Mar 07 2017 . 20 min read
Dr. Bonni Goldstein, Medical Director, Canna-Centers
Dr. Bonni Goldstein, Medical Director, Canna-Centers
Nine years ago Dr. Bonni Goldstein took a leave of absence from practicing as a pediatric emergency medicine doctor. During her break she researched medical cannabis for a friend who had cancer and “was surprised to learn that there were a number of studies on the subject and researchers had discovered the endocannabinoid system, a major system in our bodies that wasn’t part of my medical school or residency curriculum. Intrigued, I started working in a cannabis clinician’s office in Long Beach, California. It was really eye opening and I haven’t looked back since,” said Goldstein, who became an author last fall when her book “Cannabis Revealed” was published.
Nine years ago I took a leave of absence from practicing as a pediatric emergency medicine doctor because the hours were driving me crazy and I had also just had a child. So I took a leave of absence to recalibrate and get some sleep because ER medicine often includes lots of graveyard and swing shifts and I was getting a little burned out. I had taken some time off with the intention of going back. During the time off, a friend of mine was sick and had me asked about medicinal cannabis and I was ignorant about it. I started looking into it for her and started to read about it online. I was not against cannabis in general but it was not on my radar so I started to read about it. Specifically because she had cancer I started reading about that in particular. I was really surprised to see that there were a vast number of studies and that they had discovered this system called the endocannabinoid system in the late ‘80s early ‘90s, which is a major system in our bodies that I didn’t learn about in medical school and it wasn’t taught to me during my residency and I had never heard of it so I found that quite curious. I started to do my research and I was really intrigued by it. I really didn’t want to go back to ER medicine so I started to work in a cannabis clinician’s office in Long Beach, California. It was really eye opening and I haven’t looked back since.
? I started working at a medical cannabis practice in 2008 and then in 2011 I bought it. My practice is 75 percent adults and 25 percent children. What struck me after spending a month working in this office is that these were all real patients. Again, I shouldn’t have been shocked, but I was. They were just everyday normal people, the same people that show up in an ER or any other doctor’s office. They had been diagnosed with some condition that is either not responding to treatment or they are trying a treatment and it’s intolerable. We all know that not every medicine works for every single person and we also know some people get bad side effects from medicine. That was the usual case, in fact that was probably 90 percent of patients, people who had already tried conventional treatment and were just reluctant to continue because it just isn’t working out.
I have been treating patients with cannabis for almost nine years and in the last two years I have had more referrals from physicians than I have ever had in all the years before combined. There’s no question in my mind doctors are starting to listen to their patients and their patients are saying I started using medical cannabis and it’s really helping me. Patients no longer need that prescription for opiates or Xanax anymore and they want to get off x, y and z medications because they are feeling so much better using cannabis.
I think because it’s been in the media. Patients are feeling a little more comfortable bringing it up to their doctors because how else do you tell your doctor you don’t need that prescription anymore. I think part of it also is the adult-use passage of marijuana in California and advances in Colorado and Washington state. Patients are seeing lots of shows on TV like “Vice” and seeing the people on the shows have similar diagnoses to theirs. So the fact that it has been in the media and doctors are seeing that as citizens, so to speak, but also they are hearing it in their offices.
If you are a compassionate kind doctor, and I believe most doctors are, you may have poo-pooed it in the past but now they are hearing it from more than one patient. They are hearing it from the little old lady who comes every month, or a patient they have been working really hard to figure out some kind of solution for. Doctors are partners with their patients trying to find good health for them and now they are coming back to them saying, ‘Hey this is really working.’ If you are a compassionate physician than you are listening and saying there must be something to this because this person is not an abuser of medication, this person is a reasonable patient who I have known for years and now they are telling me this is working, maybe there is something to this.
I went to a few conferences and the internet is chock full of information. Anybody and everybody can go on Google Scholar and type in cannabinoid receptor or cannabis therapy and it lists all the scientific articles. You can educate yourself, you don’t need to have access to a medical library to find the studies. They are right there on the internet. There’s a huge amount of research coming out of other countries, they have restrictions but they are allowing their scientists to do research. Our Schedule 1 status in the U.S. prohibits us from doing research on the benefits of cannabis. Just recently the DEA did say they were going to open up cannabis to be researched. However, there are still a fair amount of legal barriers to research. You have to do a ton of paperwork and jump through 10 hoops in order to get access to cannabis.
What’s fascinating is that the way people respond to cannabis medicine is unique. Two people with the same condition have different endocannabinoid systems and, therefore, a different way of responding to cannabis. I have some children who have come into my practice with intractable epilepsy who can become seizure-free from the first dose of CBD-rich cannabis. Other children with the same exact diagnosis don’t respond at all. Part of that is the understanding that your endocannabinoid system is coded in your DNA and the way that cannabis interacts with that is as unique to you as your fingerprints. So why is that some patients respond and some don’t? Just like anything in medicine, there are people who respond really well and then there is the kind of middle of the road responder and those that don’t respond at all.
Often when the media does a story, the b-roll behind the news story is someone smoking a joint and they are talking about medical cannabis. There are some patients who might do that but the majority are not. I have so many adult patients who will see a pediatric patient in my waiting room and ask how do they take it. They take it just like they take their other medicine, as a liquid in their mouth. I mean how else would they take it? How do children take medicine in general? We have all seen liquid Tylenol, antibiotics that come in a bottle, mom pours it into a teaspoon and puts it in a child’s mouth. So this media reinforcement that people are smoking pot trains people to think our kids are smoking pot, which could not be further from the truth.
I try to educate people that right now you can walk into any dispensary or collective in California and there will be unlabeled/untested cannabis either in raw form or as products that just has a little label on it with the company’s name and the type of strain. Then there are formulations with all the testing such as the CBD, THC amounts, pesticide testing, additives, solvents, etc. This is medicine. I need to know that when somebody is using cannabis, they are using a safe and tested product. That’s something a lot of people don’t realize. If you find something that works, you want it to be available to you the next month and the month after that. If you find something that stops your child’s seizures, the last thing you want to do is show up the next month to buy another bottle and they don’t have it anymore. That is not okay because these kids may be weaning off other medications and that could be catastrophic for a child and certainly for an adult.
I met with an attorney when I first thought about doing this. We went over all the documents and the medical board guidelines. We went through the law and he told me how to practice medicine doing this, which is the same way I practiced medicine prior. You follow the guidelines and follow the standard of care.
There are a lot of patients who know nothing about cannabis. They have read about it and spent a little bit of time online researching it. It’s mostly people who are not using cannabis who want education and understanding and guidance from a physician. That is who I am seeing in my practice. When you walk into a dispensary these days to get medicine there is such a wide array of products that it can be completely and totally overwhelming. If it works for you and is keeping you off toxic medicine, I think you should have access. We have to get away from the stigma that people are potheads just because they use cannabis. Just because it’s available doesn’t mean you abuse it.
I wrote it because my patients were saying to me you are giving me an education but it’s a lot of information and I am going to forget most of it when I walk out of here. They wanted to know where they could go to get more information. There’s a chapter on the endocannabinoid system, a chapter on the plant, and the makeup of the plant, there are patient stories, and a chapter on how to use cannabis medicine, a chapter on how products are labeled and what you might be looking for if you want CBD-rich medicine. I took the education that I give to my patients and just put it in the book so somebody could reference and digest it in a way that makes sense.
There were some doctors who called me and said why are you seeing my patient? Don’t you know how sick this child is? That was somewhat difficult. For a parent to bring their child to my office and consider medical cannabis is not a cavalier decision. These children have years of failed treatment and have taken more medicine than any adult takes and have a severe disability in their life. But now there are neurologists all around LA who are referring patients to me and telling their patients if you are going to do it, go to somebody who knows what they are doing. Also, they are telling parents that it’s okay to try this, that maybe all the other options have been exhausted. There are children being recommended to have brain surgery but without a guarantee that it will help and its irreversible and, if you ask me, very aggressive. I am not against it if there is a chance it’s going to work, but why wouldn’t you try a plant medicine that’s non-toxic and, for all you know, may work.
We don’t really know. Cannabis is anti-inflammatory, the compounds in cannabis are antioxidants -- this is proven documented research. The compounds in cannabis have been shown in laboratory studies to kill cancer cells. It is quite possible that cannabis can be used as preventative medicine but without being able to study which compounds in what ratios, how often to take it, how much to take, what method is the best way to ingest -- all these questions will remain. I hope it will be a focus of research.
One of the things doctors say to me is we don’t know the long-term side effects of cannabis. And I agree. We have not been allowed to study the long-term side effects. But when I have a child at the age of nine who was not reading or writing but is now and is on significantly less seizure medication and just on cannabis oil, I will tell you that this is forward developmental progression not regression. The long-term side effects do not look grim, they actually look pretty good, they look like beneficial side effects. I don’t want to sell false hope, we don’t know who is going to respond. I tell parents there are no guarantees, your child may or may not respond. But this is a process, you have to be willing to really sort it out, it’s a matter of finding the right oil that works. Or patients might not become seizure-free but may they have a 90 percent reduction of seizures. That means one seizure a week for some kids or one seizure a month for some kids. What parents are seeing is their children’s brain is progressing forward.
First, I would tell them to educate themselves, learn about the endocannbinoid system and the role it plays in human health and disease. I would also tell them the same thing I would tell any doctor who is going into the field of medicine, be compassionate to your patient’s experience but practice medicine in a responsible way. Treat medical cannabis as something that it is, which is different than a single molecule pharmaceutical because it is different, it’s a plant, it’s not a single molecule medicine. At the same time, educate your patients about it and have an understanding yourself and be able to educate yourself about it. Be a partner with your patients so you can help them find what works. In my book, I tell readers you are not allowed to have an opinion about medical cannabis unless you know what the endocannabinoid system is. But we are still taught in medical school that this is a drug of abuse and we leave medical school and go into our residency saying people who use cannabis are abusing marijuana and that is not true. Many of them are using it as their medicine and as their doctors we owe it to them to know the science.
Dr. Vincenzo Di Marzo is a prolific and brilliant cannabis researcher in Italy who has written many papers and he wrote a sentence that many cannabis doctors include in discussions with patients: “The endocannabinoid system is essential to life, and it relates messages that affect how we relax, eat, sleep, forget and protect.” He really summed it up in that sentence. Patients really identify with that quote and see themselves in it. To me that’s fascinating, that there is this underlying system that if we can get it into balance it will allow patients to be in control of their pain, to allow them to flip that power from their condition controlling them and ruining their lives. To now have control of their condition and be in charge is so powerful for patients and life changing for many of them. One story in my book is about a girl who has severe intractable epilepsy. She was having so many seizures she couldn’t go to school anymore. With cannabis treatment, she’s back in school. How do you deny a child a chance? I’m not saying it’s going to work but the option has to be there and doctors have to accept that sometimes we have to think outside of the box. She’s not seizure free but she is able to go to school, she is able to learn. Reaching her full potential while on multiple drugs that affect a developing brain was very difficult. I have another story of a wonderful family who came to me with a child who had seizures for many years. He was on a number of medications and was being worked up as a possible candidate for brain surgery. They came to see me a number of years ago and he was on a number of medications which is always a concern when we are adding in cannabis because of drug interactions. Mom was just doing her research, and she wanted to know if I thought her son would respond but, meanwhile, they were going through this workup for him to have brain surgery. But the approval process was taking forever so I said let’s just try some CBD oil and see what happens while this is delayed. He has now been seizure-free for a year and he didn’t have to have brain surgery. I have another young man who I am taking care of who was having a grand mal seizure every five to seven days despite multiple medications. He was told by his pediatric neurologist his seizures would likely not respond to cannabis oil. But his parents pursued it anyway because nothing was working. So they came to me somewhat skeptical because their doctor said it wouldn’t work but they were willing to try it because they were moving into the drugs that really have significant side effects. I started seeing him in August and right after Christmas he went weeks without a seizure, and would have a breakthrough seizure here and there, but now he is three months seizure-free.
Raw cannabinoids are proving to have some medicinal value. I am seeing some really nice results from raw cannabinoids and, interestingly, at lower doses they are not psychoactive. You don’t have to worry about a psychoactive effect so that allows you to still drive your car and participate in your life without feeling high. I am seeing some nice results for epilepsy, inflammatory conditions, IBS, even autism with a low dose of raw cannabinoid preparations. They have to be taken raw and are ingested through juicing or smoothies, which is very difficult for most people because access to fresh, raw plant is hard. A number of cannabis suppliers in California are making a cold extracted cannabis oil that contains raw cannabinoids. The packaging on medical cannabis products is starting to look more like pharmaceutical medicine, meaning there’s a description of what’s in the medicine, how it is grown, the cannabinoid makeup, how much THC, CBD, and raw cannabinoids are in it. But also listed are terpenoids, the essential oils in the plant that provide some medicinal value, and how they work synergistically with cannabinoids. When you have something that is unlabeled it’s a roll of the dice, but wouldn’t it be nice to know as a patient which cannabinoids are working for you and which terpenoids are helping you? Cannabis suppliers are starting to understand that people want information about their medicine.