Increase Your Energy with Medical Cannabis

Episode 76:

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch, MD

Evan H. Hirsch, MD 00:08

Hey there, welcome back to the Energy MD Podcast. So glad that you're joining me here

today. So I'm really excited, because as you know, we are on a mission to help a million

people resolve their fatigue, long COVID MCAS and MECFS. And we're doing that by

looking at all of the deficiencies and all the toxins that are present. So one of the things

that can really help, which we haven't talked about yet on this podcast is cannabis. So

today we're talking about with the expert, Dr. Kogan, who is also a very good friend of

mine. We've known each other since medical school. So let's learn a little bit about him

today. So Dr. Kogan, is a leader in the newly established field of integrative geriatrics. He

is the chief editor of the first definitive textbook of the field and titled integrative

geriatric medicine, published by Oxford University Press as part of Andrew Weil,

integrative medicine library series, and is a frequent speaker at a variety of international

conferences on the topics of integrative medicine, geriatrics, healthy aging, as well as

medical cannabis. While Dr. Kogan's main medical cannabis expertise, main Medical

Main medical cannabis expertise in treating older patients and palliating symptoms at

end of life. He also treats a wide range of Internal Medicine problems from chronic gi

problems to cancers where use of medical cannabis can be very beneficial. And October

2021. Dr. Coburn and collaboration with Dr. John Liebman Smith and Penguin Random

publishing house published medical marijuana Dr. Cohen's evidence based guide to the

health benefits of cannabis and CBD. You'll see both of those books on my shelf. Dr.

Kogan currently serves as medical director of the George Washington Center for

Integrative Medicine, Associate Professor of Medicine in division of Geriatric and

palliative care, and Associate Director of the geriatrics and integrative medicine

fellowship programs and co host of GW integrative medicine podcast. That's a lot, Dr.

Kogan. Thank you so much for joining me here today.

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

Mikhail Kogan 02:13

Well, Evan, thanks so much. Love the mission. I think it's actually there's way more

people than a million who have all this problems, but this is true. I love I love the number.

That's a good guy.

Evan H. Hirsch, MD 02:25

I got to start somewhere.

Mikhail Kogan 02:26

I guess there's somewhere. Yeah, so yeah, fascinating topic. And, you know, I, when we

periodically get a hold of each other, and chat and stuff, and I realized that, you know, of

course, cannabis does not directly treat fatigue. I mean, that's pretty self explanatory.

But it can address so many issues, which in themselves, then can lead to the fatigue

improvement, and we'll go over it in details. But But yeah, I think it's a I think it's a tool.

And let's jump right in. Yeah, I know. You have a lot of questions.

Evan H. Hirsch, MD 03:00

I do. So let's start at the beginning. So why cannabis? What made you get into this field?

Oh, yeah.

Mikhail Kogan 03:07

Well, that that was a by random spend, for sure. Like I was in the middle of DC got a kind

of medical cannabis approved in 2010. And 2012, there started dispensing, I started

having tons of patients coming to me and saying, Hey, Doc, like I smoked back them at

my prime. And now I have this pain and this and that, but what do I do, and I will retry it

and it works. And now I want you to write me an order. And I was like order anyway, so I

had to sort of learn a lot of things. And then when I served as a board member of the

American Board of integrative medicine, I met Donald Abrams, who's kind of a

grandfather of the whole field. So he was one of the first researchers looking to benefits

not just a side effects and original research and cannabis could only be done looking at

side effects. And then well, because this is this control schedule one substance. So you

can't really use federal dollars for studying benefits. That's in fact, it's still a problem. But

now we're starting side effects, and start reporting all kinds of benefits, the nausea, the

vomiting, and this is like we talked about HIV AIDS, people dying, no effective treatment

tools. And suddenly, there's a paper on cannabis. So this was like one of the first US

studies on benefits and so I got to talk to him multiple times became close friends. And

he's sort of like got to learn this stuff. You're in geriatrics, your use of critical tool that

you got to learn and so I said, Okay, So, long story short, I kind of started learning this.

And then one of my patients connected me with her dear friend, John Lehman Smith

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

and said, Look, she's a professional writer. First of all, we're gonna write a book on

aging. We went to John's agent, and the agent was like, forget it. Nobody cares about

this topic, which of course is wrong Um But like, but she's like oh, but Kogan has an

expertise in cannabis. Let's write a book about that. So we did. Yeah, I think the book is

great. I think it's very entertaining and very case based, I think, listeners to this podcast

probably gonna get a lot of benefits from it because in the many parts of the in many

chapters that talk about different medical conditions, we touch up on fatigue as a result

of improvement of other things. And so I think it's very useful book and it's also covers

some critical basics. So with that, I think, let's talk a little bit about just take a basics of

what cannabis is right? And then sort of why is it important or how does it interact with

us, right? So we have our own cannabis system, we call it and the cannabinoid system.

Interestingly enough, in patients with chronic fatigue syndrome and fibromyalgia there is

Now I wouldn't say conclusive but close to conclusive evidence that endocannabinoid

system is disrupted. There is a famous, like probably number one cannabis expert in the

world, Ethan Russo, who basically coined this term and the cannabinoid tone, which

which what it means is that if your tone is not normal, so if you don't produce enough

your own cannabis internally, you're going to start having problems. And so one of the

definitive problems seems to be related to this lack of tone of endocannabinoid system

is fibromyalgia and chronic fatigue syndrome. Now, it's not really clear exactly what the

trigger to this is like, Well, why is this happening? I mean, I think you can arguably say,

Well, it depends on the cause of chronic fatigue and fibromyalgia you and I, of course,

know, it's like a wastebasket, there's probably 20 conditions inside of that entity itself.

So it's not true, the diagnosis is just the label. But nonetheless, it does seem to be

consistent, that no matter who the patient is, there is a some dysregulation of

endocannabinoid system, whether it's a low tone, or what I think it's less clear, but the

dysregulation is there. So the idea of use of cannabis for fibromyalgia, chronic fatigue

has been around for a long time. And we'll talk about evidence in a bit, but the idea that

you can take an exogenous substance, and then modulate your own endogenous

production and substitute for the lack of better word, what's lacking within exogenous

makes a lot of clinical sense in the practical sense, and it seems to work. So we have

this molecules that are basically it's like a key and a lock model. So you have a molecule,

the, let's say, everybody's familiar with anandamide, the second most common is

something called to a G, but there's actually a lot more. And then they, they that's the

key, and then it gets into the lack of a receptor, whether it's CB one CB two receptor, so

cool cannabinoid receptors. And then something happens. So there's some kind of a

trigger happens, then you have an enzymatic activity that follows something is made

after that trigger happens. And then the molecule that was a lock gets broken by the

enzyme because it's no longer needed. So so it's made on demand. So that's like in 30

seconds, the elevator speech for what what is on the commandments. And it seems like

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

that It regulates primarily, like four or five key domains of our functioning. So one is, is

the sleep. So if you don't make enough cannabinoids, you're not gonna be able to fall

asleep. One is the response to trauma. So when in the moment of trauma, the

cannabinoid system is dramatically upregulated. And then when you sort of you're out

of that scare you out of the traumatic experience, the tone begins to decline. This is by

the way, why cannabis has been used for many decades for PTSD successfully and only

in the last couple of years. It's becoming more and more standardized for that. The third

is kind of the eating. I think that's pretty self explanatory for a lot of people because our

appetite. I mean, people who use cannabis quite know what the munchies are right? You

smoke a joint and the next thing you know you're eating into the refrigerator. So that's

because because that's what the system is supposed to do. Right. But if you're

overstimulated, you will be eating more. And the fourth one is the pain reg regulation,

which is again, that pain closely affiliated with the whole idea of the trauma. And while

it's trauma and stress, I should go back for a sec. So it's trauma and stress. The kind of

endocannabinoid system seems to regulate both and they intertwine quite closely. And

then the pain is kind of intertwined with with trauma and stress in many ways, the way

the cannabis operates. You know, there are lots of other components. But the

interesting aspect is, for example, we all think of when we think of pain, we think of

endorphins, right? We think about endogenous morphine or opioid IT system turns out

that the cannabis controls it. So are endogenous and the cannabinoid system controls

the response within of endogenous opioid system. It basically stimulates it to get

triggered to correctly address the pain. So to sort of the block or enhance, depending on

what's happening depends on stimulus stimuli. And so, the interesting aspect is also

that we do know now that the diseases can manifest at every step of dysregulation of

the endocannabinoid system, it can happen because you don't make enough to EEG.

And that often can produce some bad responses to trauma. So PTSD is thought to

maybe related to EEG dysregulation. You know, if you disrupt the receptor, you can have

some really serious issues like the mice models of Alzheimer's disease or osteoporosis,

which are used, they're actually disrupting the receptors that can be connected to

receptors, and then they will apply some treatment methods to see what works. And

then in an enzymatic activity, so like the late stage, Alzheimer's disease, patients have

the enzyme that breaks down cannabinoids, for whatever reason, hyperactivity, it's not

fully understood. But that's really interesting. So we know that dysregulation is can

happen in any part of this system. What we don't fully understand or actually probably

don't understand at all, how some of these components then fit into the other pathways

of the body, like okay, so it regulates stress response. But how is it then fully linked into

the cortisol system and HPA axis, there's some partial understanding but incomplete.

And you look wherever like, for example, how is cannabis kills cancer cells, cells,

because it does almost every cancer so the cannabis can kill. But how does it actually

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

happens? We do know it's an apoptotic signaling. So you put cannabis in a petri dish,

but the cancer cells and they die, because there's some signaling to self program death

that occurs. But what exact mechanisms of this and what do you do to activate that for

cancer patients? Nobody knows. Right? So there's this whole idea that cancer should be

cured with cannabis, you Google it, then it's everywhere. But the reality is, there's only

like two or three clinical studies showing some possibility. But yeah, so so there's a lot

of missing points. But clinically, we though, apply cannabinoids for all kinds of things.

So I guess let's talk about that.

Evan H. Hirsch, MD 12:27

Yeah, and specifically, energy. So how can how can cannabinoids or cannabis for that

matter? And just so our audience knows, what's the difference between medical

marijuana and medical cannabis? Yeah,

Mikhail Kogan 12:43

that's a great, great idea. So well, the terms actually completely interchangeable. I think

the cannabis is a botanical term, right? So it's not a term that defines what you're going

to do with it. It's just a just a term just that describes the plant Cannabis sativa is

actually the only plant whether you're talking about hemp, where they took about any

kinds of varieties of cannabis, it's all the same plant. Now we used to think like indica

versus or DLs versus sativa. That's that's all turns out to completely incorrect. It's just

the sativa and and everything else is variants. And then there are some different big to

bigger differences between say sativa and music. The word marijuana came to be from

in the 30s. When asked Langer decided that he needed money for his newly established

Bureau of Narcotics, which is now of course we call D. And they needed something they

needed to blame all their pull the problems to get budgets. So they said, Well, let's talk

let's take cannabis, let's give it a brand name, which came to be marijuana. Nobody fully

understands how that term came to be actually, it's thought to be met from Mexican

Spanish, but the actual exact history is unclear. And so it's stuck. And the problem now

is there's a big push to kill the word marijuana. But I think a lot of us, myself included,

feel strongly that shouldn't happen because we have such a bad history of a racial

segregation and such a big historic precedent, if we remove it, we're probably gonna

forget what happened, you know, that basically, the government of the United States

used cannabis as a racial segregation tool, arresting whoever they wanted it while

whites were just smoking left and right and nothing was happening. So you know, if if

we completely move to the correct term, which from botanical perspective, makes

sense, but you know, we don't want to forget the history. So I think both words gonna

stay, I hope. So. In essence, there is no difference. What is there is a difference. So if

you're talking about recreational use of let's, I'm going to use both words periodically, so

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

recreational use of marijuana versus medical use of cannabis, right? So it's not just an

intent, that's different. What's different is is typically concentrations and dosing.

recreationally, people tend to mostly use inhaled products, whether it's a smoking or

vaping. And people do use recreationally guns, of course, but they tend to use much

higher dose often. Medically, the dosing is variable highly variable, in medical terms that

we're going to introduce concept that's critically important. That's the concept of J

curve. And I'm gonna go back and forth to this concept several times. So the J curve is

when you start treatment with a sub therapeutic doses. So you know that in the first

week or two, applying cannabinoids to a patient, they're not going to have effect, they're

going to adapt their receptors to a slow, gradual increase, so that when they start

getting to the right dosing, that they can pick it up. Because if you're under shoot, it's not

going to work. If you overshoot, it's not only not gonna work, it may worsen the condition

they already have. So if you take too much THC, for example, it can cause insomnia. But

if you take just right just at the right dose, it'll be most effective treatment for you

insomnia that I can offer to any of my patients generally, like 80 to 90% response rate

when it's done, right. So so that J curve is start low, go slow, and gradually get to the

sweet spot and then don't miss it. That's really the core principle, probably, because

that's what our body does. So our body will inevitably secrete as much cannabinoids as

needed. Because in the moment, it's constantly regulated up and down. And then when

you no longer need it, it gets quickly break down broken down. When you take a

recreational and medical regardless, you typically take a lot more, so you can't break it

down quickly enough. And so you end up overdosing, and this is probably just as

common of a problem as under dosing or taking simply wrong preparations. So so yeah.

Evan H. Hirsch, MD 17:01

So thank you for that. So let's talk a little bit about energy. So how does cannabis affect

energies of mitochondria? Is it hormones?

Mikhail Kogan 17:09

Right? So it's very complex, actually, the key there, I'll give a couple of specific points, the

key first point to understand is what's called neuro excitation. So quite often what you

know, day to day, right, so when we're talking to a certain degree of your excitation that

happens, it takes certain amount of energy on mitochondrial level when every level

actually was on the psychological level on any level. And so, endogenous cannot be in

this downregulates excitation. So if your brain is on fire, for example, because of

whatever the illness is, and whether it's anxiety, depression, you know, Lyme, anything

mold, if your brain is overexcited, then cannabis can be effectively down regulating that.

And that can give you a pretty significant amount of energy boost, if you're all of your

images wrapped up around sort of keeping the neural excitation in check. So that's a

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

first critical cellular effect, you have blocking of neurons near excitation, of course,

primarily in the central nervous system, primarily in the brain, it can down regulate the

pain. So pain can be a dramatic consumption, consumer of energy, we all know that

patients with chronic pain tend to be very down energy wise. And I don't actually know

whether it's mitochondrial, you probably know better, or if it's just a systemic impact,

because your energy is wrapped up into this kind of psychology of pain, if you will. But it

definitely can help with that. And then I mentioned sleep in, in the, in the actual practice,

the sleep always comes first because the patients who come to me, and let's just take

your typical, I don't know, let's take a like a motivation or MCAT patient right. And so the

insomnia becomes, I don't know, it's not 100%, but maybe a two thirds of all the patient

is going to have some sleep disturbances. Now, they may not have severe sleep

disturbances, but it's still contributes to everything, including fatigue. The reason we

take sleep first is because it's so effective, that there's nothing else come close the

standard of care, cognitive behavioral therapy and all that. It's like a child's play. The

efficacy may be there, but you know, it's maybe 30 50% You have to go through multiple

rounds of consultations. And it's often hard to find sleep cognitive behavioral therapists,

and sometimes it's not covered and it's slow. And the beauty of cannabis wants the

dose hits the right point 80 to 90% response rate within a couple of days. And it's often

complete resolution of your sleep problems once and for all. And moreover, you take

that for few months to begin to taper off and quite often it fixes the problem

permanently. Sometimes people have to go back and forth. Sometimes it stops working

it There is some potential dependence, but generally in that beginning have a

honeymoon period that gives people such a significant improvement in sleep that

inevitably, they come back a couple of months later and say, You know what my energy

is 50% better just because I sleep so much better. So that's the first thing that happens.

Energy wise, I think the second is the pain which I described. The third is most

fascinating one can that be in the way it's, and that's the hardest topic. cannabinoids

have probably one of the top, maybe five, maybe more tools that I have for

inflammation. I mentioned lime. So there's a there's a whole idea that you can treat

Lyme with high dose cannabinoids and not necessarily because they are going to

directly kill the Lyme. I don't think that's going to well, they're actually somewhat

effective property of several cabinet. But they're very important anti inflammatory

factors when applied correctly, there are antivirals to so the idea that CBD and CBG were

used, or still used as a COVID prophylaxis is direct. It's a direct antiviral effect. So let's

say somebody is does have some chronic something, whether it's mono or you know,

Zoster or whatnot, you can actually apply it directly. It's an antiviral. The last point is

immune modulation. I didn't mention that so so the cannabinoids tend to be a pretty

potent immune modulators. So the second set of receptors, the CB, two receptors

present very heavily in an immune system, particularly macrophages. So it's actually

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

quite well established. If you stimulate those receptors correctly, you're going to boost

your antimicrobial and antiviral impact. I think against bad bacterial infection, it's not

going to do anything but for chronic, low grade viral infections, it seems to be quite

effective. So I typically treat topical Zoster and topical herpes. Now first line with topical

cannabinoids just because low cost. Now side effects highly effective. In fact, in the

book, I talk about this, I cured my I had a chronic herpes on my lips for like, you know,

every winter it will flare up, it will cause me like, have a crack in the corner of a mouth

when I go skiing or whatnot. After this is probably 10 years ago now. So a friend of mine

who kind of got me on this birth, he's kind of one of the early adopters, we call them a

kind of coaches or kind of hackers, you know, well, we don't say that anymore because

everybody kind of hackers at this point of view. So she she gave me this little chapstick,

that was that 100 100 milligrams of THC and like in the four weeks after, like I applied it

twice a day. That's it. I haven't had a single flare since it's been 10 years now. Yeah, so

tons of different effects. And actually, for the patients with a chronic quoted now we're

seeing I was just, I was just doing the group today. And we just got to talk about this that

you know, some patients are using cannabinoids for chronic COVID and seeing some

really interesting results. And I don't think that that's because it somehow suppresses

virus directly. But it definitely changes something in the immune system that sort of

helps to decrease inflammatory response and modulating that then helps people to feel

less fatigue.

Evan H. Hirsch, MD 23:29

It sounds like it's a little bit similar to LDN low dose Naltrexone in terms of its ability to

modulate the immune system, would you say it is similar? How is it dissimilar?

Mikhail Kogan 23:42

Well, I think it's very similar from the kind of the way you just said it with this broad idea,

right? I think it's different in the sense that you know, when you take exogenous

cannabinoids, you interacting with and the cannabinoid system, when you take LDN,

you're interacting with endorphin system, right? So you're up regulating endorphins, but

the the end product of this, yeah, I knew this would happen so that if it doesn't get

edited, I'm sorry, my dogs, probably seeing someone outside anyway, so. So you cannot

regulate endorphins, you cannot regulate them the cannabinoid system, but the effect

being an anti inflammatory effect seems to be similar. I actually think that in general,

and the cannabinoid system is much more important than endorphin system because

endorphins mostly regulate just pain. Okay, well, that's not true. They also regulate

peristalsis of the gut and some other things but for the most part, when when

somebody thinks about endogenous opioid system, they're just thinking about pain.

Now, if you take the cannabis, you have to think about like half a dozen of things. You

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

have to think of the anxiety of like your emotional balance asleep, pain to some degree

for sure, you know, nausea and like your appetite, so did GI tract See you. It's a lot more

diverse impact on our body. And historically I'll throw that in as another kicker here. It

seems that the endocannabinoid system is much much older than endorphin system if

you look throughout the species, pretty much any animal has it and and the endorphin

systems is much more in terms of historic evolutionary appearances, much newer

system not every animal out there has what period receptors and doesn't produce

endogenous opioids. So it's you know, it's more of a kind of a higher animals. So there's

also like evolutionary principle there at play that's much older system.

Evan H. Hirsch, MD 25:42

So let's go deeper into sleep. Because I'd love another tool to help my folks sleep so

what do we need to know about cannabinoids and sleep? What what CBD CBG whatever

form are we looking at? What is the dosing give me some of the practical stuff that you

like to do?

Mikhail Kogan 26:02

So the interesting aspect that there's no clear like, okay, it's this way or my way, like it's

just a one way right? So no, I'll give you a couple of two different ways of looking there's

a one camp of people in our field who like really strongly think that everybody should be

taking just CBD for asleep because the THC can actually disrupt sleep. I 100% agree

with that. Take enough THC and you're going to be up all night. Like you know, some. It's

actually interestingly that those are the patients that generally have some kind of a

dopaminergic deficiencies like attention deficit folks, folks who have like the OCD

tendencies folks who are like like me, rapid tokers. So you give them THC and you rev

them up more. So they may end up that may not be a good tool for them. But I'll come

back to that in a second. So those are the campuses give enough CBD at night and

everybody fall asleep. So basically very dose dependent. The bad news for those who

believe in CBD theory that it's best for sleep, you often have to give him a crazy dose as

we're talking about 234 500 milligrams of bedtime, practically unless insurance covers

Epidiolex for you, which is epidemics is the GW pharmaceutical drug, which is a pure

CBD 200 milligrams per milliliter. So if somehow your insurance can cover it, and

ultimately does I've actually been using epidemics off label increasingly more because I

see more insurances paying for it. So then no problem. You can take 234 million

milliliters and they will work just great. But if you're buying CBD on online, you know, let's

say it's it's really hard to find how to milligrams per milliliter. But let's say you found

something like 25 or 50 milligram per milliliter, you're going to be paying hundreds of

dollars a month for that. So it's going to be very price. The THC for sleep and CBM for

sleep, right that comes up all the time, the CBM for sleep, no evidence, no clinical

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

evidence anecdotally works. Shit generally my preferred way. In certain way, that's one

of my mentors, Dustin Sulak was kind of a big name in the cannabis field. He's, by the

way has a great book. It's called Handbook of cannabis clinicians. It's more for ducks.

So it's not. It's more for doctors, not for me necessarily for your listeners. But still, it's a

great book. So he talks about just low dose THC, you know, and so the way I do this, I

tend to mix low dose THC with a little bit of CBD or CBM. So what I put in my book, it's

one to one CBD to CBM, or tissue to CBD or THC to CBD. And you just start with like one

or two milligrams, maybe 30 minutes of bedtime as a dropper, then you slowly titrate get

your sweetspot calculate amount of milligrams, usually it'll end up between five to 10

milligrams on the average, some really sensitive people could be two to three

milligrams, but most people will fall between five to 10, you're gonna have some outliers

at 20 or even higher. So once you get to the those, then you can actually take something

that's longer acting because a big problem with some patients they fall asleep but then

they can't stay asleep and wake up to three hours later and then they can go back to

sleep that's in some ways harder to treat, generally speaking. And so those patients you

will actually have to give them a form that is either this basically an edible form, whether

it's a gummy, or a capsule. My preference usually for capsules, it's a little more precise,

but no gum is can work too. You just have to swallow them instead of chewing and

keeping them in mouth. So sublingual drops is what I prefer generally, either that or

vaporizing dry flour for some patients. We're kind of comfortable with that. And the

route for sleep If you need to fall asleep, you will do a vaping or drop dry flour or you will

do drop some time. If you need to stay asleep, let's say three, four or five hours after the

event went to bed, then you would want to take an edible of some sort whether capsules

or the gummies. And and keep the dose. Sometimes you'll have to titrate the dose a

little so it's not uncommon about four to six or eight weeks in patients will call them and

say hey, you know it worked great for us for weeks and now it's not working. What do I

do? titrate up a little bit. The dependence is real. It's usually not high dependence. So

with opioids often people have to claim go up up with cannabinoids, not really you

usually go up by 30 50% and that generally suffices. So it's very unusual for me to have

somebody who would say stay start with five milligrams and end up on 25. That's

unusual. I don't think I've even remember a case. One of my most amazing cases of

sleep was a gentleman who came to me after he failed both clinical riverlink and mayo

and he had night terrors to bed disease. So night terrors is you wake up every night and

he can go back to sleep because he had a bed bed dream. So this this man was on like

four different centrally acting medications including like high dose Seroquel, which is a

tranquilizer. Trazodone Ambien and forgot what the and Zoloft so he was on this for

pills just to try to sort of manage this. After three weeks when he got to five milligrams.

He's like, you know, he said basically nowadays he only takes a little dose Zoloft got off

of everything. And you know, and he had to titrate dose so he's the only one I remember

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

who went from five to 15. So you know but he also has a pretty unusual Sleep Sleep

disturbance which very few people get.

Evan H. Hirsch, MD 31:58

So when you when you're talking about five milligrams is that just the THC is that

Mikhail Kogan 32:03

it's a THC equivalent usually the way I think or the way it's you will usually think it's we

use the THC equivalent more as a gauge of the dosing. It's much harder to do if

somebody just vaping because then you have no idea what they're actually taking,

because you cannot present but you don't know exactly how much they took with

everything else, we kind of give them an eye, they give us an idea, because it's actually

more important for us to know because when they come back for follow up or when we

have an interaction, we need to know what the equivalent is roughly so that we can

figure out how to further assist if needed or if they the bigger problem is not the

tolerance the bigger problem is the healthcare setup. Is they go back to dispensary in it's

not there. Why? Well because whatever the reason, the grower said we didn't make this

batch and that and now the different product is there dispensers like will try this. They're

like wait a second, that's not the same concentration is different. Well start with the

same amount of THC milligrams, but the impact is different. Because they're different

terpenes they're different. Other things, they have different ratios of the of the

cannabinoids terpenes are critical, by the way. terpenes are those smell molecules,

right? So everybody, like if you walk around and people, huffing and puffing and you're

like, Oh, somebody's smoking, right? I mean, that's the molecule that the smell is called

terpenes. And then there's a variety of terpenes when we're talking about the sleep,

we're particularly looking at the Lena low or Marcin. So the lynoral is the lavender smell

right? Yeah, believe it or not, cannabis has some lavender in there. But it's the same

smell molecule. But so so those smell molecules actually augment the benefit. In fact,

some people believe that the future of nomenclature, the means for cabinet for the

different products will be terpene based right now. It's this weird recreational you go in

and say I would like to have a blue Porsche or Afghan smoke. So yeah, so the future of

nomenclature is probably going to be about, you're going to look at some circle, and it's

going to tell you okay, there is half of the terpenes here, let's say myrcene. And the rest

is like, you know, linalool or beta caryophyllene, or whatnot. And so so you will know that

for your particular condition. This is the map that's the best. So that's it's not quite here

yet. But there's a lot of discussions about moving it that way. Because if you let's say,

you go from Chicago to Olympia, Washington State and you need to get same products

but the you know, they can't be made in the same state. They have to be in different

states. They have to be grown in a state where he is selling them for now, because of

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

the federal regulations and so you may not find exact same product but you can look at

A terpene map and say, Okay, well I know this works for me. Here's, it's a future, but I

hope it happens. Because right now this whole name thing is a mess because and funny

thing is the blue cushion, one area may be quite a little different from another one. And

so when they extract that and put it in, say, sublingual form and Feeco, full extract,

cannabis oil drops, then it may actually be a little bit different. And patients may say, Oh,

well, that doesn't work as this Why am dispenser say well, different batch. And that's the

actually, from practical perspective, one of the biggest problems for patients at the

moment is this constantly changing products. You know, if you prescribe ambiente, a

patient, you're not going to worry about what they're going to get in two months, from

the moment you prescribe, it will be the same Exactly. And the industry is trying to self

change that there are several companies like Liberty's one, for example, is trying to say

look, we're going to make a pharmacological, great. So we're going to make this product,

it's going to look exactly the same every batch. And so if you gotten this serenity

capsules, they will be identical to the what you took two months ago, and there's no

chance of the difference. So that's really the goal, the long term goal should really be

candy, we get to that point of assuring that the consistency between the batches is less

than say 5%, or whatever that is, that's standard pharmaceutical, I think, is 15%. But

because right now the differences can be so great that the patients call me back and

say what happened, my insomnia is bad because I can take that or whatever payments

back to them well, and then you start working with them. So that brings me to the next

point, which is it's extremely labor intensive. So we tend to work very closely with I have,

we have a cannabis coach in our practice. And we also partnering with this acute on

chronic which is a great nursing company and they see patients all over the country

because often if the patient come to me after they got my book, but they live in a state

where I don't have licensing privileges because it's not only licensing you also have to

have a DA certificate to write for the cannabis unless so let's say they come from Illinois

wherever wonderful partner lists them and those a temple do a lot of work together. So I

can just send patients to her but if the patient is I don't know this constant then have to

rely on some some other structures. So it's so acute on chronic calm really important

because then you have to rely on someone to coach the patients what they're going to

get in the dispensary. So I can give them some basic tools. They can also get the book

with sleep. There's a whole sleep chapter so they can find out okay, I'm going to start

with one to one CBD to THC A couple. But they also should hear as exactly what they

have in a local dispensary. So for that some kind of coaching is essential. It's also a very

simple reality that there's just not enough Doc's who know enough. And generally most

of those Doc's tend to not take insurances because we're all kind of scared, what's going

to happen. If somebody audits our charts and you prescribe or recommend cannabis,

it's not a federally regulated substance you need, I'm not going to lose your license. But

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

they may say, look, it's not covered service, you cannot build insurance for this. I do that

in university level, because I get referrals from my colleagues all the time. So I do bill

Medicare, Medicaid for that. But you know, I can't see everybody so we need more

doctors who willing to learn unfortunately, there are very few. There's a big shortage of

physicians who can enlist who understand this topic enough to actually work closely

with it. Writing a card is easy. What's what's difficult, what comes after that when you

start getting phone calls and saying oh, they just overdose me. I'll never forget in the

first year, I had the it's an insomnia case. I had a patient who came to me who wanted to

try so we put her on the regimen worked amazingly well. Except three months later, I get

a call from my emergency room with attending and the whole background laughing

saying Dr. Kogan we have a patient of yours who claims that she's dead. So she came

back from the vacation for forgot to shake the tincture. And so sediment went down. It

was a DM she took the same volume but it was much more concentrated. So she

overdosed, got really scared, went to the hospital told them she's there, she's dying. She

wasn't dying, she wasn't there and everything was fine. But like so the point is the

overdose is pretty common, if you so there's a lot of intricacies and so you have to really

talk to patients and make sure that they understand it and then there's a bit back and

forth so they can have access to you if stuff comes up because it's not and also a lot of

people end up on more than one product. So you have to also So like there could be a

product for the morning, let's say that they are fiber, for example, right, so you have your

chronic pain that you want to manage. So you would take something stimulating

something that's not sleep inducing in the morning. And you may take that as a, let's say,

I wouldn't take that in the morning as a gummy, you would probably want to take it as a

vape, because you want to quick relief, and you want it to kind of assembled on and off

and quick. So that, let's say you made it to function. And then you don't want to have

your cognitive stuff impacted at all. So you may want to control your pain, but then a

couple hours later, you still have partial control, but you let's say you have to do

something, drive somewhere or whatnot, you know, and then at night, you may want to

take a gummy because the union's help you asleep and stay asleep if you just vape. But

if we go to bed, it's not gonna last enough for you for three or four o'clock in the

morning. So often people end up to three products easy. You know, and often for cost

saving, I could say Look, don't buy CBD from dispensary. It's too expensive. You can get

CBD online at a fraction of the cost or I can prescribe them Epidiolex. But then if they

want to if they need THC, they'll have to get that from dispensary.

Evan H. Hirsch, MD 41:12

Oh, because you can't get it online.

Mikhail Kogan 41:15

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

Well, and we can talk about this. It's not really part of what you do. But there's this whole

also issue of side effects. Right. So the cannabis remember what I said in the beginning

Jay curve. So if you can treat fatigue with a perfect dose, sleep pain and other and

actual quality of life, actually, we do know there was just a study that I was reviewing

with one of my students from Israel in 2019. And they did a really good analysis on the

quality of life, including fatigue and fiber improved and improved dramatically in 80% of

patients. So that's consistent with what we see. But anyway, but if you take too much,

guess what I mean? Everybody knows what the stoner look like, right? I mean, they're,

they're hungry, eyes, red shot, and they look totally, like cognitively impaired and barely

moving because they're so fatigued, right? Well, that's an overdose. So remember, what

are you the thing you're treating, you're going to cause the same thing if you take too

much. So this whole idea of how could that happen? Quite, quite unclear in a way,

except that probably when you take too much, the body has a hard time dealing with

breaking down the active molecules. The most classic example is the nausea. So this

this this common nowadays used to be really a rare condition called hyperemesis

syndrome where patients come into emergency room vomiting and stuff. And turns out

cannabis causes that when they take a lot so they always stimulate them the

cannabinoid system and instead of controlling knowledge at lower doses for the sake

cancer or just chronic vomiting and nausea or even in pregnancy, and I'm not afraid of

saying that because I have prescribed cannabis for pregnancy, just in our own hospital

because often it's a horrible situation where a woman vomits nonstop at no medication

work and actually cannabis can be the safest choice. But so if you take too much you

actually can induce the vomiting the same exact for it for your listeners, you know if you

take too much you actually can cause the fatigue and it often comes in with a

depressed mood. So ya know if they overdose or they may the next day especially they

may feel lethargic fatigue and depressed. So that how you know you overdosed and you

should really kind of taper things down give yourself a couple of days taking nothing and

then restart with much lower dose so those are the some of the basic principles of not

overdosing.

Evan H. Hirsch, MD 43:43

So if I was going to dip my toe into doing more of this and I was going to work with a

product that was online sounds like it would most likely be CBD would not

Mikhail Kogan 43:52

Yeah, yeah, I would I think starting with CBD is very wise because your patients probably

you know their big issues gonna be some inflammation may be anxiety may be like this

neuro excitation so giving something that's a little like calming and anti inflammatory

would be very good. And you also don't care what state they're in right and can't have a

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

license in every state you can you can just have them buy and there's so many good

shops now and if you care I can give you the names of what I use. But you know I

interesting I don't use any big brands. The reason is I work a lot with Medicaid

population so I'm all of my partners that I work with they're all have what's called

compassionate program where they give him a major 30 to 50% discount because well

because that's the population that often kind of, you know, hard this to buy the products

and cannabis is expensive. Wherever whether you're buying THC containing products

from dispensary, or CBD products online the problem is CBD per milligram is a lot

cheaper. correct, but you have to take a lot more five milligrams of THC for pain could

be the solution, but you may need 234 100 milligrams of CBD for the same type of pain

and so it's not an equivalent dosing, you know and since I'm on this most of the time we

mix most of the time we don't just use a one active ingredient we tend to mix things like

we often talk about this ratio of like THC predominant or CBD predominant or balanced

like one to one THC to CBD. And of course there's all this other cannabinoids acidic

forms the CBDa CBGa THCA and then like others like the newer ones CBG and then

there's this whole legal high THC eight thc v THC to THC. 10 they're like Yeah, well you

know, people get creative they extract this synthetic molecules out of hemp and it's a

problem. So I'm talking about problems more nowadays.

Evan H. Hirsch, MD 46:08

So then, so then in terms of the sleep and using the CBD, is CBD the best CBN

Mikhail Kogan 46:14

CBG its individual some people will do great with a little bit of CBD like little probably

start for me little would start at 25 milligrams or 30 and go up to whatever is needed.

But if I usually I usually default to THC, and that's that's what I learned from best and but

also that's just because my experience I tend to have a lot of really sick patients and and

I find that CBD works for only few things it works for it has a calming effect. So it

definitely works for anxiety and panic attacks. And it has long term anti inflammatory

impact, but that takes weeks and months. If I have a patient with tons of symptoms, the

pain, the nausea, vomiting, you know, sleep fatigue, like I probably default to THC, I may

give a little bit of CBD at the same time to ground and then may titrate it where I may

just pick a very high CBD ratio like 10 or 20 to one to THC. CBD generally is really a good

idea for patients who are really afraid of side effects of THC because it seems to

modulate down the chances of getting side effects of THC and at the same time it

seems to add times decrease effect efficacy of THC so you take enough CBD and

actually upset some of the THC effects for pain. So some people they really don't need

much of CBD and that's misunderstanding because because it's everybody's saying oh

get the CBD gummy your pain gonna go away. That's a magical thinking. I mean, a lot of

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

the most of the claims about CBD out there are false. I say that 90% are false. So when

you're looking at some companies saying our product will help you with this. And

chances are it's a BS there are a few specific exceptions, which probably beyond this

podcast, but I talked about this in the book.

Evan H. Hirsch, MD 48:02

Nice. And so what are some of those companies that you'd like to use?

Mikhail Kogan 48:08

Well, I guess primarily to So Lily heel CBD at a tiny company in Vermont. I've been with

them for a very long time. They're just very boutique and produce very high quality

organic products, just a few products. And then the Miriam clamshell which is probably

the more preferred one because it's it has a much larger repertoire that much more for

many more products. And then I also liked this company that does pure CBD a as an

apple so that I use a lot of CBD because I have a lot of people with chronic arthritis in

my practice, just older folks. And CBD is great. It's basically substitution for Motrin, you

take enough it'll substitute promotion and and I hate NSAIDs just passionately hate

handsets, unless it's my teenagers who are running in a field being hit by the soccer ball.

You know, if you're over 55, you probably shouldn't take any announces the risk is just

too great, especially with grandkids. So I tend to switch all my patients who come to me

to the CBD first titrate the dose and see how they respond. And it used to be expected a

bigger problem. But of course, nowadays like planetary has a great price and it's very

good products and they tend to work really well. And then of course and then the last

one is of course can leave Africa This is healer.com so healer.com They have THC

products in Maryland and in Maine, but there's a healer CBD and the healer CBD is

probably a top medical line. Again, I use less of it because it's much more expensive.

But you know, you'll also get better products but the things like CBD plus Charlotte's

Web, so this is some great companies. There are also a lot of really good European

companies I think in Dhaka is one that I used in the past, but they're all seem to be a lot

more pricey and that's the that's the that's a big problem. with them.

Evan H. Hirsch, MD 50:01

Would you say there's an equivalent CBD versus 200 milligrams of Motrin. How many

milligrams of

Mikhail Kogan 50:08

CBD CBD A, so I would say the 200 milligrams of Motrin will be equivalent to

somewhere around 20 to 30 milligrams of CBD. So it's about 10 to one. That's how I

think about it. So if I need to give somebody 800 milligrams of Motrin, then I would

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

probably go with to at least 100 milligrams of CBD. The good news about CBGa there's

almost no side effects you can give a huge doses and not have any issues. Every other

cannabinoid, whether it's CBD can cause a little bit depression, it can a little bit kind of

down feeling and sometimes even a little bit of nausea CBG, which is now heavily

propagated for chronic pain, and I agree with that it's a decent pain tool. But that can

cause severe nausea, and I've seen it and also dizziness like the CBD is a problematic

one if you titrate too fast THC for sure I'm in THC and all kinds of side effects. But acidic

foreign seem to be the safest for for whatever reason, they very well tolerated. And for

someone not clear reason to me, they heavily under utilized both in clinical practice and

research. I think the biggest problem is it's hard to make them. And nowadays it's a little

easier, but it's hard to make them into stable format. And then in research, your batches

have to last for your whole project. So I think that probably is one of the problems is that

back in the day, making acidic form stable for six to 12 months was just difficult. Now

now I think a problem in the last couple of years have been solved. So we're probably

going to see rapid increase in acidic research, but But it's in my I think the future going

to be acidic forms CBG, and CBD. So those are the molecules that I think we're going to

be hugely important in the future and particularly for your patients. Because those are

the molecules that have strong anti inflammatory impact neuro protective effects, and

mitochondrial boosting effects. And it's not exactly clear what the it's in the future. It's

all going to be about combinations and ratios. And that's the part that a lot of us who do

this efficiently kind of playing and experimenting. And so, you know if any of your

listeners are really big and sort of names and one of follow a bunch of people like I'd

say, for science follow doctors for cannabis regulation. And people like Peter

greenspoon Those are the voices that are very sophisticated and very good for clinical

practice like renovations and Dustin selection healer.com. I think this is like the the top.

And then I think Bonnie Goldstein works closely with Dustin also. So that's like they're

they're forming this really advanced clinical pathways. So those are the people that I

follow very closely. And then there's this company called cannabis, a society of

cannabis clinician, so you can look up in your area. If you're a practitioner, who you want

to go to is certified by cannabis clinician society. And that's a really good training

program. And it's nonprofits. So because there's a lot of for profit cannabis training,

which, you know, they're a university trainings like we don't have one at GW, but

Jefferson has a program, University of Maryland has a great program, University of

Vermont, of course, Colorado University has a very famous program, but the you know,

they're also more for like, actual Well, some of them, maybe no surveillance, anybody

can can join the program. You don't have to have a license of any kind, you can just be a

coach and you can take the program and then get the expertise. So I think right now if

your listeners really want to find a practitioner they want to work with I wouldn't get hang

up whether they have lessons of some sort is just important that they have a good

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

training I've worked with and know a lot of coaches who don't have any formal

education rather than to just they were a Reiki practitioner and then they said look, this

helped me I want to learn they went in it. I have no problem with that at all. You know it's

better than what often happens in dispensary you walk in there and you have a 20 year

old in college who tries to make a buck who is who will tell my 85 year old Oh yeah, just

take this 20 milligram gummy it worked great for me yesterday for the party. And then

the next morning Graeme Cole's because she hasn't been sleeping for 48 hours with a

zombified eyes like this. So the level of education in the field in that industry is all over

the place. Some states like Illinois, Connecticut, I mean, those states require

pharmacists and stuff. You know, Maryland just put this berry big teaching program that

every Um dispensary must have like an educator director on staff to teach all the staff

what to say to patients but some states like this is a total Wild Wild West I always pick

on Virginia because they're you know, next to me we don't like them but like no but

they're like conservative state right so their program is the last in our area and it's the

worst and very like reductionistic and whatever but you know so there are dispensaries

are boy I mean I've had problems with them. It's changing it's changing too slow so find

yourself a good coach I say especially if you can afford one and they usually much

cheaper them for you. Because they generally in especially those who don't have like a

formal medical training or something.

Evan H. Hirsch, MD 55:49

Excellent. Well, Dr. Kogan I so appreciate you coming on and sharing your knowledge

with us. If people want to come see you if they want to learn more about what you're

doing, where's the best place online to go?

Mikhail Kogan 56:00

GW ci m.com You can put that in links to the yeah and then also like I have a YouTube

channel is just Misha Kogan, MD. With Dr. Misha Coburn. You'll find me there. I tend to

post lots of things on cannabis is definitely not my only topic of interest, but I do and

yeah, people can also email me I'm Kogan at GW ci m.com, if you want just directly so.

Evan H. Hirsch, MD 56:25

And then we'll also include the link to your book.

Mikhail Kogan 56:28

Great. Self, COPPA. Yep, softcover just came out a couple of months ago. So that's a

little bit it's updated. We added some stuff in there, we added some COVID stuff. We

added some a little bit on cbdv of newest that's one of my kind of more favorites

molecules, and a little bit more or less city coins. And it's cheaper. Yeah, I don't I don't

Increase Your Energy with Medical Cannabis with Mikhail Kogan & Evan H. Hirsch

know how they I don't know how they price the books. It's kind of a mystery. A Random

House. I worked with several publishers by now random is the best but still make a lot of

like mystery about how things happen. It's like this black box. I was like, why can't we

make this book a little cheaper because more people will buy it? They're like, No, no, no,

no, it's not a big book. It's a pretty thin book. I only have hardcover, oh, here. I have a soft

cover. And it does so that it's not that thick. You know? 18 bucks for this overpriced my

opinion.

Evan H. Hirsch, MD 57:32

Excellent. Well, thank you so much for joining me today. So appreciate the work you're

doing in the world.

Mikhail Kogan 57:38

Same with you. Huge fan of your work. Thanks.

Evan H. Hirsch, MD 57:41

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Thanks for being part of my community. Just a reminder, this podcast is for educational

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medical or other professional advice or services. Thanks for listening, and have an

amazing day.