Aug 26 2016 . 15 min read
Elevating the Conversation with Dr. Dustin Sulak
Elevating the Conversation with Dr. Dustin Sulak
Dr. Dustin Sulak never intended to make cannabis the focus of his medical practice and career. Opening his practice in 2009 just happened to coincidentally coincide with the expansion of Maine’s patient program. He was “in the right place at the right time and was forced to learn very quickly how to use cannabis as a medicine.” In addition to growing his private practice to three clinics with ten providers and nearly 20,000 patients over the last seven years, Dr. Sulak has been sharing his cannabis knowledge with the world at healer.com.
When I was in undergrad in Bloomington, Indiana, I was involved in a group called the Citizens Alliance for the Legalization of Marijuana, it was a student group that I became the president of. I learned about the value of education and how to get the message out. At that time I didn’t realize the medical value of cannabis, I was more focused on the economic, industrial and spiritual value. Later in medical school I did a rotation with an endocannabinoid researcher and that really opened my eyes to cannabinoid physiology and what great potential we have to relieve suffering and improve health using cannabis and understanding the endocannabinoid system.
Following medical school, I came to Maine and did my postgraduate training and when I opened a private practice in 2009 I was really the only physician in the state accepting new patients for medical cannabis. I never intended for cannabis to be my career. I opened a practice to focus on integrated medicine and osteopathic manipulation but I certified one patient for cannabis and then another and very quickly I had hundreds of patients on a waiting list to be seen as soon as possible. The year I opened my practice (2009) was the same year the law expanded in Maine to include chronic pain and it allowed the licensing of dispensaries, it allowed a caregiver model. It was a major expansion of the cannabis program and I was in the right place at the right time and really was forced to learn very quickly how to use cannabis as a medicine.
I wasn’t the first, but I was one of the first. I have always been and continue to be on the leading edge of the clinical use of cannabis by looking at specific dosing recommendations and different delivery methods and different approaches for people with various conditions. There has been a real shift, when I first started it was mostly me listening to people about how much they were smoking and what benefits they were having. But now it’s people who have no clue about cannabis, many of whom have never tried it before or have only used it recreationally but not for health, and they come in and want specific recommendations on what’s going to work best for them.
I work with about 10 other medical providers in two locations in Maine, we have grown very rapidly from a private practice to two clinics in Maine and we have a sister practice in Massachusetts. Among a dozen of us we take care of close to 20,000 patients who are all mostly using cannabis as a treatment. We have a few who come to us for other reasons. I see cannabis as a gateway to integrative medicine. We are unlike a lot of cannabis clinics out there, we just don’t do the certificate. We do real medical work here, we do longer visits, we give recommendations for improving health or treating the condition beyond cannabis and certainly beyond what our patients expect. They continue to follow up with us as part of their regular care. We have always offered other services like manipulation, acupuncture, hormone replacement, therapeutic laser for pain – all the things our patient population needs.
Absolutely, to the point where people are coming in, not even knowing that it’s called marijuana that they are interested in and have heard about. We have had patients come in who have heard about their neighbor using a green salve on their arthritis and they kind of know that maybe it’s cannabis but they aren’t sure. It’s getting out there into the senior community that there is something that’s safer and more effective. The other patients I am spending a lot of time with are the pediatric cases and most of them have very severe neurologic conditions, seizures, brain and spinal cord injuries.
We realized all the time and energy we were putting into educating each patient in our clinics would be valuable to people all over the world. That’s when I made healer.com which is a patient education website and it takes all the content we found we needed to save time and energy in the clinic and made it available to people everywhere. We have many different programs, there’s one on there for people who are brand-new to cannabis, and there’s also a program for people who are using too much and want to make their system more sensitive to it. There’s also a program to switch from smoking to using liquid medicines like tinctures. It’s all the things we have found most useful in the clinic.
THC-A in tiny doses can be effective for treating seizures and other conditions. We started a testing lab here in Maine because no one else was doing it. Once I started getting more and more pediatric patients I really needed to know how many milligrams of cannabinoids they were using for them to get a consistent dosage from one batch to the next. Probably 2-1/2 years ago, after starting the testing lab, we had a patient come in saying this CBD tincture was working for seizures, so we were curious to see how many milligrams of CBD she was getting and decided to test it. We tested it and it had no CBD in it and almost no THC in it, it was almost all THC-A and not a lot of it. She was having a seizure reduction with a relatively low dose so then I started realizing there is something anti-convulsive about THC-A. There’s very little on it in the literature. Just one study from the late ‘70s that tried it out on rodents at very high doses and found it effective but since that time we have been using THC-A not only for seizures, but also other neurologic conditions and sometimes we are seeing efficacy at doses that are less than a milligram a day for some children. In some of these cases a higher dose of THC-A is not effective while a lower dose is. So I really think we are on the tip of the iceberg of how THC-A works, we know that it works very differently than THC but it hasn’t been investigated very deeply yet. It’s just one of these discoveries that is very exciting with a lot of potential.
I actually gave a whole presentation on this. The strongest evidence is for traumatic brain injury and stroke; there’s a huge amount of evidence that shows even very low dose cannabinoids in the bloodstream protects people from head injury and stroke. This year alone there’s been a handful of good studies that have looked at humans and compared their outcomes…say you get a brain injury and you go to a hospital and your blood or urine has THC in it or it doesn’t and they look at those two groups, the THC group tends to do much better. The same is true to some extent with heart attacks. There’s another study out this year that shows people with THC in their system were less likely to die and less likely to have intervention and more likely to have a shorter hospital stay than those who didn’t. Cannabis is also helping with some of the leading causes of death and morbidity in our country: heart attack, stroke, diabetes and obesity. People who use cannabis are less likely to be obese and less likely to have diabetes. There’s not a lot evidence on cancer reduction but I think the most powerful finding is a study in California that showed a 45 percent reduction in bladder cancer incidence in cannabis users compared to non-cannabis users. That’s the fifth most common type of cancer so that’s not a small statistic.
We are right at the beginning of that now. Brown University has a class, University of Vermont is starting to teach it, not in its medical school but as a regular course. I have had the opportunity to present it at University of New England as an extracurricular, not as a mainstream course. It’s ludicrous that it is not part of every physiology course. It will get there, it’s not really new information anymore, it has been around for a couple of decades. In the last ten years, we have had a very clear understanding that the endocannabinoid system is part of the physiology of healing, that it is widespread throughout the body and that it is essential for us to be healthy. But to put it in perspective, most medical schools still don’t teach a nutrition course.
I have the opportunity to speak to both the medical community and also the public quite often. Especially when I am speaking to the medical community, I get a pretty good sense of when people go into that emotionally reactive defensive mode upon hearing about cannabis. The percentage of the room that has that reaction has been decreasing over the last five years significantly. Now there are providers that are recognizing they have a knowledge deficit and even though they don’t want to recommend cannabis in their practice, they are coming to lectures and conferences to learn more because they see this as a new field in medicine that’s valid. I have spoken in some mainstream settings like the Lahey Clinic and Mass General Hospital and the clinicians there are very receptive to me so that tells me we are going in the right direction within my professional community, and I believe the rest of the public is in that same boat.
I believe that 10 years from now there will be close to 100 percent acceptance of cannabis but I am used to stigma. There’s a lot of natural medicines beyond cannabis that are very effective and natural approaches to healthcare like ‘mind body medicine.’ I think that’s a great example because 10 years ago, the idea of prescribing meditation was very new and very controversial and now mainstream medical conferences often feature a meditation course so a physician can be more resilient to burnout. There’s a lot of data that shows meditation decreases inflammation and improves immune function and quality of life. I am used to seeing this trend where there are these healthcare interventions that have been around for centuries or millennia with a proven track record. Watching that unfold into mainstream medical acceptance is really exciting.
Sadly the bulk of the education that doctors receive after and, to some extent, in medical school is sponsored by the pharmaceutical industry. Cannabis education is going to be coming from the pharmaceutical industry before we know it because they are getting involved as well. We are going to be seeing more and more cannabinoid-based pharmaceutical products. The first will be GW Pharmaceuticals’ Sativex which will likely be in US markets in the next few years. They will be doing education outreach for doctors. We will continue to see other cannabinoid based medicines being promoted by the pharmaceutical industry and when they do that, it’s going to require clinicians to be aware of cannabinoid physiology and to understand the basic dosing of cannabis based medicines. We already have marinol (synthetic cannabis). There are certain sectors where doctors do understand and recognize it such as oncology and hospice and the awareness is growing there. I think that’s going to contribute to the medical community becoming more accepting. Sadly the bulk of the education that doctors receive after and, to some extent, in medical school is sponsored by the pharmaceutical industry. Cannabis education is going to be coming from the pharmaceutical industry before we know it because they are getting involved as well. We are going to be seeing more and more cannabinoid-based pharmaceutical products. The first will be GW Pharmaceuticals’ Sativex which will likely be in US markets in the next few years. They will be doing education outreach for doctors. We will continue to see other cannabinoid based medicines being promoted by the pharmaceutical industry and when they do that, it’s going to require clinicians to be aware of cannabinoid physiology and to understand the basic dosing of cannabis based medicines. We already have marinol (synthetic cannabis). There are certain sectors where doctors do understand and recognize it such as oncology and hospice and the awareness is growing there. I think that’s going to contribute to the medical community becoming more accepting.
Standardized doses and reproducible medicines. Patients knowing what they are getting and being able to get the same things next month if it’s working for them. We have seen people have real life challenges due to the inability to access the right medicine consistently. Another major direction is low-dose cannabis. I have been somewhat of a pioneer in low-dose cannabis not just THC-A, but other approaches that have better results and less side effects and I think that trend will continue. People are recognizing that they can actually use less and that less is more in a lot of situations. Cannabis for health and disease prevention is a big new direction that I’m excited for cannabis to take because it’s not just useful for people who are sick. It’s useful for those of who are healthy to stay healthy.