Sep 21 2020 . 21 min read
Elevating the Conversation with author Ruth D. Fisher, Ph.D.
Elevating the Conversation with author Ruth D. Fisher, Ph.D.
Ruth Fisher is a researcher, analyst and author of “The Medical Cannabis Primer: Ushering in the Golden Age of Marijuana.” With 20 years of experience in the healthcare industry, Dr. Fisher enjoys figuring out how products, processes, and people interact to create outcomes and how to change the products and/or processes to generate better outcomes. The co-founder of CannDynamics, Inc. works on behalf of biotech companies, early-stage biotech researchers, physicians, and healthcare technology start-ups.
How did you become interested in cannabis?
It was a process that started about five years ago. My brother was diagnosed with MS and the disease manifested itself in him as pain and he gets tremendous neuropathic pain from several different sources and he had tried a lot of different things and nothing was really working. One of his neurologists said you might benefit from cannabis, but I can’t give you any guidance. So, he got his medical card and went to a dispensary and realized he had no idea what he was doing. So he started playing around a bit and found that it was working but realized, still, that he didn’t know what he was doing and soon he called me in to help. I am a researcher and I have a lot of experience in healthcare, so it was kind of natural for him to pull me in. At that point I knew nothing about medical cannabis; it was in the periphery that they were using it for medical purposes. It was not something I had ever tuned into. I had used it in college and decided it wasn’t really for me, so it wasn’t really on my radar. I will admit I was part of the culture growing up that: This is your brain, this is your brain on drugs. I was very skeptical about the whole idea of cannabis being used for medicine but at that point I knew the journey he has been on, and it was really horrible and he was suffering from really bad pain and if he actually found something that worked then that was all I needed to know. So I said I am going to try and understand this and put aside any biases I might have and try and figure out what’s going on and how to do this right so he can get the benefits he needs. So that’s how I came to cannabis.
Why did you decide to write “The Medical Cannabis Primer”?
I started doing the research and my brother started adjusting his dosage and low and behold it was working. He’s an engineer and at some point during this process he came up with a technology to help other people find products for them without having to go through this whole ugly process that we had been going through. He came up with a matching technology, an app, so my job was to design the algorithms to figure how to match people based on their experiences, their problems and match them to different products based on what’s contained in the different products and what science says about those ingredients and how they will help different conditions. I started on this really rigorous research process trying to understand this so I could design the algorithms and it took me a surprisingly long time. I had designed algorithms for other types of projects with similar logic structures. So, I knew it could be done but didn’t know how complex it would actually be and how nuanced until I started doing the research. So I had to put together a lot of information in order to be able to design the algorithms and, of course, all along the way I’m discussing this with my brother and at some point he said you know we have amassed a wealth of information here and we should put it in a book and make it available for other people.
Due to its illegality on a federal level, the research on cannabis is limited. Did that make it harder or easier to compile your book? When I came into cannabis it took me a really long time to figure everything out because it’s such a hodge-podge. You have people coming at it from so many different perspectives. You have the traditional medical community which is coming at it from a scientific perspective which is looking at purified isolates and looking at only pharma-produced products as appropriate. And that we need the proper studies and proper guidance by the FDA in order to appropriately dose cannabis. And they say the whole plant is completely inappropriate because you can’t get consistency of dosing and you can’t get consistency of competence in a profile of ingredients in a particular sample. So, imagine when you go to buy aspirin you know that every tablet that you buy has exactly the same dose and it’s a purified form of aspirin and nothing is in there but aspirin.
In cannabis if you go to the whole plant, every bud that you get has a completely different profile of compounds. And if you try and ingest 10 mgs then depending on the form, a very different number from 10 mgs is going to end up in your body and that’s really difficult for the traditional community to deal with because that’s not the way modern medicine is done.
On the other hand, you have the traditional organic cannabis industry which comes from the whole-plant medicine community and they are much more open to some of that inconsistency because they say you are getting the whole plant and you get all the compounds working together so you end up with better benefits. And, yes, you might give up something in consistency of product and in consistency of dosing but it’s more than worth it.
What topic in the book was the hardest to tackle? The hardest part for me was understanding all the different processing. You have pharmaceutical forms and you then have these things called dabs, and you have bud, weed and shatter, vaping, and smoking, RSO, and butane hash oil. I had a really difficult time trying to understand the process of how cannabis goes through from seed to product. And that was really difficult for me to pick out the different parts. You have processing and you have forms of use and then you have final products. And people mixed and matched the different terms because they understood what they all meant but for someone who has no idea what the difference is between distillation and butane hash oil—well one is a process and one is a product so it’s almost an apples-to-oranges comparison. It took me a long time to figure out these are all the processes, these are all the inputs into the processes, and these are outputs from the processes and understanding exactly what the value chain is in that process. There’s a table in the book that’s my pride and joy that took me a really long time to put together and it reflects understanding exactly all those different components.
What’s one of the things that surprised you most about cannabis?
One of the earliest things I learned about was the ECS (endocannabinoid system) and I was shocked that someone who had spent as much time in healthcare as I had and done as much research had never heard of this. That just really blew me away. I realized it was only discovered in the ‘90s, but still I am a healthcare researcher. That said to me it wasn’t really penetrating mainstream society. That’s not a judgement, that’s an observation. Once I started learning about that and again about the plant, and the constituents of the plant, the cannabinoids versus terpenes then it becomes very apparent that there is much more than THC going on.
Will the concept of buying cannabis using the method of indica, sativa and hybrid become outdated? Absolutely, we are in a paradigm shift right now. I believe it started out as this community of users viewing the plant from the indica/sativa perspective, but researchers are finding that what is really important for medical use are the compounds contained in a particular sample. If you take a bunch of samples of indica/sativa and look at the underlying profiles, there is really no correlation between what’s in the plant and whether it’s an indica or sativa. In other words, for medical users, indica and sativa labels are not really giving users the information they need to make a good choice.
What should consumers look for when they shop for cannabis?
Increasingly what consumers want to know and need to know is exactly the profile of compounds that are contained in the different products out there. It’s appearing in the industry in different forms and ways. But hopefully an ideal end result would be for all the products to have QR codes on them so users can pull up COAs (certificate of analysis) or the lab results to see the profile of ingredients as well as the fungus, mold and pesticide tests and verify for themselves what actually is contained and what compounds are in a particular sample. And verify in fact that they have passed all of their safety tests.
Dosing cannabis is complicated. Why? I’ve heard different opinions on this. Personally what I believe is people are going to be able to get some idea of where to start, but then they are going to have to go through an iterative process of moving toward their ideal dose or ideal product. And when I say ideal product that’s a little ambiguous because people want different things at different times of the day. For example, I might use one formulation to wake up in the morning and have another one to use before I go to bed at night. I might have different ones for chronic versus acute episodes or problems. So, each person doesn’t have one right dose. However, because people’s endocannabinoid systems are different, and their bodies are different they are going to respond to products differently. Cannabis is personalized medicine and you are always going to have to iterate. Hopefully we will have better information so that the iteration is a much shorter process than it currently is but short of having everyone go through genetic testing and having a full health history, I don’t think you will be able to dose cannabis.
What is a similarity between traditional healthcare and cannabis?
We think in the traditional healthcare system that the medications we take have been dosed to us iteratively. I know my doctor starts me out on one dose and adjusts it to get me to my right dosage. One of the big issues I have with cannabis is people judge cannabis differently than they judge the traditional system and there is a lot of downsides and pitfalls with the traditional system that people just accept yet they criticize that those same problems exist in cannabis.
Based on your research, what’s the one thing you would tell someone who was interested in trying cannabis for the first time? I think the most important task for society right now is to become more educated about how cannabis works. I think a lot of people have used it without really understanding it and they have had a bad experience and that has killed the potential for them to turn to cannabis in the future, which is really a shame because I think cannabis can help people in many different ways. I think they really need to have some information before they start using so they don’t make that mistake. There are so many prophylactic measures: the neuroprotective measures, the antioxidant measures, it stimulates bone growth and there are so many protective and wellness features from cannabis that I think everyone can benefit from, but a lot of education needs to happen.
When you discovered the entourage effect were your surprised by how whole plant cannabis works on the body? The entourage effect is very near and dear to me. If you had asked me 20 years ago, I might have been more surprised. I have become very much a systems person; where I see everything determined by many different factors. So, when you are talking about healthcare, the industry has tended to come at it from a very systems-specific approach. You give someone something to treat the pain as opposed to trying to find the underlying problem that’s creating the pain. In order to understand the underlying problem that’s a systems approach. So, if you are looking at society, society has problems. It’s not a matter of putting a band aid on or fixing the problem, to fix the problem you have to look at the system. So, when you are talking about cannabis and an entourage effect that is very much talking about something that’s working within a system and is complex and has interconnected effects.
Over time as I interacted more with the healthcare system and the world, I’ve come to appreciate that everything is very complex. Nothing is simple, everything is multifaceted, it’s not black and white and when you are looking at how anything comes to be there’s always a lot of contributing factors. So if you look at why someone grows up to be the way they are, well it’s not just their genes, and it’s not just their friends or their culture it’s a combination of everything, their experiences, their genes, who they have talked to, where they have been, what they have done, what society has to say—it’s a combination of everything. Our bodies are very complex systems and in order to try and address a problem it’s not a matter of just taking a pill. There is really some complex interaction going on and I believe very strongly in the interconnectedness of everything. And so it makes perfect sense for me if you are taking a plant or medicine and something that’s helping our bodies so prolifically and pervasively as cannabis, it can only be that there is a lot going on there. If there is a lot going on, it doesn’t surprise me that there is more than one compound. Actually, there are many different compounds working with one another using different mechanisms of action in our bodies.
How improbable did you initially find cannabis’ wide-ranging medicinal effects?
When I first came to cannabis, you heard people say it’s going to cure cancer, it will treat your headache, it will help with arthritis, your back pain. And I was like there is no way that one thing can do all this. I totally didn’t believe any of it and I think cannabis has lost a lot of credibility because people are saying it does all this. Most people like me think there is no way something like that can be true and it must be a crock of crap.
Then when I learned about the endocannabinoid system (ECS) and how it essentially controls everything else in your entire body, and how cannabis acts on not only on your ECS but all your other systems through different mechanisms of action, it became crystal clear to me. It became probable to me that a single plant with multiple compounds could address so many different problems in our bodies.
So, this all goes to the entourage effect. Once me as a systems person understood that the plant is a system and our bodies are a system and they work together in a systems of systems, it became much clearer how everything was being accomplished and that it was true, that it wasn’t fantasy.
Do you see cannabis’ entourage effect as similar to a traditional drug cocktail?
Taking a whole plant cannabis product is essentially like taking a drug cocktail. It is several different traditional medications taken together at the same time, which healthcare providers are increasingly using in AIDS, cancer and complex diseases. Essentially cannabis, as one product, is replacing a handful of individual medications that are being used currently by the traditional healthcare community. They are just not comfortable with having them altogether in a single pill. Mother Nature has put together all the right compounds that make sense in doses and ways that enable one another, whereas the way pharmaceutical cocktails have been put together is scientific. I am not saying it doesn’t work, but it took scientists a lot of time to figure out what Mother Nature has already done for cannabis.
For THC to be most effective, must CBD also be present? That’s generally true. They work together and they enable one another. THC is very underrated. People think THC is just used to get high. I think THC has amazing health benefits and it works in conjunction with CBD, it’s kind of like lemon and lime. You have all these lemon and lime beverages together and it’s not a coincidence; lemon and lime is way more popular than lemon or lime. It’s kind of the same with THC and CBD. CBD helps potentiate THC in many ways and it also helps mitigate the side effects. If you take THC with CBD together you tend to get better positive effects, fewer worse effects and you can take lower doses and achieve the same benefits.
How old should you be when you start using cannabis?
Your brain is still developing until you are roughly 20 or 25 and your ECS is still developing so if you use cannabis that might interfere with the development of your cognitive abilities and there is still a lot that is very unclear on the subject. But they don’t know for sure that it’s not great, but they don’t know for sure that it’s not harmful. There is a lot of caution about kids using cannabis. There are certain conditions and cases where they use only CBD, especially for kids and epilepsy. Certainly, for specific conditions like epilepsy they find CBD to be very beneficial on its own.
Why has there been so much hype around CBD?
I will say in my view the hype and focus on CBD is almost entirely due to regulation. It’s the fact that cannabis or the THC part of it is regulated differently from the CBD part of it. While I am certainly not saying CBD does not have benefits, it has tremendous benefits. By focusing only on CBD you totally eliminate having to deal with any of the regulations or the regulatory environment on THC, and it makes it much easier to bring a product to market and to sell it. One of the reasons you are seeing so much activity and focus on CBD is because you can actually do business in that area. Whereas if you want to try and do a cannabis product that’s really really difficult. You need all sorts of licenses that are very difficult to get and there are all sorts of regulations and compliance you have to deal with in order to sell your product. If you are in CBD, on the other hand, you don’t have to deal with all of that. Once you bring in THC it makes it much much more difficult to try and deal with that product in legal commerce and so that I believe is one of the reasons for all the hype around CBD.
What was one of your biggest misgivings about cannabis that your research upended? I really did not have a great view of cannabis. I thought it was kind of a stoner thing. I was really blown away by the potential of cannabis and every day I am blown away by it. The more I try and learn about cannabis, the more I have to learn about how our bodies work. Our bodies are so amazingly complex and so fantastic I don’t have words to express it. The second thing that blows me away is the potential of cannabis and how well it works with our bodies. Cannabis is one of the earliest plants they have ever found growing. So cannabis and people have evolved together over millions of years. Cannabis blows me away in its sophistication and in its complexity.
What’s been the most meaningful thing to happen to cannabis? The most meaningful that has happened for cannabis is the discovery of the endocannabinoid system (ECS) because that validated cannabis’ use as a medicine, and it validated us to help our health and well-being. And that was essential in gaining acceptance and credibility. The other thing was cannabis was increasingly used during the ‘90s because of the AIDS crisis and also at the same time we had the discovery of the ECS. That was just the beginning of understanding how it worked in our bodies, but it has gained a lot of credibility by those two things.
As you discovered all the science behind cannabis how did you feel about its politicization?
Since the beginning of doing my research I have spent a lot of time looking at the history in society and in past times. But if you think about the 1900s, especially the political history, I felt a real deep sense of anger that the government had made illegal a product that for so many years had the potential to help so many people. I’ve seen so many people who are passionately committed to cannabis, evangelizing it because it has literally saved their lives and so many people have been failed and been left behind by the traditional healthcare system and they found renewed life in cannabis. I have never seen anything like this. If you think back to 1937 when cannabis was banned and there wasn’t access to it and all of these people had needlessly suffered—that makes me really angry because it’s just a political issue not scientific or factual or whatever.
What is one of the biggest assumptions you made about cannabis?
What I had assumed since I started researching cannabis four years ago is that had cannabis not been illegal, scientists would have discovered the endocannabinoid system (ECS) in the ‘70s or earlier. I actually did an analysis of this: Would it have been discovered earlier? In order to do that analysis, you need to understand how science and technology progressed and what researchers were looking at and what the problems were that they had. And what prevented them from discovering the ECS. And if it was true that they just didn’t have access to fund their research.
You could probably say that the system would have been discovered earlier. However, I was really shocked and surprised to find that no, the ECS would have not been discovered any earlier simply because it’s so complicated and we didn’t have the technology and science available earlier to be able to discover it.
When you get to the ‘80s and earlier you had many different scientific teams including Raphael Mechoulam (Israeli scientist best known for this discovery of THC and CBD) and others who had isolated THC but were trying to figure out what it is doing in our bodies. They had certain speculations and they were testing these and they weren’t right. They couldn’t figure it out. In the late ‘80s/early ‘90s new imaging technology came out and MRIs and CAT scans allowed you to see digitally into the brain. This new technology came out not just for cannabis but coincidentally around the same time for imaging radio tagging…you know when they take a dye and they can essentially see what’s going on in your body. They are using radioactivity to make certain chemicals glow. So they inject the chemicals into you and they bind to THC so now the THC in your system was glowing and they could follow it in the imaging and they found that it was clustering and that’s how they discovered the CB1 and CB2 receptors.
There’s an interview with Raphael Mechoulam and he was saying they were working on this. He was using a form of product that he was testing, and it turned out to be a very essential form because of the way they were able to extract it or not extract it. Then one of the pharmaceutical companies came out with a super powerful version of THC that essentially supercharged it and enabled them to track it better in the research. Mechoulam was able to use it along with the new imaging technology and that’s how he discovered the receptors and in turn the ECS.