Podcast Diaries: The Cannabis Conversation E9

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The Cannabis Conversation. A European perspective on the emerging legal cannabis industry.

So welcome to the Cannabis Conversation with Anuj Desai, where I explore the new legal cannabis industry by speaking to the professionals that are helping shape it. Thanks for joining us. If you're new to the show, welcome.

Today we've got a great show, which is the second part of my interview with Dr. Dani Gordon, who this week will be talking to us about the practical difficulties of getting cannabis prescribed on the NHS. Despite the changes of the law at the end of last year, not that many people are actually able to benefit from medical cannabis. So we'll be talking to Dani about why it's so difficult and how she's helping to change that. Cool. Enjoy.

Okay, so welcome back. I've got the wonderful Dr. Dani Gordon on the show again, who very kindly told us the real story about psychosis and cannabis last week. And she's come back kindly, to talk about the more general topic of cannabis as a medicine and the challenges that exist in relation to how that gets prescribed. So welcome back, Dani.

Thanks for having me back.

Pleasure, absolute pleasure. So, yeah, now we talked about psychosis last week, but another really interesting topic to hear from a medical doctor point of view, is around cannabis as a medicine and the actual realities in making it a medicine that doctors could prescribe. Because I think everyone got very excited back in November last year when cannabis was made legal to be prescribed, but actually turns out that not many people have actually been able to get it on prescription. So I was just wondering if you could sort of give us a bit of the background there.

Absolutely. So we were just chatting about the fact that I arrived to the UK about a month before the legislation changed and then saw the change happen. And yes, people were going to their physicians, potentially using it themselves for years to treat chronic conditions like inflammatory bowel disease, Crohn's disease, chronic pain conditions. And I think people were quite excited about being able to legitimize that potentially as a medication and getting some guidance on that. And in reality, what's happened so far is in the NHS, it hasn't really been able to be prescribed, practically speaking. And that's because of a number of kind of hurdles that patients have to go through.

The first one is that in order to prescribe medical cannabis in an NHS practice, the physician prescribing has to take full responsibility and personal liability for that medication, and they have to have it approved by the NHS trust that they work for. There's a number of reasons why that doesn't happen. One of them is because currently, physicians have no training in medical cannabis. And to be told that you have to be personally liable for a medication you have no training on, that's also highly litigenous in a political sense; highly politicized, is very scary for physicians. Not to mention the fact that they feel ill equipped to provide their patients with a rational use of this medication in dosing and knowing how to use it. So they're worried about maybe harming their patients. So these are some of the things that doctors are really facing.

So I'm involved with training some of the first physicians up for the first private clinics in the UK, who are going to be prescribing medical cannabis. And the first one just opened in Manchester. And what I'm doing with those physicians is basically imparting my knowledge from the Canadian perspective. And I've been treating thousands of patients with cannabis products, medical cannabis products for years, and put together an education program for them. And that's part of it, but the other part of it is of course, private medicine, we've got the first kind of crack at it and patients can get an appointment, but the real cost isn't the cost, even though the private appointment.

Private appointment's just like any other private appointment in the UK, you go in and you spend 200 pounds and you see a specialist for an hour. But the real cost is the actual cannabis prescription. So at the current moment, that could be anywhere from 500 to 900 pounds a month, especially for patients who are needing higher doses of the medication.

And to be clear, these are really high CBD, low THC products that we'd be advocating. So it's not that we're snowing people with THC, it's that some of the conditions we treat require quite high doses of CBD to be effective, especially because we want to minimize the THC.

So the reason why this is so expensive is really down to the importation. So right now, we're starting to get some bulk importations of medical cannabis products from the Canadian producers, but so far that's been in very early stages. And because of that, because of the scale, and because the pharmacies that are set up to receive those medications are very early stages, it's so expensive. So it's not that the NHS is trying to block anything per se from a cost perspective, but it's actually, logistics are very tricky right now.

And the other thing of course, is it's not open to GPs to prescribe. So currently you have to be GMC registered specialist to prescribe. I think that probably will change as I think GPs are quite well equipped with the proper training to handle cannabis medicine products in the UK, similar to what we've seen in Canada. And I think once that happens and once we have more access to the medications and pharmacies are able to hold stock of say the medicinal oils in bulk proportions, hopefully we're going to see the cost come down similar to what it is in Canada.

So in Canada, my patients are usually spending maybe around 200 Canadian dollars, so that's about 130 pounds a month on their prescriptions.

Wow.

So, that's quite different. And I think you're going to see that happening in the UK, and I think you're going to see it opening up, but it's going to take time. And we have a lot of legislative hurdles to overcome. And one of those is the NICE guidelines, which really drive a lot of prescribing-

NICE is-

NICE is National Institute for Clinical Excellence.

And they look after what medicines are able to be prescribed? Is that-

Not really, and I mean, this is probably where I have to look up exactly. Basically, NICE guidelines guide clinical practice.

Okay. So to recap, the high level, the problem's around the cost and the level of doctor education, because not everyone knows or is comfortable enough to recommend cannabis as the medicine needed for some things?

Yes. And I think having, again, the legislation to support its use in NHS, we need more research. And then of course, how are we going to define that research is good research, given that this is a whole family of compounds, not a single compound, and it's not going to lend itself in the same way to randomized and super control trials.

Right.

Yeah.

Yeah. I think that's something we picked up on a previous episode was kind of opium based medicines are a bit more simple, in terms of the number of active compounds. Whereas you've got the, don't know what the word is, plethora of amazing things in cannabis, which is a blessing and a curse, because you don't quite know how to get the right ratios yet.

Exactly. And really opiod medications brocade, what's called the U receptor, the MU receptor and that's just kind of one receptor we have to worry about. It's a bit more complicated than that, but basically that's the main one that's the target, versus cannabinoid based medicines. You have activity, you have what's called the CB1 receptor, the CBT receptor. You have what's called the modulation activity of CBD. Which in English means that CBD doesn't really even sit in either one of those receptors. It kind of can ... Just like the master controller of the whole system in about 100 different pathways.

Right.

And these are only the two compounds that we know most about.

Okay. So there's a lot to learn. Okay. That's great. That's good to understand some of the challenges that doctors in general have, because I've heard anecdotally from GPs I know, that anyone and everyone is asking for it. So maybe not all of them need cannabis, but that they're, the GPs themselves also a little bit hesitant about how and when to prescribe. So what do you think really needs to change then in order to ... I mean, you've talked about education. Are there any other things that-

Well, I think education, research and legislation are the three areas that we really have to work, move the conversation forward in the UK. So this hypothetical ability to access that we had in November, becomes an actual ability to access a whole class of medications that might be very helpful for a variety of different symptoms and conditions; just like any other rational use of any other class of medications.

In my opinion, as a medical doctor, it shouldn't be that cannabis is different than any other rational use of any other medication class. It should be assessed in a rational way, based on the patient's symptoms, based on the available treatments and based on the patient preference as well, I think should play a role.

Well, one of the things that I've learned over my time being involved in this, is actually the nature of medicine. And one of the difficulties of a plant is the ability to have a consistent dosage. How do you kind of see, before we can get to that stage, what do you think the kind of interim solution is?

So I think it's a really good, good question. So as far as the dosage of the active ingredients, the ones that we know the most about, the THC and the CBD, the products that, for example, I use medically in Canada, have those dosages reported on the label of all the products.

So for example, if I'm using a cannabis oil, they will be a reported exact amount of milligrams per milliliter. So for every drop of the cannabis oil, you'll have the known amount of CBD and a known amount of THC. Now that's part of the picture. That's the most important part of the picture, in terms of avoiding side effects or minimizing side effects in THC. And then you also have things like strains and something called the terpene profiles, which would be aromatic acids of the plant; those also play a role.

And the more we know about a product, the more we can direct and match up a patient's symptoms to that product. So I think that is possible. And the companies that are providing these medications are getting better at that.

Great. Yeah, give a lot of comfort. I think again, just the stigma and the kind of cliche of cannabis, essentially everyone usually thinks you're smoking it, but in a medical context, it wouldn't be that, it would be oils and different ways of ingesting, I suppose.

Correct. So usually what we would do with the patient in most instances, and there's a few exceptions to this, but we started out with an oral based medication, like an oil or a tincture or a spray in the mouth, and that's going to give them the baseline of the treatment for the cannabinoid part of things. And then for some symptoms like headache, migraine headaches, for example, we might add on a bit of a vaporized cannabis, flower products, in quite a controlled manner for immediate symptom relief. Because the onset of action for those products would be within minutes.

So for symptoms that come on suddenly, like spasm and acute pain as part of a chronic pain problem with chronic headaches or in MS, multiple sclerosis, the spasticity, for example, that's where vaporized cannabis can play a role, but it's done in a very controlled fashion. And again, avoiding the really, really high THC.

Yeah.

Yeah.

Very interesting as well. I think again, it talks about opening people's minds to different ways of treating medicine rather than just a pill. And there's a journey for everyone to go on there; both the medical community, but also patients, I suppose.

Absolutely. A lot of my patients in Canada, most of them have never tried cannabis. A lot of them are in the geriatric age group, so over 55, over 60. And one of the things I find interesting about a vaporized cannabis, is it still carries a lot of stigma, even though it's not burning the plant, it's getting the oils off the plant through a machine, basically called a vaporizer.

But one of the stereotypes is that, that's a nonmedical use, because it seems so close to smoking in some people's minds, especially older people. So one of the things I usually point out is that, asthma medications are inhaler based medications. There's other medications we use other than a pill form. And those are accepted without question.

So in a way, this is similar, although it does have differences, of course. It's an herbal medicine, so it is still different; we have to acknowledge that. But vaporization can be a legitimate form of treatment for some things.

Yeah. That's really interesting. And particularly around older people, I was what your general experiences of the attitudes, because I've met some older people who are, "No, I've always grown up with it being a bad thing, so I'm very skeptical." But then I've met others who were like, "You know what, I'm getting on in life and I need something to sort me out. Why not try this thing that might help me?"

Yeah. I think a lot of what I'm seeing my older population, is in the same person, those two conflicting ideas. So these are my patients who want to try cannabis, who've never tried it before. Number one, the first thing they usually say to me is, "I don't want to feel high." But we can usually do that if we use really low THC products, at least to start off with. And a lot of times these people are quite healthy, but they have a chronic pain condition that's really holding them back. And the medications they need for that condition to just get them through the day are having terrible side effects. So for them, at this point, they're willing to try anything.

But yeah, then they have this kind of stereotype in the back of their mind. They're afraid of their neighbors finding out. Sometimes they are afraid of their kids finding out. And that's something we just really partner with together, and usually that kind of evaporates once they understand that they're going to be using their medication in a very medical context and a very controlled fashion. And they actually feel quite in control of their medication after they get used to it, and they usually go and tell their friends about it and it opens the conversation.

Yeah. And crucially, it works.

Mm-hmm (affirmative), yeah.

I guess if it's helping, you find it easier to overcome the kind of stereotypes in your head.

Absolutely.

That's really good. What do you think the kind of risks or dangers are in this area? Because it would be remiss to not acknowledge those, I think.

So because like any other medication, this has potential side effects, especially if you're using higher THC products, it's important to look at the patient profile really carefully. So one example is patients who have a history of heart problems, whether that's a funny rhythm of the heart, or they maybe had a heart attack in the past and now they're fine, they're stable, but it's in their history.

And that's important because THC, especially in someone who's not used to, it can have effect, basically put more workload on the heart, especially until someone develops a tolerance to THC. So that's the cardiac side of things is something we have to be careful of. Of course, we have the mental health things we have to be aware of, the psychosis history, history of substance use disorders, that kind of thing.

We also have the pregnancy and lactation concerns. CBD's a big question mark around pregnancy and lactation. So in general, there's something called the precautionary principle in medicine where you basically generally avoid something unless you know it's safe, especially in pregnancy and breastfeeding mothers. So that's my current recommendation still for CBD. Even though it might be fine, but we just don't know.

For THC use in pregnancy, we only have studies again, similar to the psychosis, of women who have smoked large amounts of cannabis in their pregnancy. So that's pretty different than what we would be using clinically, but even still, some of that research was heavy smoked cannabis use in pregnancy, is turning out that it might affect the cognitive or the thinking of children in the preschool ages. And so that's somewhat concerning. So again, pregnancy, breastfeeding, we avoid it completely at this time.

Yeah.

Those are some of the areas we have to be quite cautious, actually.

And they might make a lot of sense, actually. Yeah. And one question that just came up in my head was, is cannabis still often the prescription of last resort? A, you've exhausted all of the conventional pharmaceutical type products first before you looked to prescribe it? And how do you think that should change?

That's another really good question. So right now that's how it's positioned in the UK. And Professor Barnes and I talk a lot about this, because in Canada, patients, sometimes they're coming to see me, referred from one of their other physicians, and they don't want to use it as a last resort. They've tried a few other things, but they've decided that even though it's considered a still quote unquote experimental medication, that it's their prerogative and it's their legal ability to access it, and they want to try it.

Now sometimes actually because they've had side effects from other medications, usually that is the case. But as far as should it always be last resort? Well I think when it comes to chronic pain, if you look at the chronic pain outcomes, when you use them like an opioid based medication, especially chronic lower back pain, the treatment outcomes with opioids are quite poor.

So do I think that opioids need to be tried first before you go to cannabis as medicine? I think that that's actually doing the patient a disservice, and potentially subjecting them to the treatment that's not very effective, that has lots of very real side effects and dependency potential; much higher than cannabis, before they're able to access something that most likely is going to, and at least to my clinical opinion, and some of the studies are now providing a corroboration for this, is to work better than those medications. Yeah.

That's interesting. Yeah. I think there's a kind of shift that needs to happen, in order for it to be accepted.

Just moving on before we kind of finish, can we talk a bit about your personal story? What brought you to kind of look and practice in this area?

Yes, definitely. So I've been practicing, I think we touched on this on the last bit, as an integrated medicine doctor for the last decade. And so, integrated medicine is basically evidence-based natural medicine, but I'm also a fully qualified, normal doctor. So this is basically what I've been doing in Canada for the last decade. I focus on chronic disease management, on difficult cases that don't respond to a single pharmaceutical agent.

So this was all kind of great, and it wasn't doing any cannabis prescribing in my practice. Although a lot of my patients are actually using it. In British Columbia, where I practice, many of my patients grow cannabis and they actually put the raw plant through the juicer, use it for health benefits. And not to mention only that, but I had some of my palliative care and end of life cancer patients, using it in a tincture form, to help reduce how much morphine they needed, to kind of ease their transition at the end of their life. And I've been in contact with many, many patients using it like this. So I've learned a lot from my patients, even before I started prescribing it.

And I guess really the shift for me in going to actually prescribing it actively and becoming a specialists in this area, was about, I guess four and a half years ago. I had a really bad accident and I was hit by a motorcycle when I was jogging and I was overseas. And I've had to have two surgeries on my left hand, and hardware installed. And basically was told I was going to have chronic nerve pain for the rest of my life, and that I should go on quite a few strong medications to handle the pain.

So that wasn't really a palatable to me. And I decided not to take those medication options. So I started using a lot of my mindfulness practice to deal with the chronic pain, and it was working somewhat. I was still having night pain that was waking me up. And so about four years ago, I went to, like I do every year, I went to the Integrative Medicine Conference in San Diego; the American Board of Integrative Medicine Conference. And one of my colleagues in Colorado was there. He's a psychiatrist and he's started to use some of the cannabis based medicines with his epileptic children who has some crossover with the psychiatry and in his multidisciplinary practice.

So he actually introduced me to the fact that some of the people at the conference, a few of the vendors were actually selling cannabis topicals. So basically, I got sample of this cannabis topical, and I dutifully very kind of skeptically, put it on my wrist and all over my scar tissue every day, a couple of times a day for the whole week. This is in California, of course; it's all legal there.

Mm-hmm (affirmative).

And by the end of the week, I was no longer waking up in the middle of night with pain, it made a quite a dramatic difference.

Wow.

And I just kind of thought to myself, "If this topical preparation has done that much for me in a week, it's not a cure, but it helped me so much," that that was really the final impetus I needed to push me over into getting into it in Canada.

So I left in California. Even though it was basically CBD, I just left there and back to Canada. And I started looking into how I could prescribe it, and I actually joined a practice, that they'd been kind of asking me for a while, when my practice partner had set up a cannabis based medical clinic. And so I said, "You know what, I'm ready to come on board." And that's how it all started.

Fantastic.

Yeah.

I mean, that's great, and it adds so much credibility to what you're doing when you can actually say, "It has benefited me in a very obvious way." Well, thank you, Dani, that's brilliant. And for both shows that we did together, and really fantastic meeting you, and great to hear you speak so eloquently on both subjects.

Thank you very much for having me. I really enjoyed being here.

Cool. Thank you.

Okay. Thanks for joining me on that show. I hope you enjoyed it; another really interesting topic. I think people don't quite appreciate how, whilst there's a lot of excitement around cannabis, it's still relatively new in the mainstream. And that certainly applies to doctors, who having to re-look at stuff and learn new things about the endo-cannabinoid system. So it's a definite journey for them, and we need to kind of push that on, in order for people to get access to cannabis as a medicine. So it's great to hear about what Dani's plans are and how she's sort of helping that progress.

Okay, as ever, if you enjoyed the show, please subscribe. It makes it much easier for you to get the show on a regular basis. Hope you're finding the topics really interesting. Of course, if there's things that you really want to know about, please ask me. I'm meeting so many amazing and interesting people all the time now, that there's plenty of scope to do a whole host of interesting shows.

This week, I'm actually going to be interviewing a couple of international rugby players who've set up a CBD brand. So that episode will be out in a few weeks time, and hopefully that'll be quite an interesting cannabis and sport angle that we can add to it. In terms of next week, we've got the brilliant Tom Gray from Blume Jobs on, who will be talking to us about how to find a job in this wonderful new industry.

So I hope you have a good week and until then, keep well.

 

Show Notes:

In this episode I speak to Dr Dani Gordon in part 2 of our chat, where we discuss the challenges that face doctors in the UK when it comes to prescribing medical cannabis, despite it now being legal to do so.