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Cannabis Is Medicine
How Medical Cannabis and CBD Are Healing Everything from Anxiety to Chronic Pain
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Millions of people around the world are healing illnesses with cannabis. Nonetheless, many physicians remain reluctant to discuss cannabis medicine with their patients. And with so much conflicting misinformation from unreliable sources, finding out if cannabis could be an effective treatment for you or a loved one can feel nearly impossible. This book is the comprehensive resource for people who have not found relief from conventional medicines.
Bonni Goldstein, MD, has helped thousands of patients suffering from chronic, difficult-to-treat conditions improve with cannabis. In this revelatory book, she explains the current state of scientific research on how cannabis interacts with human physiology to create homeostasis — balance — leading to good health. Many of the plant's compounds, including CBD and CBG, and their therapeutic effects are explained in detail. Readers will learn how to best navigate the multitude of available cannabis-based products, with detailed guidance on safety and usage, and how to customize a personalized cannabis regimen. And Dr. Goldstein presents 28 common conditions for which patients have found cannabis treatment to be effective, including cancer, insomnia and gastrointestinal disorders.
As medical cannabis laws continue to evolve, it is more vital than ever for struggling patients to understand the benefits of this plant from an honest, medicine-based perspective. Educational, practical, and thorough, Cannabis Is Medicine empowers patients to make informed decisions about this natural medicine and improve the quality of their lives.
Excerpt
Author’s Note
First, Do No Harm
I don’t recall exactly when I learned my mother had suffered from seizures. I think I was in high school when she finally talked to me about her medical history, and while there had always been intimations, I felt shocked to hear about it. When I look back on my childhood, I see clues, despite her keeping it a secret from just about everyone.
My mother didn’t drive when I was a little girl growing up in Brooklyn. Because there was an abundance of public transportation, it didn’t seem that strange, and most of my friends’ mothers didn’t drive either. When we moved to the suburbs in New Jersey, I noticed that my mother was the only one who didn’t drive. We never talked about it, and eventually my mother did get her driver’s license, but it was many years before I learned the real reason she didn’t have one in the early part of my childhood.
At about the same time that I began dreaming about being a doctor, I became aware that my mother took medications every night. Two big prescription bottles sat in the upper cabinet next to the kitchen sink, and whenever I asked about them, she gave a vague answer. I remember getting a sense that this wasn’t something she wanted to talk about, so I stopped asking. A few years later, when I was a teenager, I was standing next to her by the kitchen cabinet where the medicine bottles were kept and again asked her about her medications, completely unaware of the story she finally decided to share.
That day she told me that when my sister was two years old and I was just an infant, she had her first grand mal seizure in a Brooklyn playground, followed by two more seizures over the next few days. She eventually went to see a neurologist, and while she was in his office she had another seizure. She was hospitalized and immediately, she, my father, my grandmother, and my uncles were told that she might die. Diagnostic studies of the brain in the early 1960s were quite limited, and the doctors did not know what was causing the seizures. Started on phenytoin (Dilantin) and phenobarbital, she responded positively and was told to continue taking them for the rest of her life.
My grandmother, an uneducated and superstitious immigrant, was in complete denial that my mother had epilepsy. She was terrified and embarrassed at the same time. Because of this, my parents became tight-lipped about what had happened. It just was not discussed or shared with anyone.
I learned much later that even though the medications stopped her seizures, the side effects were difficult to tolerate. She became excessively hirsute and had significant lethargy and fatigue, making the care of two small children particularly challenging. She also had severe gingival hypertrophy, an overgrowth of gum tissue and a common side effect of phenytoin, which led to a lifetime of problems with her gums that still continue. I recall being in middle school and finding out that my mother had to have oral surgery for a terrible problem she was having with her gums. She stayed in bed for days with severe pain after the procedure. I can still see her there with ice on her swollen cheeks, black-and-blue, unable to talk or eat. Little did I know at the time that this was a result of her seizure medication.
After my sisters and I graduated from high school, my mother decided that she just couldn’t tolerate the side effects of the medication any longer and that she was finished with it. She didn’t consult her doctor or even gradually wean herself off the drugs but rather just stopped taking them. Fortunately, she experienced no repercussions from this arguably risky decision and remains seizure-free today. Meanwhile, I continued to pursue my medical degree and eventually became a doctor, working primarily in pediatric emergency medicine and urgent care. I loved my work, saving lives at the county hospital and teaching medical students and residents, but once I had my son, things changed. I had thought I could manage working nights and being with my son during the days, but after a few years, it grew more and more difficult, as I didn’t feel truly present when home with my family. I was a very good pediatric ER doctor, but my frustrations from the exhaustion of night work and trying to be a caring physician in a broken system eventually wore me down.
After I took a leave of absence, a sick friend asked me about medical cannabis, putting it on my radar for the first time. Once I started reading the scientific literature, I grew incredulous that despite the discovery of the endocannabinoid system, the most widespread receptor system in the human brain, and my years of science-based education and medical training, I knew absolutely nothing about cannabis and how it works. Intrigued, I continued to read and study everything I could find about cannabis and soon decided to work part-time in a local medical cannabis clinic. I was surprised to find that the patients I met were just everyday people who went to work, had families, and had medical conditions that were not responding to conventional medications or traditional Western medical interventions. These were people who simply wanted a better quality of life.
I haven’t looked back since.
Cannabis was not medically available or used as an anticonvulsant during the years my mother took antiseizure medications. In 1970, five years into her epilepsy diagnosis and treatment, the federal government classified cannabis as a Schedule I controlled substance with the passage of the Controlled Substances Act. Defined as a “drug or other substance that has a high potential for abuse, has no currently accepted medical use in treatment in the United States, and is lacking accepted safety for use of the drug or other substance under medical supervision,” cannabis maintains its Schedule I classification to this day. This has virtually shut down all research on the multitude of compounds in cannabis that we now know have low risk for abuse, true and proven medical use, and an excellent safety profile, especially with medical supervision. Scientists had started significant cannabis research in the 1960s and were gaining knowledge of the phytocannabinoids, but this act by Congress completely closed the door on advancing cannabinoid science. After the discovery of the endocannabinoid system in the late 1980s, investigations in the field have exploded, especially in the last decade and mostly outside the US.
I am angry that my mother suffered, and continues to suffer, from the side effects of medications she took to alleviate her epilepsy. My mother’s suffering was in part due to the propagation of false claims about cannabis, claims based on ignorance and greed. The false claims persist, despite the fact that millions of patients who could be helped by cannabis continue to suffer with medical conditions that are not responding to conventional treatments, and millions more grapple with intolerable side effects of those treatments. As a physician, I took an oath to “do no harm.” After treating thousands of patients with medical cannabis, I can assert that the compounds in cannabis relieve unnecessary suffering with few or no adverse side effects.
I have witnessed sick and desperate patients have a complete turnaround in the quality of their lives. Cannabis medicine must be available as an option or alternative to current first-line treatments, especially if those treatments have harmful or potentially fatal side effects. If a pharmaceutical with the properties of cannabis were synthetically created and introduced today, the medical community would embrace it with open arms and tout it as a miracle drug.
It’s been over fifty years since my mother developed epilepsy when I was a small child, and I get emotional thinking about her needless suffering. Many physicians find their vocation from early experiences with ill relatives and friends. While I had little awareness of my mother’s struggles with seizures and medications, I find that her life and experience have indeed informed mine. I wish medical cannabis had been available to my mother. I cannot undo what she endured. I can help others, though, by sharing the current knowledge about cannabis and cannabinoid science. I have written this book so you and your loved ones, who may be suffering as my mother did, can move past the false propaganda that continues to this day and understand how cannabis is medicine.
Introduction
Written by my patient Elise, as told to me in February of 2016, and whose story appears in chapter 5:
As a little girl, whenever I was alone—outside digging in the dirt or absentmindedly swinging on the swing set, splashing or playing in the bathtub—I would start humming a tune. I’d start softly and then grow bolder, add in little trills and jazzy riffs, each note a bit louder than the next. As I got older, I’d experiment with dropping my voice down to get to the lower notes and more dramatic effects. I had been exposed to singers like Judy Garland, Billie Holiday, Frank Sinatra, and Nat King Cole, and then to songwriter-artists like Joni Mitchell, Bob Dylan, and Carole King. I listened to James Taylor, Cat Stevens, and ’60s Motown, and I recall at age twelve or thirteen thinking that Phoebe Snow was the ultimate in cool. Singing brought me freedom and joy, always, or at least until the pain started and I was diagnosed with rheumatoid arthritis. Over those years and the many that followed, in my late teens and early twenties, I didn’t do that much singing, but on the occasions when I did, singing was one of the few things I could do to forget almost completely the way my body felt. During those moments, I tasted a little bit of freedom and was released from the pain and the loss of everything I used to be—all of my former life—even for a few minutes. I have noticed lately, though, that during the process of taking my cannabis medicine that I am humming again, albeit weakly with little breath or power. The humming grows stronger as I feel the medicine through my system, and I find myself adding jazzy riffs right and left, treating my voice like a slide trombone. I can go mournfully low and tragic like Billie and then trill upwards sweet and high like Ella. I imagine myself as sultry and sassy, as confident as Peggy Lee. It’s as if cannabis has helped me to unlock the box in which I’ve kept my own personal songbird. This may be a small thing, but if anyone knows how it feels to be trapped in a constantly malfunctioning body, they would realize what an enormous gift it is to feel well, to feel strong and capable at something again for the first time in over a decade. I was locked in a prison of illness and pain, and cannabis unlocked the door for me to break free.
How to Use This Book
I have spent the last decade educating and explaining medical cannabis to patients, politicians, and medical professionals. In order to understand how cannabis can do all that it is advertised to do, you must first understand the plant itself. In the first part of this book, chapter 1 discusses the many different compounds that make up the cannabis plant. Chapter 2 explains our endocannabinoid system, its purpose, and how it interacts with the compounds found in cannabis. Diseases associated with an imbalance of the endocannabinoid system are also discussed. The safety of cannabis use is discussed in chapter 3. Chapter 4 delves deeply into the science of the various medicinal compounds found in the cannabis plant, reviewing the latest research of how and why they are effective. Chapter 5 gets into how to use cannabis as medicine, including how to read labels, ratios versus concentrations, and dosing. Special considerations for certain conditions and populations are discussed in chapter 6. Part II details a multitude of ailments in which cannabinoid medicine may play an important role.
Interspersed throughout the book are incredible stories of patients who have had success with using cannabis medicine. These patients were able to overcome medical conditions that were negatively affecting their quality of life, and they were all so eager to share their journey that led them to cannabis treatment. (Note that the names of some of the patients who shared their stories have been changed to protect their privacy.)
The appendixes include a time line of the history of cannabis as well as information on the pharmacokinetics of cannabis medicines, discussing the absorption, metabolism, and excretion of cannabinoids. Facts about the phytocannabinoids and terpenoids are listed in two charts that readers can use as references.
This book is not meant to give specific medical advice for your particular condition, as the use of cannabis medicine is not “one size fits all.” Each person has their own goals of treatment and will respond uniquely to the many options within the cannabis medicine armamentarium. The goal of this book is to help you understand if cannabis may be an option for you or your loved one. The latest scientific information is presented in addition to my clinical experience with patients; however, research on cannabis is still severely restricted, leaving us with many unanswered questions. Please consult your physician before starting a cannabis regimen.
PART I
The Science of Cannabis
CHAPTER 1
The Cannabis Plant
In order to understand the medicinal value of the cannabis plant, you first need to learn about the many compounds found within it. The cannabis plant is dioecious (meaning it has male and female plants) and is made up of more than five hundred different chemical compounds.1 When taking cannabis as medicine, you are by definition taking a mixture of many natural compounds that work together in balance with one another. In contrast, pharmaceutical medications routinely contain only one active compound.
The Latin name of the plant is Cannabis sativa, in the family called Cannabaceae. Other plants in this family are Humulus (hops) and Celtis (hackberries). These plants share an evolutionary origin but are quite different from one another. The cannabis plant contains biologically active compounds called phytocannabinoids, terpenoids, and flavonoids. These chemicals interact with the brain and body chemistry, causing certain effects. Hundreds of different cannabis varieties are grown all over the world, each containing varying amounts of the more than five hundred different compounds. Some varieties may have more or less of certain cannabinoids or terpenoids; it is these differences that cause the various medicinal effects. Contrary to popular vernacular, plants do not have “strains.” We call the different varieties or types of cannabis “chemovars,” which is short for “chemical varieties.”
What Are Phytocannabinoids?
The term “cannabinoids” is very general and refers to a group of chemical compounds that are typically made up of twenty-one carbon atoms in a three-ring structure. The prefix “phyto” added to the word refers to the cannabinoids that are found exclusively in the cannabis plant. The two predominant and most studied phytocannabinoids are THC (delta-9-tetrahydrocannabinol) and CBD (cannabidiol). Approximately 140 phytocannabinoids have now been identified, and likely more will be discovered; however, only a few have been researched significantly.
Other phytocannabinoids found in the cannabis plant, often referred to as “minor” or “secondary” cannabinoids, include cannabinol (CBN), cannabigerol (CBG), cannabichromene (CBC), cannabicyclol (CBL), cannabivarin (CBV), cannabidivarin (CBDV), and tetrahydrocannabivarin (THCV). The medicinal effects of the most commonly used phytocannabinoids are reviewed in detail in chapter 4.
Molecular structures of THC and CBD.
A Few Important Notes About Phytocannabinoids
• Phytocannabinoids were initially thought to be species-specific to the cannabis plant, which means they are not found in any other plant species. However, phytocannabinoids other than THC have been discovered in a few other plants, namely those from the genera Echinacea, Helichrysum (sunflowers), and Radula (liverworts).
• As mentioned, the term “cannabinoids” is very general, and it refers to a specific group of chemical compounds. Cannabinoids are found naturally in two places: plants and animals, including humans. “Phytocannabinoids” refers specifically to the cannabinoids that occur naturally in plants. “Endocannabinoids” refers specifically to the cannabinoids made by cells in humans and other animals. Cannabinoids can also be synthesized in a laboratory setting; these are referred to as “synthetic cannabinoids” and are primarily used in research.
• Do not get confused by the acronym “CBD.” CBD stands for the phytocannabinoid “cannabidiol,” not “cannabinoids.” Many people incorrectly say “the CBDs,” but CBD is not plural. THC is not referred to as “THCs” because it is one compound. CBD also is one compound.
How the Cannabis Plant Makes Phytocannabinoids
Phytocannabinoids are synthesized and concentrated in a viscous resin in an unfertilized female plant’s glandular trichomes, which are tiny, sticky hairlike formations on the cannabis flowers.
When the cannabis plant synthesizes phytocannabinoids, geranyl diphosphate—the precursor to both phytocannabinoids and terpenoids—couples with olivetolic acid to produce cannabigerolic acid, which is then exposed to three enzymes: THCA synthase, which creates THCA; CBDA synthase, which creates CBDA; and CBCA synthase, which creates CBCA.
THCA and CBDA are the predominant phytocannabinoid compounds in the raw flowers of the cannabis plant and are the precursor compounds to THC and CBD, respectively. THCA and CBDA convert to THC and CBD, respectively, when they are exposed to heat. This chemical reaction is called “decarboxylation.”
Trichome of female cannabis flower (circled).
One way different types of cannabis plants are categorized is based on the genetically determined expression of the chemical composition of the phytocannabinoids, often called the “chemical phenotype,” or “chemotype.”
• Type I: High THC content and low CBD content; often called “drug-variety” (more than 0.3 percent THC by weight)
• Type II: Roughly equal THC and CBD content
• Type III: Dominant CBD; can be fiber-variety (less than 0.3 percent THC by weight) or drug-variety
• Type IV: Dominant CBG (cannabigerol) content
• Type V: No detectable phytocannabinoids
The majority of medicinal cannabis plants are genetically Type I and thus take the pathway that leads to THCA and ultimately THC. A small number of plants are Type II, meaning they have genetics that will lead to a higher amount of CBDA; we call these plants CBD-rich chemovars. The genetic dominance for THC explains why most drug-variety plants are higher in THC potency and lower in CBD potency. The rampant crossbreeding of chemovars over the past few decades has also promoted higher THC content. The average THC content of cannabis confiscated by law enforcement in 1972 was 1 percent, increasing to 4 percent in the 1990s, to a national average of 17 percent as of 2017.2 THC-rich cannabis flowers currently available in California dispensaries have THC content between 15 and 28 percent, with a corresponding CBD content of less than 1 percent. Concentrated forms of THC-rich cannabis (such as hashish) can be as high as 90 percent potency. The increase in THC content has led to a decrease in CBD content, and at one point it was thought that CBD-rich plants might no longer exist. However, the popularity and increased demand for CBD in the past decade has led to the stabilization of Type II plant genetics, leading in turn to the increased availability of CBD-dominant cannabis products.
How the cannabis plant synthesizes phytocannabinoids.
Type I and Type II are what we call “medical marijuana” or “medical cannabis” and are available through state-regulated dispensaries. Type III is either medical cannabis with high CBD content or fiber-variety “hemp” products that have become very popular in recent years. The concern with hemp products is that they remain unregulated and the CBD content claimed on labels is frequently incorrect. (More on this to follow.)
The Entourage Effect
Of the 140 known phytocannabinoids, only a few have been thoroughly studied. Each of these phytocannabinoids, when isolated in a lab, has been shown to possess its own array of medicinal properties. However, when taken together as they occur naturally in the whole plant, they balance one another in a synergistic action first called “the entourage effect” by Israeli researcher Raphael Mechoulam, who was the first to isolate THC and CBD in the early 1960s. The entourage effect means that the cannabinoids work better together than when isolated from one another. This synergy can enhance or modulate effects beneficially.3
As an example of synergistic enhancement, both THC and CBD, when taken separately, have been found to provide pain relief, but studies show that CBD enhances pain relief when used in conjunction with THC, compared to THC used by itself.
As an example of opposing effects, CBD may decrease some of the intoxication, memory loss, and increased heart rate THC can induce.4
What Are Terpenoids?
Terpenoids—also called “terpenes”—are the essential oils that occur naturally and exist in all plants, including the cannabis plant. More than twenty thousand terpenes have been described, of which about two hundred occur in cannabis.5 These oils give cannabis its odor, color, and flavor. They have evolved within the cannabis plant as a defense mechanism against insects, bacteria, fungi, and other plant predators. Terpenoids can be categorized by how many carbon units they contain: monoterpenes (10 carbons), sesquiterpenes (15 carbons), diterpenes (20 carbons), and triterpenes (30 carbons).
Some Important Facts About Terpenoids
• Terpenoids are genetically controlled.
• Production increases with light exposure.
• Production decreases as soil fertility decreases.
• The US Food and Drug Administration recognizes terpenoids as safe.
• Terpenoids vaporize near the same temperature as THC.
• Concentrating cannabis into hash or wax may reduce the terpene content and may cause medicinal effects to change.
• The terpenoid profile of any cannabis plant can be determined by laboratory analysis.
Terpenoids are known to be biologically active, just like phytocannabinoids, interacting with human cells, neurotransmitter receptors, and other parts of human physiology.6 The unique combination of phytocannabinoids and terpenoids in a specific cannabis plant accounts for the varying effects felt when different types of cannabis plants are used. Most importantly, phytocannabinoids and terpenoids work synergistically to provide certain therapeutic effects. Terpenoids are also synergistic with each other, again enhancing their medicinal effects.
An example of a prominent cannabis terpenoid is limonene. It is a monoterpene found in lemon and other citrus fruits, and is the second most common terpenoid found in nature. Limonene has potent antidepressant and antianxiety activity as well as anticancer effects.7 It also has been used successfully to decrease the symptoms of gastroesophageal reflux.8
Table 1 shows four of the most important terpenoids in the cannabis plant, including other plants where they are found, known medicinal effects, and aroma. (Please refer to the terpenoid chart in appendix D for a full list of the clinically important terpenoids.)
Terpenoid: Limonene
Also found in: Caraway seeds
Citrus rinds
Dill seeds
Juniper berries
Peppermint
Rosemary
Medicinal effects: Analgesic
Antianxiety
Anticancer
Antidepressant
Anti-inflammatory
Antioxidant
Bronchodilator
GERD suppressant
Aroma: Citrus
Orange
Spicy
Terpenoid: Beta-caryophyllene
Also found in: Basil
Black pepper
Cinnamon
Cloves
Hops
Lavender
Oregano
Rosemary
Medicinal effects: Analgesic
Antibacterial
Anticancer
Antifungal
Anti-inflammatory
Anti-itching
Antimalarial
Gastrointestinal relief
May reduce alcohol intake
Aroma: Spicy
Woodsy
Terpenoid: Alpha-pinene
Also found in: Basil
Dill
Eucalyptus
Parsley
Pine trees
Rosemary
Sage
Medicinal effects: Analgesic
Anti-inflammatory
Bronchodilator
Increases focus and alertness
Increases permeability of blood–brain barrier
Reduces THC-induced memory loss
Aroma: Pine
“Skunky”
Terpenoid: Linalool
Also found in: Birch trees
Citrus
Coriander
Lavender
Rosewood
Medicinal effects
Genre:
- On Sale
- Sep 29, 2020
- Page Count
- 368 pages
- Publisher
- Little Brown Spark
- ISBN-13
- 9780316500784
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