Episode 41: Dr. Mikhail Kogan, MD on Medical Cannabis: History, Use and Clinical Applications

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SPEAKERS: Dr. Andrew Wong, Dr. Mikhail Kogan, MD

Dr. Mikhail Kogan, MD

With cannabis, the mantras are start low, go slow and then I added this one and deliver where it needs to go. So it’s actually most important in three in my opinion because we often think of cannabis more like smoke and take it orally forgetting that there’s all these other applications. I’m actually working now with a very cool group on trying to figure out how can you put cannabis in the eye? Because for glaucoma, people smoke currently. That’s not a really good intake because it doesn’t last very long and can have a lot of side effects and that’s really the main reason. You put something directly where it needs to go, the amount of what you need to put there is way less and so you avoid the systemic toxicity, you’re cutting the cost, you’re making it logistically a lot easier because often and you’re literally often removing any serious functioning problem because one of the big practical reason why a lot of people don’t want to use cannabis they’re afraid of getting high. Let’s put it this way. You know, if you have pain and you smoke cannabis and you get high, people say well “My pain is better, but I’m high. I don’t want to be high” So what do I do here? Well if you have a pain in your feet, for example, neuropathic pain, we’ll try topical first. And I’d say that in the some percent of people with works works really well, and then in the small group, take anything orally and suddenly you have a tool that is highly effective, relatively low cost and zero central or kind of overall toxicity. I mean, you can’t have theoretical toxicity there but it’s way, way less likely to happen than when you take things orally or when you inhale them.

Dr. Andrew Wong

Today we are happy to discuss medical marijuana. This is one of our hot topics today. Medical Marijuana has been in use for the last few decades even before that as an alternative to help with anxiety, pain, inflammation, sleeping issues and much more. Nevertheless, it can be confusing and even controversial to understand how and when to use it. Today’s guest Dr. Misha Cogan, is here to help us demystify medical marijuana and discuss origins and therapeutic uses. Dr. Kogan is medical director of the George Washington Center for Integrative Medicine, and Associate Director of the Geriatrics Fellowship Program there at GW and as Associate Director of the newly formed GW Interdisciplinary Integrative Medicine Fellowship. He also recently published an amazing book Medical Marijuana— Dr. Cogan’s evidence based guide to the health benefits of cannabis and CBD. I am Dr. Andrew Huang, co-founder of Capital Integrative Health. This is a podcast dedicated to transforming the consciousness around what it means to be healthy and understanding the root causes of both disease and wellness. Don’t miss this discussion with Dr. Kogan about the benefits of medical marijuana, or rather we should say medical cannabis and what you need to know before using it.

Well thank you, Dr. Kogan. Thank you, Misha, for coming on today. Great to have you on. Thank you so much for taking the time here.

Dr. Mikhail Kogan, MD

Thanks, Andy, for having me.

Dr. Andrew Wong

Yes. So Misha has been a good friend and mentor for a long time now integrative medicine. Certainly one of the aspects that Misha you’re an expert on is medical cannabis. And I know you recently published a book called Medical Marijuana: Dr. Kogan’s Evidence-based Guide to the Health Benefits of Cannabis and CBD. Let’s kind of start with the basics. I think I learned this from the conference that you hosted at GW, did the IOM press conference and I think you had bethere you know, you had you were talking about how basically this idea of cannabis as, as a you know, one of the you know, originating from one of the original crops that you know, we have cultivated in the agricultural times, to becoming essentially, you know, maybe demonized or something or having this idea of, you know, this is not a good substance or something. So, let’s first talk about what is cannabis and marijuana and you know, what’s the difference there and just kind of getting that basic first.

Dr. Mikhail Kogan, MD

Right, right. It’s interesting, you brought up like, the history here, because this is one thing that history comes in full circles, right? I mean, before the prohibition, cannabis was kind of everywhere. It was the part of the treatment plan for so many different issues, including it was actually part of a Pharmacopoeia in US, which is a standard prescription guide for something like a century and before that, it was one of the oldest medicinal plants that was used for a variety of different reasons. And not just internally, externally it was used a lot as well. Originally, it was used a lot so it was pretty common and no one ever looked at this as something controversial. I feel like it always been with humans for thousands of years simply as part of our not just medical but a lot of daily routines for a variety of reasons. And so we are now rediscovering this of course, we are rediscovering the molecular structures, we are rediscovering how the plant interacts with our own and the cannabinoid system which turns out we have. So I think this whole conversation should sort of be circling around this particular topic where, turns out, we have our own cannabis system inside of us and it’s extremely profound and complex. And it is much older than the endorphin system. It seems to be much more important for regulation of not just the brain activity and things like pain for example of perception, but also immune system and bone develop and muscle development and harm function and pretty much almost anywhere you look with very few exceptions that cannabinoids have some kind of regulatory or direct impact on a particular function of our physiology. And so, with that in mind, here you have a plant that we now call marijuana for past whatever decades before of course it had it was just called cannabis and different languages, different words. And now we have this terms as hemp CBD and a lot of terms that are very new, right so the term marijuana, which is basically describes cannabis one. We argue though, that the cannabis is a botanical term and Marijuana is more legal term or recreational term, if you will, but you know, there’s a lot of problems with that and I mean to begin with. I’m just going to use it today interchangeably because I feel like marijuana is more of a historic word now that doesn’t describe anything botanically or medically relevant. It’s just there because the whole culture grew up on this because there’s a huge political attachment to it. And actually, I feel there was a lot of discussion in our smaller circles of the experts in this field who feel like this word should be removed from dictionary because it’s, in a way, made up word only has a negative connotation when they made up the word. It became popular in a culture and we’re still using it so let’s get rid of it. So that would go back to cannabis and just keep it strictly medical in terms of the work. The problem with that is then what do you do with the whole history here? Because unfortunately, history here is not very good. There’s a lot of racial disparities. There’s a lot of segregation based on the board. And so I think it’s essential to keep the word more as a history and say, Look, you know, we got this one totally wrong. We had the government telling us total BS for decades, claiming that this is dangerous substance with no medical use. It turns out not only they were wrong, but they were just simply using all of this political reasons and now we’ve known the history, starting with Anslinger. Going back to the 1930s, where they needed to escape gold money to establish basically to establish DEA office, in essence, and they got this money and they’re still operating on that budget decades later. And the entire industry here quote, unquote, “was established with a lie.” I think it’s worth for the public and for everybody to know that and so I feel kinda let’s keep the term. So let’s go to the CBD term and hemp term and THC which is sort of the highest used words in our cannabis vocabulary. So the hemp is literally usually we mean it’s an industrial product that has less than 0.3% THC and then its application is not for medical use, but just for industrial use for the textile for me and for the protein for the food for now, the most fascinating thing with that I’ve seen this there’s a hempcrete and apparently it’s one of the simplest, fastest growing industries in the construction industry in the world.

Apparently it’s stronger than a regular concrete that’s fireproof. There’s all kinds of benefits of having hempcrete it’s also rapidly generatable and renewable and, you know, I have no idea don’t ask me that’s not my area of expertise, but I’ve just went to the conference where this was discussed heavily. So, you know, so they have this industrial, the CBD from hemp is now sitting in that agriculture bill. So, which is not even the CBD from south from hemp is now not even considered supplements. So by the way, those listeners who are wondering sort of why the CBD has a totally separate purchasing process and you can’t even buy it in the regular supplement stores like large respective distributors like well away their fullscript. That’s the reason because the supplements are regulated by FDA, and CBD is not. CBD is under the agriculture bill. It’s not even considered food. It just sitting there completely separate like domain, similar really, to some degree to cosmetics. So it’s a very interesting legality here that puts it in a weird category, so CBD from hemp is there and then we traditionally use the word non psychoactive. Now we don’t use that we say cytotoxic. So psychoactive is much broader word, cytotoxic means you know something that makes you euphoric. So CBD is not going to make you euphoric no matter how much you take. It’s the THC that will, right? And THC is pretty much the only ingredient in cannabis that will. I know it was a long answer.

Dr. Andrew Wong

No, no, that’s very comprehensive. Great overview to start with. So it sounds like there’s medicinal uses for cannabis or marijuana, depending on how we say that. What are the conditions that either medical cannabis or CBD are most helpful for in your experience?

Dr. Mikhail Kogan, MD

Right and I’ll put the blog for the book here because the book has intro in some orientation chapters, but then you have a lot of medical chapters. And what we tried to do with the book we tried to say look, what are the most common and most evidence applications of cannabis and let’s group them in categories and center chapters around those categories. So there’s a significant symptom support, and I will divide those symptoms in several categories. So pain is a huge one. And this is where both THC and CBD has a role to play. THC probably has a bigger role than CBD, but there’s a lot of lack of clarity as to what is the best makes us, what are the best combination, what are the best kind of doses ratios, routes of administration for specific types of pain. But in general I would say cannabis should be somewhere between the first and second line of treatment for any chronic pain. I’m not going to be afraid to say that in public and open and it’s not just based on 2017 National Academies of Science conclusive report that says evidence for cannabis for chronic pain is Grade A, and we have not a single drug for any chronic pain that is considered Grade A evidence. We have Grade B, we have Grade C, we even have Grade D drugs and for the listeners if you don’t know what I’m talking about, so there’s an evidence based medicine there’s a gradation of the quality and level of evidence. And so there is, when somebody say Grade A it usually means gold standard treatment. So if I were to tell you that for a particular disease, there is a Grade A treatment you will assume that it’s a first line gold standard recommended by every agency and every standard or every organization in the country. To give you an example, it would be a statins for coronary artery disease. This would be Grade A recommendation for existing cardiac disease. The statins would be recommended with Grade A evidence support. For chronic pain what there is a Grade C and Grade C means borderline evidence. Never use firstline, never never use second line. Maybe third line use.

So in the cannabis then, they ask would into Grade A. Just so then every listener would understand. Now this isn’t an independent organization. It’s not a government organization, but it’s not an industry either. So and this was a summary of 60,000 articles. So it’s a massive assessment, a massive review by kind of top leaders in the country. So you know, I still use that as the kind of the #1 evidence, chronic pain. You have a lot of applications, a lot around the cancer which are also often Grade A or maybe B. So nausea and vomiting, pain as I mentioned but even things like weight loss and appetite and general well being so we do think that cannabis taken for cancer patients not only going to decrease nausea and improve their symptoms, but they’re going to feel overall better and especially those who are in the last six of what six months of life. So there’s a very critical palette of use of cannabis. And that’s one aspect that always intrigued me the most because we knew this for thousands of years. There was a historic documentation of cannabis use for people and end of life dating many thousand years ago not just to Chinese medicine but to all over the world. In Siberia, the discovery of Siberian Princess, their mommy in the ice that had breast cancer and had a large pile of cannabis right next to her in Frozen Ice. So in every parts of the world where cannabis existed as a plant growing out there, people figured out that it was to be used for that. So that’s another big category. Of course there’s a whole discussion of cannabis cure the cancer. Actually so happened to present today later in the day Journal Club when an article this actually saying slow the horses. There’s some evidence beginning to hear that maybe cannabis is not good for every cancer patient and for some it may actually do the reverse of good. I would say this is a very unclear topic. And part of it is simply we do not have enough quality data. We have a lot of patient stories. So I expect that we’re going to see an explosion of more cases. My personal opinion of cannabis for cancer is mixed. I think we’re going to see some cancers where it’s going to take its own proper disease modifying place and it’s already sort of thus in some of our clinics, but the evidence is very weak. The only evidence we have is a little bit for curing cancer, supporting cure of cancer, brain cancer. Everything else is the evidence is not existing whatsoever, at least in brain cancer. We have a small study, randomized study showing that the 1:1 mix of THC and CBD actually prolongs life. That’s one study in like, less than 20 patients. I mean, we don’t typically use evidence like this to make any conclusions right. So that’s that. I think anxiety, sleep, like depression. Psychological symptoms can be very effectively managed with cannabinoids, it gets a little complicated there. Interestingly THC at low doses can be extremely anti anxiety and theory effective for chronic sleep. However at high doses, THC actually could be anxiety and panic attack provoking and actually blocking sleep. So you got not as simple relationship. CBD seems to be good for a lot of psychological issues: anxiety, there’s some even some data on in schizophrenia you can decrease side effects of medications-balanced patients with CBD. So there’s a lot of data that suggests from certain things without being inconclusive. Definitely a lot of people use CBD for anxiety. And I’ve seen this being quite effective. The problem is you have to use a lot and then it becomes reasonably expensive. If you’re using it for them.

Dr. Andrew Wong

And follow up question about that, CBD can be metabolized by the hepatic enzymes the P450 system. If someone who has anxiety depression and they’re on let’s say, an SSRI or other medication or they have some other you know, psycho psychoactive medication. How does CBD interact with that and is it better to, you know, check with pharmacy and all the drugs and drug-herb interactions there?

Dr. Mikhail Kogan, MD

You must be preparing yourself to take a certificate and being a kind of a cannabist.

Dr. Andrew Wong

I’ll probably work on that. I’ll learn from the best.

Dr. Mikhail Kogan, MD

Yeah, we were just writing questions about this yesterday. So that’s exactly right. So CBD, in theory, can it’s a competitive inhibitor of 50 or so in principle, you can see a blocking metabolism of some medications and increase in side effects of certain things. And so there’s definitely a concern and warning about it. The funny thing is that we’re just not seeing this in practice. You know, those of us who actually make recommendations of course, are very careful. I have this weird idea which I don’t know where I got it from. That keep everybody under 100 MG a day when you’re just managing symptoms of CBD. It’s not based on anything. Just FYI. It’s just sort of my experience has been but I heard stories that people take over 1000 MG a day and we’re not seeing anything. So we not seeing anything because those tend to be younger and healthier people who take these massive doses and it’s just the time and we will see something. Why is it maybe that it’s possible that those interactions are not clinically relevant? And some of the experts like foremost experts in this field like Ethan Russo believe that they’re not clinically relevant? I don’t want to quote him here, but I’ve heard him say this multiple times in different settings make me believe that it’s true. I think I’ve seen one or two things and even I put some a couple of things in the book. I mean, there was a case when I remember early on when a patient was taking high dose oxycodone, which is a narcotic pain medication, like morphine, and the person was recommended by somebody to take massive doses of CBD several times a day and it felt like that person was overdosing on oxycodone. Was it real? Was there other things involved? I’ll never know but the caution is there I would say.

Dr. Andrew Wong

Okay, so let’s go down our first rabbit hole here. Some questions based on your amazing answers. So we know that the 2017 and as papers recommend a great aid that you know, cannabis use for chronic pain, why isn’t it that more available versus opioids at grade C.

Dr. Mikhail Kogan, MD

So this is not a rabbit hole, I think it’s a.. I think the future generations will look at this and say there was so much criminal intent in the pharmaceutical industry that’s been happening and we’re gonna look at this as dark ages of pharmaceutical industry, I have no doubt because in my mind we have not only data cannabis is grade A, we have data that if you combine cannabis with opioids, you’re gonna save 30% of lives lost. So if we have, you know, say 50,000 probably closer to 100,000 deaths a year, just from opioid overdose. I’m not even talking about side effects and links of side effects to other complications. That’s over, well, all of the meds combined that’s more than a quarter of a million people dying every year. If you just look at the opioid overdose, let’s say it’s 100,000. That means that 30,000 lives a year can be saved by introducing cannabis for the whole country. I mean, the data is there and it’s published in JAMA, in New England Journal of Medicine. I mean, we’re talking about top journals that the high-end quality studies publishing this data now for about five or six years consistently across every state that legalizes cannabis in every single setting. Cannabis is becoming an exit drug for opioid induced.

Dr. Andrew Wong

So, just to be clear, if someone’s on opioids, you can start to wean them off by simultaneously introducing cannabis?

Dr. Mikhail Kogan, MD

If you add cannabis and that percentage and exact dosing is not really clear here, but if you have somebody on opioids, if they’re addicted and you start them on cannabis, you have a very high chance of having off opioids within a short period of time. And the data is such that if you do that 30% of mortality will be saved in this setting. And in my experience, upwards of 50% of patients will be off all opioids within 3 months when you do that.

Dr. Andrew Wong

That’s incredible. I mean, if you think about the opioid crisis, right?

Dr. Mikhail Kogan, MD

50%. That’s right. And there’s no actually, nobody’s talking about it. There is not even close in terms of efficacy that anything’s out there like for example be bupropion and narcan, and all those drugs. I mean, they’re of course saving lives left and right. The problem is they’re not an exit strategy often. They are, the bupropion is but it’s a lot more complicated and people assume and so the effective management because it’s not like, let’s just stop the opioid you got to address why a person went on to the opioid in the first place. If they have a chronic neuropathy or some other chronic pain syndrome, and you simply say let’s taper it off. What are you offering to a patient? The cannabis offers not just the exit drug, it offers the solution for pain simultaneously, and basically, completely safe, I would say when you use it right.

Dr. Andrew Wong

So then that becomes the cost and access issue right? That’s where we might get into social justice and access to health care.

Dr. Mikhail Kogan, MD

That’s just what if it’s not covered but you also have to look at this a little differently. At the same time, you have to look at the total burden to the society. Yeah, the cost happens for opioids, you know, we talked about $1,000 a month for many generics are way way cheaper but you’re still looking at say 100 bucks a month at minimum and a cannabis cost per month can be in $20-30 if we have a national legalization and bigger you know, right now it’s probably closer to the same $100 but you know in terms of total cost to society to your future, you’re also going to save some money.

Dr. Andrew Wong

Save money. Yeah, yeah.

Dr. Mikhail Kogan, MD

And you will transfer money from pharma to elsewhere. And I think that’s partially here is the resistance is that everybody understand so.

Dr. Andrew Wong

so there’s a few things we want to talk about. Well let’s go work more with you said, there was, you know, obviously indications for chronic pain, for quality of life for cancer and maybe some small studies showing it’s helpful as these monitoring agent for brain cancer., some anxiety, depression, mood nerve vegetative symptoms, anything else that are kind of big conditions that you want to highlight that you focus on in your book?

Dr. Mikhail Kogan, MD

Yeah, so anything that’s related to neurodegenerative conditions, which is multiple sclerosis, Alzheimer’s, Parkinson’s, there’s, you know, very large categories of use. Primarily, we’re talking about symptoms related to those conditions like behavioral disturbances and Alzheimer’s, or motor symptoms so the tremors and spasticity in Parkinson’s disease , spasticity in Multiple Sclerosis, with the oldest conditions cannabis can be very helpful for. There is a beginning of a new whole field of saying “Could the cannabinoids, exogenous cannabinoids, the extract of cannabis plant in some way be used as part of the long term strategy of curing neurodegenerative diseases? It’s premature to say that we have a clarity but if we have multiple signals that say it’s going to be within a decade, I expect that it will be part of the standard treatment. And I’m talking about reversal. I’m not talking about symptom management here. So that stay tuned the data is all over the place. I’d say the most important areas for those conditions are sleep disturbances. I agree with the kind of agitation and motor symptoms. So those are the very big categories.

Dr. Andrew Wong

Are you saying the research that’s still out there, they’re researching say like cannabidiol or CBD CBG or..

Dr. Mikhail Kogan, MD

I’m not gonna go there because this is a rabbit hole which we will not come out of for next 30 minutes if we get there. The long story short is, you know most of the cannabinoids specifically you mentioned CBD and CBG have some strong neuroprotective characteristics. The problem with looking at those molecules and looking at something like let’s say Alzheimer’s disease is that the trials need to take potentially decades because you, it’s a very slowly progressing disease you have to look at them accordingly. And you have to apply protocols and study them accordingly. So we simply, it’s going to be a long time. I am actually not convinced that CBD and CBG are the most important molecules. I’m actually wondering if CBDV and some THC metabolites and even THC itself is going to be just as critical if not more critical. So long story short, here’s a one word of wisdom for listeners. THC in young age, in large amounts for the developing brain seems to be quite detrimental. There’s no argument over that. That’s one thing we know for a fact so it can take a young brain so they are somebody in their teens or early 20s And they recreationally taking a lot of THC they definitely doing themselves a harm. There’s no discussion over it.

Dr. Andrew Wong

What’s the mechanism for that, Misha, for that?

Dr. Mikhail Kogan, MD

So yeah, we understand it, actually reasonably well. The main mechanism that what happens is your natural production of your internal cannabinoids, let’s say anandamide is something that’s primarily done on demand.

Let me give you an example. Let’s say you are under a certain stress and you are telling your body we need to manage this stress and the critical part of management of that stress is your own THC. So you’re anandamide. You will make it enough to control that particular stressful event. And that THC, from regulatory perspective will help you to create further downstream signaling that will allow you to get over the stress healthy in a good way. Now imagine you suddenly take an exogenous molecule that’s inconceivably higher spike, your endogenous production gets suppressed physiology, the results have shifted in the thinking is that that leads to all kinds of downward effects, decrease brain development, potentially loss of some cognitive functioning, potentially increased risk of schizophrenia, potentially increased risk of accidents and all kinds of other issues. So there’s no question that there is a negative impact.

Now adding CBD maybe eliminating some of those impacts and probably not maybe but I’d say for sure, just not clear whether it’s eliminates everything whether the safety level goes back to baseline if you combine THC, what should be the ratio– should it be 1:1, CBD to THC, should you take 10:1, CBD..

I mean, there’s a lot of holes.

Dr. Andrew Wong

Do we have a general sense because a lot of people are young at heart, right?

Dr. Mikhail Kogan, MD

Alright so let’s go back to the other side. So you have young people and then you have the older. It turns out that they’re actually some of that extra THC becomes brain protected. So here you have what we sometimes call a J-curve. At one age, you have a negative impact and at another we have a positive impact on the same part of the body. I’m talking about just the brain right now.

Dr. Andrew Wong

Okay.

Dr. Mikhail Kogan, MD

So why that is? Not really clear except for one thing, as we get older on our own endocannabinoid system or endocannabinoids tone, as terms would like to say, drops. So we make more molecules that break down anandamide, we have less receptors in the brain, we have less than anandamide so we can’t generate as much anandamide. And that’s actually a thinking partially why some of these neurocognitive conditions evolve in older age, almost always because you have this chronic disturbance in the endocannabinoid system that triggers in part. I am sure there are tons of other triggers, but it’s one of the triggers for evolving of Alzheimer’s and Parkinson’s.

Dr. Andrew Wong

Sounds like as we get older, we need more juice, essentially. We might need more juice.

Dr. Mikhail Kogan, MD

All kinds of different juice.

Dr. Andrew Wong

Yeah, what kind of juice, pineapple juice, kiwi, you know, whatever.

Yeah and that’s great. So, what about other neuro conditions? Because I felt like what I’ve seen too is that people with migraines, people with mood issues, I’ve read before, maybe you could incorporate this as you know, in the cannabinoid deficiency your could be causative at least either triggering, causative of perpetuating..

Dr. Mikhail Kogan, MD

Well that’s what I’m saying. I think anything brain related whether or any neurological issues or psychological issues I think cannabinoids can have a huge role in the future. I mentioned anxiety but definitely for depression. I mean, there’s a lot of people who use cannabinoids for depression in different combinations and makes us PTSD. So I mentioned stress before for a purpose. Turns out that our endocannabinoid system is #1 regulatory system of stress. Not the way we used to think that it’s so like..

Dr. Andrew Wong

Not adrenal.

Dr. Mikhail Kogan, MD

Yeah, no, no, not adrenal. Adrenal’s a secondary. Cannabinoids regulate how adrenals are going to respond to stress.

Dr. Andrew Wong

Adrenals are in second place in the race, is that what you’re saying?

Dr. Mikhail Kogan, MD

I would say they’re in third place? They’re kind of, you just support them but you don’t, you know.

Dr. Andrew Wong

What’s the second?

Dr. Mikhail Kogan, MD

Well I mean, the central mind body right? So if you don’t, if you don’t learn the primary regulation, if you’re don’t teach your body to self regulate, trying to support adrenals is like, you know, putting water on a major fire at the same time putting logs to that fire.

Dr. Andrew Wong

Yeah, adding some more laws.

Dr. Mikhail Kogan, MD

Exactly. So the cannabis turns out to be critical. So definitely anything chronically stress related, there’s some depth definite use already. I’m not even talking about precise applications that’s going to come in the future when we have a lot more research out there.

What else in terms of psychological? Well, seizures of course everybody’s talking about especially since Sanjay Gupta has, I think that’s number 6: Weed Series, he particularly talked about seizures and well, I mean, we have FDA approved drug for seizures, which is CBD right Epidiolex which was approved in 2019. It’s nothing but pure CBD.

So we know that even the FDA, even the medical communities already agreeing with some of this completely. But you know, I see that this is going to explode. Other whole topic, which we could speak for hours, is dermatology. So turns out.

Dr. Andrew Wong

I’m sorry. What’s that?

Dr. Mikhail Kogan, MD

Dermatology. Turns out you can probably manage almost all dermatologic conditions with cannabinoids. Eczemas, any rashes, any allergies, any skin breakouts, infections of the skin like herpes infections, Zoster, every image of cannabinoids and we have a whole chapter on this. I don’t want to go in there in great detail. Partially, that topic is so fascinating because obviously for those things if the problem is localized, you can put enemas topically right on the lesion and it often is profoundly effective and low cost because you’re not taking some massive doses internally. You’re applying small amounts right where it needs to go. Which brings me to this whole concept of what I often say cannabis monitors, you know, in relative care, we have this whole bunch of monitors like the hand that writes for the opioid that doesn’t right for the, bowel regimen should be cut off. Like we have those things and in a palliative way..

Dr. Andrew Wong

It’s pretty hard! Yeah. That would make sense.

Dr. Mikhail Kogan, MD

.. teaching fellas that you just have to do certain things, right?

So with cannabis, the mantras are to start low, go slow, and then, I added this one and deliver where it needs to go. So it’s actually more important than in three in my opinion, because we often think of cannabis more like small can take it orally forgetting that there’s all this other applications. I’m actually working now with a very cool group on trying to figure out how can you put cannabis in the eye? Because for glaucoma, people smoke currently that’s not a really good intake because it doesn’t last very long and can have a lot of side effects and really the main reason if you put something directly where it needs to go amount of what you need to put there is way less and so you avoiding systemic toxicity, you’re cutting the cost, you’re making it logistically a lot easier because often and you’re literally often removing any serious functioning problem because one of the big practical reason why a lot of people don’t want to use cannabis they’re afraid of getting high. Let’s put it this way. You know if you have pain and you smoke pot and you get high people say well, “My pain is better but I’m high I don’t want to be high, so what do I do here?” Well if you have a pain in your feet, for example, the neuropathic pain, well try topical first. And I’d say that in some percent of the public works and it works really well. And then in the small group, take anything orally and suddenly you have a tool that is highly effective, relatively low post and zero central or kind of an overall toxicity. I mean, you can’t have theoretical toxicity there but it’s way way less likely to happen than when you take things orally or when you inhale them. So the whole area out there.

Dr. Andrew Wong

Wow, that’s amazing! Do you think the eyedrops could potentially decrease intraocular pressure if they have, if people have glaucoma?

Dr. Mikhail Kogan, MD

So it’s actually not necessarily 100% clear. So it appears that THC will definitely decrease pressure. Problem is THC is not very water-soluble so you have to dissolve it into a substance that would be allowed to be put in the eyes so you can’t put oil in the eye. So, you have to put aqueous solution. But acidic forms of THC and CBD: CBD-A and THC-A are more water soluble so this is I think we’re gonna go. You can kind of try to put those molecules and try them up but they all history is very clear here. CBD actually could theoretically increase interact over pressure so nothing. If I learn one thing about cannabinoids, there’s nothing here simple. There’s just nothing simple. It’s a highly complex system with a lot of intricacies and details and this is why you should take the course. No, I’m just kidding.

Dr. Andrew Wong

Absolutely! I’m considering it for sure.

Dr. Mikhail Kogan, MD

My point is, or my point brings me to the next really important topic which I wanted to just touch up on, and that is we have to teach. Forget the current generation of physicians. So this is just like.. now it’s just too complicated, unrealistic. The data is just coming out now. We’re not going to teach them, they’re not going to learn. We have to concentrate on the future generations which is what I decided to take a sort of my psyche because I don’t want to get involved in the industry here.

Dr. Andrew Wong

You have a course? So, do you have a course?

Dr. Mikhail Kogan, MD

Oh, no, we don’t. I don’t have a course there’s a lot of courses that are really good and there’s a lot of people who are much better educators than me, but I decided that what I do know how to do is how to get things done in academia. So we are actually trying to create a process in which we will create a set of minimal standards and we’ll take up minimal standards to the guarding body of all the medical schools in the country and actually in the world and we’re going to tell them “Look given what’s going on. You must assure that every medical student graduating from medical school has some minimum knowledge of this topic.”

Dr. Andrew Wong

Yeah.

Dr. Mikhail Kogan, MD

Because right now when they graduate, they only know the following: cannabis causes side effects, here’s the list of side effects, here’s what cannabis can interact with, and that’s it. It cannot do any benefits. Nobody teaches in terms of clinical applications of benefits. They’re only teaching pharmacology about toxicity and metabolism. So currently, the students get excited by this topic, that’s when to find a mentor. There’s very few mentors out there or they get us to sort of wait until they are fully trained in their field, graduate, get their degree, start working and then take one of those like fancy high-end courses.

Dr. Andrew Wong

It’s a bit tilted against learning about the true applications that this is a big disturbance to I guess everyone you know.

Dr. Mikhail Kogan, MD

And not only that, there has been historically in the last five years a tremendous oppressive force from the AMA and from a guarding agency that makes CME so that every doctor has to take X amount of CMEs per year in order to continue being licensed. And that’s actually applies to everyone, it’s not just doctors, but PA, nurse practitioners, everybody. And so there’s been tremendous pressure against not granting CME so I’ve , last year I was giving a talk at Andrew Wiles conference, and they were highly apologetic even and they called me and said, “Look, we’re sorry, we can’t give you CME for your talk on cannabis”. So Donald Abrahm’s was a good friend of mine and a mentor. He got furious. He send the letter to the head of CME at the University of Arizona saying what the hell is going on? It’s a highly evidence presentation. I reviewed it myself like what is this? How can you not grant CME? And the reason for that is very simple.

It’s a large medical industrial complex, they are afraid of this whole topic. They don’t know how to handle it. There’s no standard of education. There’s no standard guidelines of anything here. So there’s an oppression happening from not knowing, being ignorant, maybe some pharma industry, I don’t know, I don’t care but like it seems like until we get past the crap and get to a point where minimum standard education exists. Every medical student and every nursing student and whatever have some basic knowledge when they come out of the training.

Dr. Andrew Wong

It’s a good idea.

Dr. Mikhail Kogan, MD

How far from it are we? We don’t know. But so I felt like let’s try to do something in line with that because if we achieve even the publication of such competencies out there in a very good journal, then it’s the first moving step. So everything is going to move here very slowly. So if you’re a patient and you’re looking for cannabis expertise and good luck, you’re going to need it.

Dr. Andrew Wong

Well go see Dr. Kogan that’s definitely, you’re going to see Dr. Kogan.

Dr. Mikhail Kogan, MD

Well, yeah, yeah, oh my God!

Dr. Andrew Wong

Well, we can talk offline about the training program because I do think that would be really helpful for you know, us to learn and I think there’s just need to be more people trained, you know, out there.

Dr. Mikhail Kogan, MD

There used to be more people trained. There are hopefully going to do more and more academic programs because part of the problem there’s a lot of great programs, you know, society of cannabis clinician, Dustin Sue, like as his own training. Just a lot of, there’s a lot of good people who are doing, I think Bonnie Goldstein has a court like there’s a lot of really great courses. The problem is when they’re not inside academia for when they are run by the industry people you create it, it’s an automatic tension. Only a true enthusiasts will take those courses and it’ll leave everybody else out and they’re going to be highly skeptical of coming, joining this program. And that’s just a part of evolution.

If you look at every other field that came before the integrative medicine, for example, right, it’s exactly the same it took how many decades for like, integrative medicine silo organizations stay there, but now like you have some kind of integrative medicine in every Ivy League, every medical school in this country pretty much. So it’s just a matter of time. It’s a matter of continuous effort. It’s a matter of creating standardization in the field. But, you know, but the good news is that it’s growing rapidly, just as there’s so much money in this and there’s so many new doctors coming out saying

Dr. Andrew Wong

And there’s people who are demanding that you know, that this is you know, being more accessible. So let’s say to the patient out there listeners out there, they want to try cannabis, medical cannabis or CBD, how do they access this at this time? Is it different in every state?

Dr. Mikhail Kogan, MD

So it depends on the state since we are in our tri-state area. Let’s talk about that first.

So if you’re in a district or in Maryland, and I’ll talk to Virginia and separately, you go and you get your card predict, you know, within say 4-6 weeks, you have to have a doctor who will give you a recommendation for the card and then they’re set up dispensaries and district has been doing this since it was approved in 2010. And dispensers first, I believe was in 2012. So it’s been now 10 years. So they’re quite experienced. There’s a lot of different products, prices gradually has been trickling down very slowly. We’re still not anywhere near where we should be. Like we’re still 2 or 3 times more expensive than Maine or California. So there’s a big discrepancy still, but nonetheless it’s going in the right directions. So, Maryland is much newer. DC and Maryland have reciprocity. So if you are a Maryland resident go and get your cannabis from the district. If you’re a Virginia resident you can also get it from District three, cannot get it from Maryland and Maryland cannot get it from Virginia.

So, Virginia is a newest, it has been very recent that they added. Their dispensaries are still like just starting to have reasonable products right now. It’s just the flour and meat. It’s some gummies but it’s really not anywhere near where it should be. But, you can get a license from Virginia and I’m gonna get it from the District. Every single one of my patients.

Dr. Andrew Wong

That’s great. That’s great! Great to know.

Dr. Mikhail Kogan, MD

You know in Virginia cards are in some ways even easier. The process there, the way they set it up is very simple. So your doctor has to have been approved to be a recommender of cannabis. We don’t say prescriber, it’s recommender.

Dr. Andrew Wong

Right, right. But how, when they go to the dispensary who is actually recommending to them the ratios and the like the forum and stuff like that.

Dr. Mikhail Kogan, MD

Oh, that’s where the things, that’s where the problems are. So like recently was talking to Head of Internal Medicine at GW and I said look, do you want me to start training our residents in this topic? He’s like “Oh no, no. We’re doing it ourselves.” And I’m like, “You’re doing it yourself.” And I’m like, “so what are you doing?” “Oh, we just teach them how to write the cards.” And I’m like, “Oh my God”.

This is what’s happening. They’re just teaching them how to do the card. And then you have problems and you have problems probably at least in the future some of the cases because the patients and in the best case scenario, they’ll go to a dispensary that’s much more medical that has a staff that understands what they’re going through that they can ask them the right question that they have enough knowledge to recommend the right ratio, right route, right dosing, right titration all of those things. The reality is that unfortunate is highly mixed. The bartender’s are often clueless. We have a lot of people who are like 20-year-old kid who just finished.

Dr. Andrew Wong

That’s a roll a dice. I mean, it sounds like.

Dr. Mikhail Kogan, MD

It’s like a roll of the dice. Now Maryland is aggressive at trying to say that shouldn’t be happening. Every going forward, every dispensary will have to have a medical person on staff.

Dr. Andrew Wong

Okay. Okay.

Dr. Mikhail Kogan, MD

Like, you know, a pharmacists, nurses, somebody who, who is licensed, who can guide the dispenser.

Dr. Andrew Wong

That’s good, that’s good.

Dr. Mikhail Kogan, MD

District is trying to design something like Virginia’s, as always, in Dark Ages of The Inquisitory time whatever, wherever Virginia is. Not trying to pick on them. They’re always behind for cannabis.

But anyway, so it’s gradually gonna move to the right place but, but right now the whole point of the way we wrote the book is to, for somebody to get the chapter that they need, let’s say chronic pain, open it up and have a precise recommendation that they can take the dispenser and say, give me this in this dose and this is how I will take it now. Of course, it’s simplified. I still think that it’s really hard to just use the book and go get something you really still have to have a guide because the reality is, it’s still more complicated than people think. And there’s, you know, especially if you have other medical problems, you’re taking multiple medications you can run into a lot of issues if you don’t know what you’re doing.

Dr. Andrew Wong

Cut time to take your, the courses that you recommend. I’ll talk to you more about that offline, Mikhail. Well, thank you so much for coming on today.

Everyone that’s listening, please check out Dr. Cohen’s book, new book, Medical Marijuana Evidence-based Guide to Health Benefits of Cannabis and CBD. It’s a great book and I think it’s a great, great start like you said, it is more complicated than that for people with a lot of medical issues but certainly even in the..

Dr. Mikhail Kogan, MD

But even but even for those patients there is a actual kind of ground foundation what to do and it’s actually was written for I had a lot of my colleagues say, “Hey, I got the book and I read it and I now know what to tell to the patients” like so it’s, it’s not it’s not like it’s like an introductory level. It’s just the reality is when you start somebody on it, and if it’s gonna become a tool, chances are that it’s gonna get pretty sophisticated and they’re going to be on two or three products potentially, and they’re going to be mixing and matching them so so there’s a lot of learning and there’s a lot of like understanding and moving forward. So the book is putting you on that step to learn but eventually you’ll have to have more advanced knowledge.

Dr. Andrew Wong

I wouldn’t, I wouldn’t expect knowing you, Mikhail, anything you read to be introductory. It’s very in depth and thorough. So yes, that’s great.

Well, thank you, Mikhail, for coming out today. How can listeners learn more about you and work with you?

Dr. Mikhail Kogan, MD

So, yeah, so GWCM.com, it’s a clinical site. Those people who are in Medicare and Medicaid they actually can try to get into my insurance-based practice. However, if you have a private insurance, I don’t recommend that because the whole point is that leave my time open to those who are vulnerable because I do try to balance my practice both out of pocket battles insurance-based at university. So you can find it too at www.Doc’s.com,

I’m there and you can try to get through to me that way.

We only do telemedicine now for local states, I believe, because that’s changing. I used to do telemedicine for the whole country. But I think that’s shifting now. But in my practice we still do that. And for the book, people can find it anywhere. I mean, it’s a Random House. So it’s Amazon everywhere. They have a ornicle. Actually, I’m kind of proud because the audible was recorded by the same guy who did Life of Pi and Harry Potter.

Dr. Andrew Wong

Oh, nice.

Dr. Mikhail Kogan, MD

So because, so yeah, I think they did well with that. And then the softcover is going to come out next year. I guess they spreading them out by about a year and a half between hard, because the right its just the hardcover. So that’s going to be much cheaper because the hard..

Dr. Andrew Wong

Got it. I know you also The Integrative Geriatrics book that you wrote I think earlier than that Right with Dr. Wong.

Dr. Mikhail Kogan, MD

That textbook. So I thought okay, now I do have my next book which is coming out hopefully within 6 to 12 months. Unfortunately going to compete with Mark’s book, that exactly the same topic and healthy aging. But hey, you know, I didn’t know he was doing this.

Dr. Andrew Wong

That’s enough demand out there I think to learn you know.

Dr. Mikhail Kogan, MD

Well mine, I think, it’s gonna be a little bit more towards complex geriatric conditions rather than I think Mark and Carr’s book are official they’re more like, how do you stay healthy and what are the, I think mine’s a little more toward You’re already a bit older and you have multiple problems.

Dr. Andrew Wong

Complexities and stuff. Yeah, I look forward to that as well.

All right. Well, thank you, Mikhail for coming on today and a..

Dr. Mikhail Kogan, MD

Thank you, I’m doing this today. Thanks, guys.

It’s wonderful to hear that you were local and that you’re here and then we collaborate and all kinds of.

Dr. Andrew Wong

Yes, exactly. And thank you all for listening. and I hope you guys have a good rest of the day. Thank you.

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