Section: CME Category: Pain Management

Medical Cannabis

Wenjay Sung, DPM

Wenjay Sung, DPM discusses the current research that exists regarding the indications and efficacy, as well as the potential adverse effects that exist regarding medical cannabis therapy.

CPME (Credits: 0.5)

  • CME Progress
  • Pre-Test

  • View Lecture ( CPME Credits: )

    Lecture Transcript

  • Post-Test

    Requires: Pre-Test, View Lecture
  • Survey

    Requires: Pre-Test, View Lecture, PostTest
  • Certificate

    Requires: All Content Above
Method of Participation

Complete the 4 steps to earn your CE/CME credit:

  1. Complete the Pre-Test
  2. View the Lecture
  3. Complete the Quiz (Min. 70% Passing Score)
  4. Complete the program Survey
Goals and Objectives
  1. Review the current research regarding medical uses for cannabis
  2. Report the current research that exists regarding the use of cannabis
  3. Report the effects of medical cannabis and the potential adverse effects that exist
  • Accreditation and Designation of Credits
  • CPME (Credits: 0.5)

    PRESENT e-Learning Systems is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine. PRESENT e-Learning Systems has approved this activity for a maximum of 0.5 continuing education contact hours

    Release Date: 05/09/2019 Expiration Date: 12/31/2020

  • System Requirements
  • To view Lectures online, the following specs are required:

    • PC Pentium-III class or better processor
    • 256MB minimum of RAM
    • Cable or DSL broadband Internet
    • Browsers must have javascript enabled. Most browsers have this feature enabled by default.
    • Adobe Acrobat Reader (Free) to print certificates
    • Supported Browsers:
      • Chrome
      • Firefox
      • IE 10+
      • Safari
      Supported Mobile OS:
      • Apple iOS 4.3+
      • Android 2.3+
      • Honeycomb 3.1+
      • Blackberry Playbook
  • Disclosure Information
  • It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems sponsored programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.

    ---

    Wenjay Sung has nothing to disclose.

  • Lecture Transcript
  • TAPE STARTS – [00:00]


    Male Speaker: I look forward to hearing what he has to say on the use of medical cannabis in podiatry. So let's welcome Dr. Sung.

    Wenjay Sung: All right. Thank you. It looks like a packed room, let's take a picture for the records. All right. So medical cannabis. Thank you all for attending, thank you, Present, for inviting me. So, oh, we begin here. There you go.

    Like I have disclosures for this presentation and if you have attended any of my lectures before, I'd like to use a poll everywhere. So you have your cellphones, please take them out and just text 37607. Text that number and just text "wenjaysung". All right. So just one word "wenjaysung". Text that word to 37607 and then you'll enter into the poll. And then from there, we're going to just do some polls together, all right? So we're going to begin that.

    All right. So again, it's not being recorded. No one will know your answer, but have you ever tried marijuana before? Whether smoked, edible, oils, vapor, et cetera. So if you're in the poll, just – huh?

    [OFF-MIC]

    Wenjay Sung: It's on the bottom right there. So if you just text wenjaysung at 372 and then once you joined, then answer the question, A, B or C. So once you enter, let's just see what the reaction and what the room polls.

    Wow, 100%. Is it legal here in New York now? I didn't know that, or at New Jersey. Excuse me.

    [02:01]

    Okay, 100%. Wow. All right. So it seems like an overwhelming percent has tried it. I love people who live through the '70s here fairly, yeah.

    All right. So let's begin. I'm trying to go forward with this. All right. Hey. Steve, can you go forward? Can you go forward to the next slide at this now? There you go.

    So let's talk about some news. Canada is, of course, the second nation in the world that legalized marijuana. This just happened last year. And interestingly enough the ETF for marijuana is one of the highest performing ETFs right now in the stock exchange. So throughout the 40% growth compared to everything else that's going on, it's 40% more growth than everything else in the ETF buying market. So if anybody's into stocks, you should have bought in the marijuana when you had the chance.

    Also the FDA approved of marijuana drug based on CBD, or cannabidiol late last year. And this has been used since – to get some good studies, but they're also doing some post market studies as well. And I will be talking about that as well.

    So marijuana. Let's just talk about it. What is it? Well, it's a plant and it's genus is Cannabaceae. There's actually three types of cannabis, cannabis sativa, indica and ruderalis.

    [04:01]

    Nobody really knows much about the ruderalis because it's not as popular, it's also doesn't – it's not easy to grow. So we mostly know about sativa and indica. It's a dioecious flowering herb, meaning there's both a male and a female. And for the female, I think most people know that there are flower buds and resin, whereas most people call it marijuana and – the male is actually known as hemp.

    So marijuana, the name actually comes from a Spanish word or Mexican term. It's actually more of a coined term. It actually doesn't mean anything. It's just more of a jargon or – it's just more of a jargon or slang term. So the marijuana actually isn't a real word but we've adopted it. But cannabis is a real word.

    What's important about marijuana are they're cannabinoids or what we're here to talk about. The cannabinoids which work on our endocannabinoids system. So there's two popular cannabinoids that are out there. THC or tetrahydrocannabinol and cannabidiol. So the THC and CBD you tend to hear in the news often. And most plants and most species that you hear about smoking or what they put on the cream or edibles have some type of percentage of more THC or more CBD, also depends on what you prefer more indica or more sativa.

    But what's also interesting about marijuana is over 500 active chemicals – 500 active chemicals just in marijuana. And not just THC, not just CBD. There is tripenoids or isoprenoids also in marijuana which are more of the smell, the more flowering smell and also oils in there as well. So there's over 500 active chemicals but I think the most people want to know about is CBD and THC. We're going to go focus on that.

    [06:00]

    So THC. What is it? It's a cannabinoids that reacts on our cannabinoids or endocannabinoids system, our receptors in our brain, not just in our CNS, not just in the central nervous system, but also our peripheral nervous system as well. Or in other words, this is what gets you high.

    So what is CBD or Cannabidiol? It also is a cannabinoid that reacts on cannabinoids receptors on the CNS and or peripheral nervous system but this does not get you high. You have to remember.

    The timeline of legalization of marijuana has been changing ever since, of course, California kind of lean the way. From 1996, they had a medical exemption and then Colorado and Washington the same year started doing legal exemptions, just completely legalizing marijuana. And now there are about 33 states in 2000 – actually, 33 states plus the district of Columbia, at least it have some type of exemption for medical marijuana or marijuana usage.

    Most of them do require a doctor's recommendation when it comes to medical marijuana. And what does that mean? That means it could be as exactly that. It could be my recommendation and you just go into a – into a dispenser and say, "I got a doctor's recommendation." There's actually no statutes especially the one in California, they actually didn't even list a prescription or what need to be on there. It just says a doctor's recommendation. So a lot of them are loosely based off of California.

    Of course the DEA is looking into this as well. So if you think it's just no big deal of the doctor's recommendation but of course the DEA also has a role in this starting in the 1970s. It's been a long history regarding marijuana but in 1970 is actually when Congress in the Nixon administration, always comes back to Nixon, but the Nixon administration declare that marijuana was a schedule 1 drug and is a dangerous drug which has no benefits to it from the 1970s.

    So what did they come up with as their statute?

    [08:01]

    Well, they want to prevent drug driving. They want to prevent growing it on public lands and use on federal property which also includes the VA. Now what's interesting is just recently the VA, doctors are now allowed finally to speak about medical marijuana. Before, they were actually restricted and actually could have been a crime to talk about marijuana at least the doctors do. But they passed a bill and they're allowed now to officially discuss medical marijuana and possibly uses of that.

    And another thing that Congress charged the DEA was also to prevent distribution to minors, prevent sales to criminal organizations, enterprises, gangs, or cartels and also interstate trade of marijuana. What's interesting today, if you were to fly with marijuana in your bag, the TSA actually doesn't do anything. They throw it away or they give it back to you and tell you, you just can't fly with it. But you don't get arrested, you don't get fined or anything. It actually happens in LAX a lot. There's bags of marijuana just in the trash. So if you ever – I am not joking. Don't try it because I said so. But it's actually quite legal to travel with marijuana if you don't get caught, no one says anything.

    So the DEA. Again, in 1970, Congress label as level one drug, which again has no benefits whatsoever. In 2001, even though California passed the medical exemption rule, the Supreme Court denied the medical exemption rule for sale and distribution. And so it's tested again in 2005, the Supreme Court denied medical exemption for individual use.

    And then in 2013 under Obama administration, the DOJ said the enforcement priorities did not change the opinion that marijuana is still a dangerous drug, however the conversation was active. And in 2014, a bipartisan amendment was passed that says the DEA and the Justice Department could not use federal funds to prosecute and to arrest people using marijuana, especially in states that actually have passed legalization.

    [10:05]

    However in 2017, Congress didn't block it and the current administration at least with that Mr. Sessions said that they were not in favor of any decriminalization or legalization of marijuana. But Trump maybe changing his mind. So we don't know how he's going to take – feel about it with this new Attorney General. He hasn't actually put out statement of it, but we may hear about it from Trump soon.

    So what does the evidence say? So what everyone tends to go to since 1999 article by the Institute of Medicine, and they found out when they did this huge study with that smoked marijuana has no medical value – smoked marijuana. Why? Because it can lead to further complications of those who are already ill and smoking could cause bronchi of abnormal cell lining or premalignant lining. And also those who smoke, it could be developing risk for respiratory cancer.

    What they put and this is important, that smoking marijuana should not be used or developed as a drug. However, marijuana could be and could be used as a stepping stone for delivering systems of some cannabinoids. Excuse me.

    Again, from that study, all these new studies have come out since. And so, there's been a lot of great information coming out what the reactions and what the effects of marijuana are on individuals whether it's for medical or just casual usage. And of course, there are level one studies and level two studies on medical marijuana, believed it or not.

    So Gemma actually looked at 79 trials of marijuana usage and uses a – reviewed database of 28 databases to come up with 6,000 some patients. That's a lot of patients. To give you an example of how many patients there are, of our knowledge of Charcot, I think we only have a database of about 1,500 or maybe less than that patients in all of history Charcot papers.

    [12:03]

    For Gemma, from 1999 until now, we found studies that up to 6,000 patients. So with this, there's a lot of data about how medical – excuse me, how marijuana reacts on humans. And from there, they found that of these symptoms that we use to treat marijuana, three actually has showed significant benefits, nausea, chronic pain and spasticity.

    In 2017, kind of like the update of what marijuana usage in the body of science, the National Academy of Science came out with a big report and is now what most people refer to when it comes to the effects of cannabinoids and cannabis on humans. They found that marijuana or – excuse me, cannabinoids can be effective in chronic pain. And oral cannabis could be effective for nausea control and spasticity control. And what's interesting – what's very interesting is that they found that cancer was actually – excuse me, smoking cannabis does not actually increase – does not increase for certain cancers like lung, head or neck. However, it does show some moderate – I mean, cannabis can be associated with testicular cancer. So women, good for you. Men, we're out of luck. All right.

    There's also inclusive evidence that cannabis can benefit your immunity or also decrease your immunity. So that's actually really important. A lot of people say, or at least you hear from people who smoke marijuana that it helps boost your immunity system while the evidence isn't there, also the evidence doesn't show that it does anything to affect your immunity.

    However, there is a limited evidence suggesting anti-inflammatory effect for those who do expose to marijuana more frequently. So it's actually an anti-inflammatory effect when it comes to cannabis rather than inflammatory effect.

    Also what's sad is that – because of the – I guess more of the movement of marijuana or more recognition of marijuana in our society, there's actually been a lot more increase in motor vehicle death in marijuana – marijuana usage.

    [14:07]

    People who use marijuana within 24 hours may have impairment of cognitive learning. I think we all kind of know that. But also, it's interesting that limited studies shows that cognitive impairment continues even after stopping smoking marijuana. So there may be some long term effects in your cognitive abilities even if you stop smoking marijuana. And of course, don't smoke marijuana when you're pregnant.

    This is highly controversial, but this was something that I thought was quite interesting. The more usage – that you use marijuana, the more likely you already try alcohol, the more likely you're going to try other drugs. Now it's always been, I guess, one of those old wives tale or a myth which you say about marijuana being a gateway drug. But the evidence does show that there is some increase usage – especially the younger you are, the more risk you're willing to take because if you use marijuana earlier, maybe it's more of a personality issue.

    Now the FDA does study marijuana for those who don't believe it. Remember, the FDA – any drugs have to get approved to the FDA require at least two adequately powered randomized clinical trials prior to beginning the approval process. This is prior the beginning. Currently or at least under the Obama Administration, there was a 125 research for studying cannabis. We don't know much about the current administration. They don't actually release a lot of information about the FDA now.

    But under the Obama administration, there was a 125 researchers studying cannabis. Currently, there are no drugs that are approved or have been approved with significant increase for side effects. And there are no drugs approved with more than one or two active chemicals. So again – usually, there are no drugs approved with more than one or two active chemicals. And marijuana or cannabis has over 500 documented active chemicals in it.

    [16:01]

    And in about 113 different strands of cannabinoids. So this is kind of the chart of different THCs, different CBDs, CBNs, THCA, THCV and so forth. So there's a lot of different chemicals in it that do have different reactions to the body depending on what's in it.

    Now some of you may be asking, "Why doesn't the FDA just take the THC or CBD and sell it or approve it?" They have. It's been on the market since the '90s. Marinol has been on the market since the '90s. It is THC, it's actually schedule 3 medication. You can prescribe it today. How it got started on lecturing marijuana, was actually I was talking to a cancer group that – was that for some reason, I got started talking to a cancer group about medical marijuana and they introduced me to Marinol and Cesamet, I believe, it's what they call it in the UK, but it's just THC. It's schedule 3 medication. It's effective in pain management, effective in nausea, and slower onset. But that actually may be why it's not so popular because it's lower onset.

    Another thing is that there are some mild side effects with it like any medication and most side effects is actually nausea.

    So CBD oil, I'm sure some of you are questioning about this. CBD oil tends to be the – I guess more popular flavor of the month right now. But CBD actually does have a lot of studies but I bet smaller in short term regarding human trials and there's – starting to show some benefit. Again, CBD as far as an oil abstract or something you put on topically, there are small and short-term studies.

    Now when it comes to inhaling or – excuse me, ingesting or some type of taking CBD or cannabidiol ingesting it, there are some benefits for specific symptoms like epilepsy, spasticity and pain relief. But when it comes to topical medication, they're right now, there are positive studies but they're all small and short term.

    [18:00]

    What is important to realize with CBD and because it's so new is the accuracy and labeling. This is actually one of the biggest promise right now with all the CBD companies out there is that sometimes, the labeling is not what you get. It's not like you go to CVS or Walgreens, you buy ibuprofen. You know there's ibuprofen in there. You know it's with naproxen in there. But when you buy CBD, about 7 out of 10 did not contain the actual amount dosage that they listed. 40% contain too little CBD to be effective. I believe at 0.5 – excuse me, 5 micrograms or 0.5 nanograms. And I believe 26 contained too much CBD or more than the advertised. One in five actually contained THC.

    Now legally, you're allowed to actually shift THC in topical medication as long as it's below 0.5% THC. But some of these products that were actually a CBD products actually had more than that. Again, what you get really is kind of the Wild West out there. So it's very important to ask whatever company you're plan to use or if you plan to use for a third party independent lab and get them tested to see how accurate they're labeling it as in actually what is in there.

    So this is where medical marijuana is legal. You just want to look at the map. However, this is where CBD is legal. All the states except for those four. You can use CBD and you can get this on Amazon. This is – you literally can buy CBD from Amazon, you can go to any – I think CVS now is starting to sell CBD. I think Walgreens is going to also sell it as well. So it's all across the market now so if you're ready for it or not, it's coming.

    Also, what's great for states is tax revenue and now that's not necessarily taxing CBD, but actually it's for medical marijuana and marijuana usage. Colorado you can see, they made 200,000,000 in the fourth year that it's been legal.

    [20:03]

    Washington really killed it with 300,000,000. This is all before California's data of from last year. So California hasn't actually released their data of how much they revenue they create – excuse me, generated. However, it's interesting to see how much California did.

    Another thing that's very important to understand is that our minds in what marijuana is, is changing. Before, marijuana – at least when I was growing up, it's considered a dangerous or risky drug, very risky drug. Now it's no longer as risky compared to say like alcohol or meth. Marijuana actually is not almost like an over-the-counter medication seems like. And the opinion of everybody – at least when I was growing up until now, seems like the majority of people are okay with legalizations. Just more and more in the media that's okay for marijuana. However, the problem with it of being okay and being safe are two different things.

    So now it seems like at least AAA has found that pot is actually becoming one of the most common drug driving problems out there. There's increase in fatalities with marijuana as supposed to, say, alcohol. What's interesting and what's kind of sad is that State Farm did this study and they found that we've done a great job with telling our teenagers to not drink and drive. And driving under the influence in 2000 went 40% of kids – children who died or teenagers who died while driving was because of alcohol. And we did a great job bringing that down. However in 2010, now drugs or marijuana was actually 40% the reason why teenagers drive – died behind the wheel. And cannabis again was well over 28%, and the next drug was ecstasy and the next drug was cocaine.

    All right. Now with all that information I gave you – again, back for the poll.

    [22:02]

    You can text A, B, or C if you're already in there. How likely are you to recommend marijuana or its extracts to your friends, your patients or whoever?

    [OFF-MIC]

    All right. Again, it seems like the majority in the room seems that somewhat likely or likely to recommend marijuana. All right. Oh. One person waiting on Trump. All right.

    All right. Well, the take-home is there's a lot of information out there. There's still a lot of information that keep coming out, everyday it changes. There's a lot more studies coming out with regarding CBD as medical marijuana, THC, CBD and all the other medications – excuse me, all the other active chemicals in marijuana. So just to understand as – even though I tell you today, tomorrow, there's going to be more information. So please take that to heart.

    Any questions? All right. Thank you.

    TAPE ENDS - [23:18]