet. Hopefully soon, once we have trials going and have results.
Host: Right. Well, what a fascinating topic, Dr. Kogan. I want to thank you for the work that you're doing, and also, thank you for coming on the show today. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Kogan or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment. I'm Dr. Mike Smith. Thanks for listening.