Marijuana and MS with Dr. Mikhail Kogan | S4E21

Bio:

 

Dr. Mikhail (Misha) Kogan, MD, ABIOM, RCST is a leader in the newly established field of Integrative Geriatrics.  He is the chief editor of the first definitive textbook of the field entitled “Integrative Geriatric Medicine”, published by Oxford University Press as part of Andrew Weil Integrative Medicine Library series and is 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 is in treating older patients and palliating symptoms at end of life he also treats a wide arrange of internal medicine problems from chronic GI problems to cancers where use of medical cannabis can be very beneficial.  In October 2021 Dr. Kogan, in collaboration with Dr. Joan Liebmann-Smith and Penguin Random Publishing House, published Medical Marijuana, Dr Kogan’s Evidence-Based guide to the health benefits of cannabis and CBD. Dr. Kogan currently serves as medical director of the GW Center for Integrative Medicine, associate professor of medicine in the division of Geriatric and Palliative Care, and associate director of the Geriatrics and Integrative Medicine Fellowship Programs and director of Integrative Medicine Track program at the George Washington University (GWU) School of Medicine. Dr. Kogan is also the founder and the executive director of AIM Health Institute, a 501(c)(3) non-profit organization in the Washington, D.C. metropolitan area that provides integrative medicine services to low-income and terminally ill patients regardless of their ability to pay. 

Questions:

 

Background

 

• You have a diverse and impressive background, including integrative medicine, serving as an Associate Professor of Medicine at George Washington University, founder of a health nonprofit, and author. So cutting to the chase, what has gotten you to the place where you’re one of the leading medical experts on cannabis?
• People have all sorts of associations with cannabis, mostly around its reputation as an illicit substance. Of course now it’s being legalized for recreational use in many places around the world. Can you speak to its use for medicinal purposes? What’s the medical backstory of cannabis?
• Maybe we can shift to a little rudimentary chemistry and biology to understand how cannabis works medically. Can you provide a layman’s explanation of the human endocannabinoid system, how the cannabis plant interacts with it, and the difference between CBD and THC?

 

Dispelling Myths

 

• There are a number of perceptions around cannabis and its use, and I wanted to see if we could validate or dispel some of them:
  • Firstly, is cannabis a gateway to harder drugs?
  • Is it safe to use? Are there side effects?
  • What about the argument about how effective it truly is for medical use? Can you speak to the efficacy ranges for cannabinoids?
  • Is there an evidence base to suggest cannabis is effective as a medical treatment?

 

Cannabis and MS

 

• If we shift the focus to MS, can cannabis be helpful?
• How does cannabis impact MS spasticity?
• And what about using it for pain management. Does it alleviate pain that may be associated with MS?
• So are there any downsides to using cannabis as part of an MS treatment regimen? Perhaps adverse interactions with DMDs?
• Which cannabinoids should someone be taking to get an anti-inflammatory effect?
• How do you prescribe or recommend the use of cannabis in your own medical practice? Maybe put another way, how does someone determine if they’re a good candidate to use cannabis medically?
• The organization behind this podcast, Overcoming MS, is a big advocate of healthy lifestyle choices. How does cannabis fit with healthy lifestyle choice in your view, Misha?

 

The Future of Cannabis

 

• What is the current research activity around cannabis? Anything we should be aware of down the pike?
• What does the future hold for using cannabinoids for disease modification?
• And lastly, your book. You’ve just released a new book called Medical Marijuana. There’s a link in the show notes for more information and where to buy it. Can you tell us a bit about the project, what it’s about beyond what the title implies, what kind of impact you hope it will have?
• Thanks so much for being our guest on Living Well with MS, Dr. Misha Kogan. We are thrilled to learn about the amazing work you’re doing to help people navigate the intricacies and benefits of medical marijuana. And I encourage everyone to learn more about you and your work by checking out the links and more in our show notes for this episode. Thanks again, Misha.

 

Links:

 

• Kogan’sbio
• Kogan’s new book,Medical Marijuana, selected as one of the summer 2022’s best science reads
• Kogan is Medical Director of theGW Center for Integrative Medicine
• Kogan isAssociate Professor of Medicine, George Washington University
• Kogan is Founder and Executive Director,AIM Health Institute, a DC-based nonprofit delivering integrative services to underserved
• Kogan’s personal website can be found here
• Kogan can be found on social media here: Facebook and YouTube

 

Coming up next:

 

Join us for the 35^th installment of the Living Well with MS Coffee Break series, and get to meet Ann Coulson, who has been part of the OMS community even before such a thing existed and has been following the work of Professor George Jelinek dating back to its inception. Ann is undertaking an exciting adventure – sea kayaking around the Isle of Wight – to raise awareness of and funds for OMS. You won’t want to miss this dynamic discussion!

 

Don’t miss out:

 

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S4E55 Transcript

Medical Marijuana

 

Geoff Allix (00:00):

Welcome to Living Well with MS, the podcast from Overcoming MS, the world's leading multiple sclerosis healthy lifestyle charity, celebrating its 10th year of serving the MS community. I'm your host, Geoff Allix. The goal of our organization and this podcast is to inform, support and empower people with MS to lead full and happy lives. We're excited you could join us for this new episode. Make sure to check out this episode's show notes for more information and useful links.

 

You can find these on our website at www.overcomingms.org/podcast, or on whichever podcast platform you use to tune into our program. If you enjoy the show, please spread the word about us on your social media channels or leave a review wherever you tune into our podcast. Have questions or ideas to share? Email us at podcast@overcomingms.org, or you can reach out to me directly on Twitter @GeoffAllix. We'd love to hear from you.

 

Finally, don't forget to subscribe to Living Well with MS on your favorite podcast platform so you never miss an episode. Now, let's meet our guest for this episode. This episode of the Living Well with MS podcast is marijuana and MS, a conversation with Dr. Mikhail Kogan. Dr. Kogan is medical director at George Washington University Center for Integrative Medicine in Washington, D.C., amongst many other things, and is the author of the book, Medical Marijuana: Dr. Kogan's Evidence-Based Guide to the Health Benefits of Cannabis and CBD.

 

Welcome to the program, Dr. Kogan, and thanks so much for-

 

Dr. Mikhail Kogan (01:38):

Thank you.

 

Geoff Allix (01:38):

... joining us on Living Well with MS. Firstly, are you okay if I call you Misha? I believe-

 

Dr. Mikhail Kogan (01:41):

Yeah. Yeah. I much prefer that.

 

Geoff Allix (01:43):

Okay. Excellent. You have a very diverse, impressive background, including integrative medicine and serve as an associate professor of medicine at George Washington University, you're a founder of a health nonprofit, you're an author. To cut to chase, what got you to a place where you're one of leading medical experts on cannabis?

 

Dr. Mikhail Kogan (02:07):

Random and not so random set of events. Well, so I think I always was leaning towards holistic or integrative medicine even before the medical school. That was just given. But in early 2010s when D.C. approved medical cannabis, I started finding myself patients asking me all the time. I realized that, well, I have two choices. I can just follow the crowd, so to speak, or I can jump in it because it felt to me at the time that some of my patients, at least the older patients, could potentially benefit a lot.

 

Then at around the same time I met Donald Abrams, I don't know if you heard his name, and he's a grandfather of the cannabis research field, if you will, in clinical settings. So he also helped me to establish comfort zone. I think for me, the big problem was not just, does it work or doesn't it not work? It was more around this whole background information. I grew up in Russia. It was thought to be this terrible drug that if you take it once, then that's a life of alcohol addiction, prostitution, gambling, and early death.

 

This is how we've been told. I think some of this was completely ingrained in me. The hard part was just to kind of get over that and say, "Okay. I'm going to put aside everything I've ever heard about this. I'm just going to really learn it." In the beginning, learning was tough because there's nothing. 10 years ago, the amount of information like a formal learning was extremely limited, so I think I ended up learning a lot of things from a close collaborator I worked with.

 

Beth Hayes is one of the people who taught me a lot. If you want to say she's a cannahacker. The early cannahackers. After that, of course there started to be a lot more data and a lot more formal training programs. I've taken some courses here and there. I've listened to a lot of experts. I don't actually call myself a cannabis expert, believe it or not, mostly because I integrate cannabis in a very broad spectrum of treatments.

 

There are people who just do to cannabis and that's all they do. They're cannabis doctors, I'm not, not even close. Cannabis is just one of my skills. I've learned to be comfortable with some parts of it, but there are definitely things that I don't know. Like I don't treat much of kids or I mean, I don't do pregnancies. I mean, I'm not a gynecologist or... So there's a lot of things I don't do and so I don't necessarily claim any expertise there.

 

MS is one of those things that I do treat. That's why I thought it would be good to talk to you because as a geriatrician and especially as a palliative care doc we see a lot of cases of patients with progressed MS, patients who are older and have MS. So I've learned to be very comfortable with cannabis for this condition.

 

Geoff Allix (05:24):

I think everyone's probably aware of the recreational uses of cannabis, but what sort of medical history is there? Is there a background to it being used medically?

 

Dr. Mikhail Kogan (05:40):

Well, if you go back... And this is thousands of years ago, this is one of the oldest drugs known to humans. China used it more than 5,000 years ago and India pretty much any culture had some use of it in one way or another pretty much. I mean-

 

Geoff Allix (06:01):

This is a medical use rather than the recreational use.

 

Dr. Mikhail Kogan (06:04):

Well, yeah, I mean, I think back then, who knows how those things were... They were overlapping just like now, so somebody would use it for aches and pains, but also would use it ceremonially. I don't know if back then the word recreational was in the vocabulary. There was of course a lot of ceremonial use. Yeah, but we don't really know exactly what they were doing with it. I mean, we think that the Siberian princess story was pretty fascinating.

 

They found this mummy in Siberia that had breast cancer and there was a cannabis next to her, presumably she was using it topically for applying right in the breast cancer. But those are all speculations. The reality, who knows? But the real documented use that was really documented use was in the Chinese Materia Medica. I think that's what they call it, where it was clearly documented it was part of their standard care for all kinds of conditions.

 

Then modern times, I think we ought to mention some of the pretty well-known positions. One of them is in your own backyard, used to be in your own backyard, O'Shaughnessy. He brought cannabis from India to England, and first was using it with royalty, with people from the palace, palace folks. Then it propagated from there. In the 1800s, mid-to-late 1800s, it was all over in Europe and America. In the U.S., they were using it as a standard drug.

 

It was written into a standard [inaudible 00:07:37] of U.S. up to sometimes in the 19^th century. It was just a standard medication. Back then, there was not this discussion, does it work? In fact, it's crazy to think about this now, but in 1937, when U.S. government tried, or actually did, institute a tax, it wasn't a huge tax, but it was a tax that basically put most of the medical use of cannabis out of business because they taxed it at the point where consumers said, "Forget, we're not paying for this."

 

In one little swoop, it was all destroyed. The only organization that spoke against it was the American Medical Association and the commission of the AMA to The Hill basically said something along the lines of, "This is one of the most effective tools for all kinds of medical conditions and it's basically irresponsible to tax it because it is a medicine. It's a drug." That's actually documented in the Library of Congress.

 

That particular statement that was sitting there as historical evidence that back before prohibition, the standard medical association would say, "It's a drug. We use it every day." And every pharmacy was carrying it. It was sold left and right. They were combining it with morphine tinctures. They were combining it with all kinds of other things that for now, for them, for decades after we were like, "Oh my God, this sounds scary." No, it's not.

 

It's just we have forgotten. We're coming back to well-forgotten things and we're trying to now prove their efficacy again. It's like spinning the same wheel again and again, but it has to happen.

 

Geoff Allix (09:31):

Now that we understand a lot more about how things work, could you explain a bit about the chemical, biological side of how the endocannabinoid system works and what actually happens and the different cannabinoids as well? What's the difference between CBD and THC and what is actually going on now that we do have some understanding?

 

Dr. Mikhail Kogan (09:56):

Yeah, yeah. Sure, sure. By the way, so while we were using cannabis for thousands of years, but the actual understanding of how it works and what it does is relatively fresh. I mean, the THC was discovered in the 60s, same with CBD, but the actual endocannabinoid system, that took another 20 years or more. It took a pretty long time to get to a point of understanding, and I have a strong suspicion that we're only in like baby steps, that we are going to learn way more.

 

But not to go into this topic too much, because in itself it's a whole system of medicine really. The listeners can think of it this way. We always talk about the endogenous opioid system. Our body produce morphine-like equivalents and that controls pain and that makes us feel euphoric or feel well. Well, turns out there's what we call an ECS, endocannabinoid system. Instead of THC, which is what the plant produces, tetrahydrocannabinol, we have 2-AG and anandamide, so those are the two primary.

 

There's actually a lot more, but those are the two big ones specifically, and the anandamide, which in Sanskrit I think means bliss. Those are the internal molecules that work like a lock and key. You put the lock in a key and you open certain pathways, you trigger certain things to happen. There are big categories of things that can happen when our own endogenous cannabinoid system gets triggered or activates itself.

 

One is that we of course can't control the pain similar to opioids. But the bigger one is thought to be a couple of other things. One is neurotransmitter regulation, so we can control excitation or neural excitation with cannabinoids. That's one of the key reasons why cannabis is thought to be so critical in trauma resolution and that's why so many patients with post-traumatic stress disorder are heavily using it because it's the most effective tool that makes perfect theoretical sense.

 

Since our own system controls the trauma response, why wouldn't the exogenous molecules do the same? They do. There's no question really about that. That's one big one. There's a very strong regulation of immune system, and that actually is important for MS. There is more and more understanding that cannabinoids, endogenous and exogenous can regulate the immune system appropriately. That is very complicated by the way. It's not just based on... Because nervous system can also regulate the immune system.

 

It's a lot more complicated. There are other direct immunological receptors and immunologic pathways that can be regulated. Some molecules in cannabis, like CBD for example, have very strong neuroprotective and immunomodulation in the Petri dish. Now it's a little different in humans and animals. There's just not that... I mean, there's a lot less understanding yet, but it does seem to have those effects that I just mentioned.

 

Geoff Allix (13:16):

Is there double-blind placebo controlled-

 

Dr. Mikhail Kogan (13:20):

No. That's what I'm saying. No. There isn't.

 

Geoff Allix (13:23):

All right.

 

Dr. Mikhail Kogan (13:24):

Yeah. These are basic theoretical works. Some of them are in Petri dishes, so what we call in vitro, some of them are in a small or larger animals, but in terms of an actual human data, there's not a lot. I think what's really missing from human data is a combination of clinical data. I give THC to a patient with pain, the pain gets better. We have a little bit of that. Well, actually we have some of it, but then what actually happens on a mechanistic level at the same time?

 

Parallel studies doing both clinical, but also deeper dive into the physiology of change are few and far in between. But there is an explosion of that. There's an explosion of interest. There are explosions of studies. I actually think, Geoff, you mentioned that England is more conservative. It may be clinical, I don't know. I don't practice there, but I would say in terms of research, you guys probably are a little bit in a way ahead of the pack, because actually there's a lot of studies coming out of England.

 

U.S. has had cannabis as a schedule one. What that means... A DEA schedule one. It means that as a physician, I have to get a very special license to study cannabis and I cannot, under any circumstances, obtain actual government funding to study its benefit. I can only obtain government funding to study toxicity and side effects. That set us backwards decades. We would've been way further ahead.

 

Only now in the last few months there's been shift that now at least government says, "Okay. Fine. We're still not going to allow you to study benefits on government funds, but at least what you can do, at least we're going to give you access to more products." Because in the past it wasn't just, I can't study the benefits. That was one issue. The other issue was, well, you only get like two/three products that somebody growing out there, like specific... Those products are like back from 70s and nobody uses them in the real life.

 

You go to dispensary and you... We just talked before the... Right? You went to Seattle to check those things out and there's hundreds of products there. That's what's in real life. But studying that real life has been very challenging because of the legal status. Now, what's going on in England is of course the Sativex and Epidiolex have been available, which are the pharmaceutical-grade extracts of nabiximols what we call it. It's a direct extract of the plant, a different ratio.

 

THC and CBD one to one with Sativex and pure CBD with Epidiolex. You have drugs and then drugs are a lot easier to study from a legal perspective. Now in the U.S., we actually only have Epidiolex and everybody is really interested in studying more with THC because CBD has some great things that it can do, but it's highly limited and really as I often joke, [inaudible 00:16:43]-

 

Geoff Allix (16:43):

We have a strange situation in the UK where theoretically, you can be prescribed Sativex but there's the National Health Service, which is broken down into regional units, and the proportion that actually do prescribe it is tiny. For example, I can't get Sativex. In Wales, you can get Sativex but there are very few places that actually do prescribe it.

Just to come onto actually why they don't, because we have a large moral side to this that a lot of the print press say that cannabis is a gateway to harder drugs. I don't know if this is an area where you would have any knowledge. Is it a gateway to harder drugs? Is it safe?

 

Dr. Mikhail Kogan (17:32):

Oh no, no. This is such BS. I'm sorry, I'll be so critical. This is like what we know. The data is very clear. It's not a gateway. It's an exit drug. There's no question about it. I mean, there has been study upon study in U.S. and for me, I'll tell you why it's so critical. I'll come to that in a second. There's been multiple studies to say, "If the state approves the cannabis..." And it doesn't even matter for what condition, because once it's approved, people can say, "Look, I have cancer."

 

But they're going to use it for... Nobody controlling that. Right? Once they have access to it, they can use it recreationally for what they care. What we know, this is a practical data, this is why I was so critical. The moment the state approves the cannabis, you see a dramatic decrease in medication use. We are talking here, listen to the data, more than a million prescriptions per day, or more than a million drugs taken per day per state that has legalized it.

 

That includes opioids, benzodiazepines, and a bunch of other drugs. In essence, the sleep aids go down, pain use medications go down. The data goes like this. Not only is that the total amount of opioids goes down in some massive amount, but you have 30 to 40% decrease in mortality related to the opioid toxicity. Now think of it this way, in America, every year, you have tens of thousands of deaths from direct application of opioids or indirect toxicity, both.

 

If you can save 30%, I mean, we are not talking about a few deaths. We are talking about tens of thousands of lives every year saved if cannabis gets approved and yet there are still politicians who say, "Oh, you take it once and you're done for." It's very unclear to me, why is this still happening? Because the data is out there. I mean, I'm talking about studies in JAMA, New England Journal of Medicine. I am not talking about some obscure medical journals.

 

I'm talking about researchers who are NIH-funded, main institutions of United States of America. Yet we are not moving. I'm guessing... Or well, my father used to joke. It takes like literally generations to die out before academia and politics shift. I think it's actually even more than that. I think we have an institutionalized fear and institutionalized racism related to it and nobody wants to give it up.

 

It's comfortable to say that, "Oh, only Blacks are using this because it's bad for them and they're getting addicted and all of that." It was very good strategy to use as a tool for racism, and it's still the same way. It's changing very slowly and there is an attempt to maintain the status quo. What shocks me is that usually in medicine, when you have data of the magnitude I just mentioned, that usually shifts the needle within, I would say a decade.

 

We are not seeing that. The studies I mentioned, first of them started coming out 10 years ago. Like 2012 was one of the first studies to say if particular states that have been early adopters of cannabis, they've been seeing dramatic decrease in mortality related to the opioid use. Subsequently, we have better data. The data after that would be more precise, it would say, "Okay. Well, so this how many less prescriptions of opioids are taken per day? This translates to X amount of an actual decrease in mortality."

 

Now that data is also about five years old. Why are we not seeing any political discourse? I talk about this at every corner, because I believe that it has to be brought up as a universal tool for pain, and with that, we're probably going to see a massive drop in use of opioids. Of course, I don't really care about saying this-

 

Geoff Allix (21:51):

I think what's happening in the UK is that... I mean, so here it's illegal essentially but I know I could buy cannabis today because I walk with my dog and I go past and there's a field where there's a bench and quite often there's kids there or teenagers there.

 

Dr. Mikhail Kogan (21:51):

That are smoking. Yeah.

 

 

Geoff Allix (22:10):

I can smell they're smoking cannabis. It's distinctive, isn't it? I know that I could probably... But the thing is, if I then find out who the dealer is who's supplying them, almost certainly that would be somewhere where I could also buy cocaine, MDMA, LSD. That's really in my mind where it becomes a gateway, because actually you're forcing people who want to use cannabis to go drug dealers [inaudible 00:22:36]-

 

Dr. Mikhail Kogan (22:36):

Right. Right. Right. But we are not talking about that. I mean, we are talking about a medical tool. I'm actually... I'm having a great time because I didn't realize that England is so backwards actually, because in U.S., most of the states by now have approved medical. There is no question that within less than decade, we're going to have an entire country approve it just because of money.

 

The governments of the states, they're making so much revenue on taxation that everybody wants it. This is one of the few universally bipartisan issue in every state that gets passed through every state legislature with no problems because they want it. I mean, both sides say, "Hey, we need money, so let's get cannabis through because we need to fill up the coffers."

 

Geoff Allix (23:26):

Yeah. I believe we're one of the biggest producers of medical cannabis in Europe, but not-

 

Dr. Mikhail Kogan (23:26):

Probably.

 

Geoff Allix (23:31):

But it's exported.

 

Dr. Mikhail Kogan (23:33):

But it's exported.

 

Geoff Allix (23:34):

Which is insane.

 

Dr. Mikhail Kogan (23:36):

Yeah, it is. It is. It's... Yeah.

 

Geoff Allix (23:38):

To come onto MS specifically, can cannabis specifically be helpful for MS and what help could it be? Would it help things like spasticity of the brain?

 

Dr. Mikhail Kogan (23:49):

Right. Right. Well, when I was preparing for this, I thought of doing a couple of things. One, of course people can go to my book and there's a whole chapter that I kept it open here on MS, starting on page 190. We talk a lot about symptom management in that chapter. That's the first part. The first part is multiple sclerosis of course is characterized by the spasticity and chronic pain from that spasticity.

 

The cannabis for that is proven. It's not just proven, maybe. It's undoubtedly proven. What's not a hundred percent clear is though what should be the best products to use? We think that the daily dose of THC for MS needs to be somewhere high in contrast to some other conditions. For MS, you probably need somewhere between 20 to 50 milligrams of THC per day in whatever the form you need to take it in.

 

But what's not clear is okay, well, is the cannabis itself, medical cannabis as a whole, plant extracts or smoking or vaping or whatnot, better or worse than let's say an oral medication? Whether it's Sativex or whether it's Marinol in U.S. or whatnot. That's not very clear. There have been very few side by side studies, but what we do know for sure that somewhere close to half of all the patients with MS using cannabis, they often don't report. That's also known, and they generally universally say it's helpful.

 

Now, is that randomized trial data? No, it's not, but it's in such mass that there's no doubt in anybody's mind. Whoever takes care of as a provider... Myself included, takes care of patients there's no doubt that it's effective. Question becomes, okay, safety versus effectiveness. In medicine, you always do no harm. Yeah, if somebody's smoking cannabis and they have MS and they already have spasticity and their lungs may not work very well, is it smart? Probably not.

 

You may want to consider giving them something under the tongue or oral preparation so they don't put potential toxic substance on inhalation into their lungs. That's one domain. The bigger question in my mind, and this is a very radical thought process here. Can cannabis play the role in disease modification of MS? Meaning, can people take certain formulations of cannabis that will actually slow down or even reverse progression of MS?

 

I'm not afraid of saying that because what I'm trying to say is this, there seems to be a very strong signal in every neurodegenerative condition, whether it's Alzheimer's, Parkinson's or MS or ALS for that matter, that the cannabis plays a role. What we don't know is this, okay, if I have a patient in front of me, what should I give them to help their disease process not just their symptoms? To help their symptoms, we've already been doing it for decade plus.

 

Now, can I do something to them practically to alter the course of MS? The answer to that is we don't know, but we think, yes. The data from control trials doesn't exist, but we seemingly have preliminary data from in vitro studies and also small animal models that says, yes, just like with cancer, we're seemingly able to affect the disease process itself. If you think about this, it makes a lot of sense, because you have to think about what is MS?

 

Well, it's a neurodegeneration and it's characterized by a strong inflammatory state, neurons die and the spasticity forms as a symptom, not necessarily that that's a pathology in itself. Different cannabinoids... And there's more than one. There are probably dozens if not hundreds, that actually have those neuroprotective and anti-inflammatory properties. How much should we take? Should we tell all patients, everybody should take 200 milligrams of CBD per day? No clue.

 

This is why I think the future of the next decade should not concentrate on, does this work or not? Okay. There are tons of skeptics. There are people saying, "Well, only oral medications work. There's no data that cannabis works." I don't care. Patients are going to be using it. Those experts can say whatever the they want. That train is so far gone and they're so in the past that just they're in academia and they think that they know something. It's just nonsense.

 

The question is, what should the study designs look at in terms of an actual disease modification? Here, I have certain opinions. First of all, I feel strongly that the minor cannabinoids, we're not talking about CBD and THC, we're talking about rare things or less common things, acidic forms, so CBDA, CBGA and THCA. Those tend to be very potent anti-inflammatories, all three I mentioned, and what dose should we give them? That's one critical aspect.

 

The second aspect, we also know that there's a whole bunch of other cannabinoids like CBC, CBG and CBN and a whole slew of them. What should the ratios be and what should be the target dosing? Like with cancer, some thought process goes around like this, don't worry about particular cannabinoids, pick some basic ratio and then give as much as a patient can take in. Okay. That is one way to think, has no evidence to support that, but that's a way to think, because we know that from animal studies, there is a certain threshold.

 

For the symptoms, your mantra is start low, go slow, deliver where it needs to go. For the disease modification it's a different model. It's what is the minimum dose that's required to start altering particular process? We just don't have the data. We think we do, and there's a lot of experts way over my pay grade who say, "Look, not only do you need to titrate it up like crazy, but you also need to give different routes at the same time, because they do get in differently and they do trigger different things slightly." It gets quite complicated very quickly. The bigger issue is also partially practical. THC dosing can be quite limiting because of euphoria or-

 

Geoff Allix (30:38):

That's what I was going to say, because I think... I mean, personally, if my spasticity was resolved, that would be the biggest single improvement for my life at the moment, but-

 

Dr. Mikhail Kogan (30:50):

That's for the moment, but the disease is still progressing.

 

Geoff Allix (30:53):

Well, yes.

 

Dr. Mikhail Kogan (30:54):

That's the problem, you know? That's the thing.

 

Geoff Allix (30:56):

But if you went for a high THC, that's the thing that makes you high, isn't it?

 

Dr. Mikhail Kogan (31:01):

Correct. I think-

 

Geoff Allix (31:01):

Is there any way to alleviate?

 

Dr. Mikhail Kogan (31:05):

Yeah. That's why I mentioned the ratios because most of us would say, yeah, we know that the THC has a ceiling and I mean, yes, there are some people who can take crazy amounts and function, but an average person, they wouldn't want that. You'll get them to a certain limit. You'll spook them off and they won't go back to it because it's too altering. You can get most people tolerant and so you can gradually titrate the dose and keep titrating and they get more tolerant.

 

That's one way to do it, but actually a more common way we think at practice is the ratios. We would put more of other cannabinoids, not THC. More CBD, more CBDA, more CBG, more CBC. Then we would say, "Look, when you give all those other non-psychotoxic, that's the word, cannabinoids, you can add some THC in there for the synergistic effect."

 

Of course, there's also what we call an entourage effect, which basically means, okay, if I just give, say Sativex which is pure THC and CBD and nothing else, there's no terpenes in there or nothing. If I give that versus if I give the same exact concentration of a dose, but I keep everything else that originally was in the plant inside of that prep, whether it's a tincture or an on oil, whatever, we... Not think, we know that the efficacy of that is way, way higher.

 

It's probably somewhere two to one, or maybe even three or four to one. I need to give way less of a dose of the full extract oil than the Sativex. That data has been around for quite some time. Now, that doesn't necessarily mean I know how much to give a particular patient to cause the disease modification. It's simply a base understanding of what's out there in the market and what we are using.

 

But my next big project is really to look into some of these neurodegenerative conditions and try to say, "Can I figure out particular ratios? Can I titrate it up and see what I see?" The problem is that work like this tends to take a lot of time because these conditions are slow. They're not like cancer where you can give somebody a couple of months' supply and if the cancer changes, that's it.

 

The neurodegenerative conditions, they take years to evolve. They're very slow. Assessing whether something is effective, requires very sophisticated tools and a lot of time. That causes just pragmatic challenges to-

 

Geoff Allix (33:51):

And just nothing happening can be a benefit.

 

Dr. Mikhail Kogan (33:54):

Actually, I argue this. We have this very large Alzheimer's program and I argue with so many family members. They're like, "So when am I going to see an improvement of my..." I'm like, "You're really not understanding this, are you? Praise God that your loved one is not getting worse." I mean, that's all we... First step. I mean if we can get them better, great, but that's the first step. It's actually this whole slew of these neurodegenerative conditions.

 

In one way, they are a blessing because they're slow. The family have a lot of time to adapt, but they're so disfiguring from a mind perspective, then people gradually lose themselves. You watch them deteriorate, not just physically, but cognitively and mentally. In few years, you may not even recognize that the person with you is the same person you always loved. That part is extremely hard.

 

I think we have to research cannabis very aggressively because the signal is undoubtedly there. I have no doubt, I have zero doubt that within few decades, the cannabis will be at the forefront of curing these conditions. Why am I saying this? Well, because actually we know what happens in the models of all these conditions and MS is included. The cannabinoid system gets completely dysregulated, and the further condition progress, the more that dysregulation occurs.

 

Now, somebody could ask me an obvious question. Well, how do you know it's not a secondary problem? Like it just occurs because the disease is there. Sure. But we also know that if you take an animal with those conditions and you give them replacement, they seem to do better. The animal models are faster to study, like especially mice. I mean, mice models of Alzheimer's and MS are pretty easy to study because they're rapidly progressing compared to humans.

 

We know that it's there. Again, as I said, we just don't really have actual controlled clinical data to guide our patients into particular treatment protocols. That's the painful part.

 

Geoff Allix (36:12):

You've mentioned some things where it might have effects which are equivalent to disease-modifying therapies, and in much of the world an MS patient could actually go out and try a variety of different cannabinoids and find one that works for them. But is there a risk that could interact with a medical, like a drug-based disease-modifying therapy?

 

Dr. Mikhail Kogan (36:44):

Sure. Sure. If somebody thinks that this tool has no problems, they're completely wrong. I mean, just like anything, I always joke, you eat cucumbers, you will die. It's like everything has some toxic side effects. The reality is that while we don't think anybody can die from overdosing on cannabis, unless you run the car into a tree or something, but you're just not going to die from overdose. That doesn't mean there's no problems.

 

The THC has a lot of different side effects. Dizziness, dry mouth, memory loss in young people, some increased risk of paranoia and all those things. There's no question, but there are also some other big concerns. Could there be drug-to-cannabis interactions? A lot of people with MS of course take a number of medications. Could they be interacting with cannabinoids? The answer is yes. The good news is that the answer is yes, mostly theoretically.

 

We're not actually in practice seeing those interactions. We have a lot of people taking different cannabinoids, including high-dose CBD, which is actually the biggest concern. The biggest concern with the interactions is not the THC, is that the CBD in the liver it affects the liver in a way that it causes the drug-to-cannabis interactions or drug to CBD interaction. It's a really big concern for example, for patients on a high-dose Epidiolex and CBD with seizures.

But at the same time in practice, we're not seeing that. We're just not really seeing what we see with other medications. We see a lot of drug-to-drug interactions in actual hospital, or somebody shows up into emergency room with toxicity because there is an interaction. We're not really seeing that. Why? I don't know yet. Maybe it's because we haven't reached the critical mass to yet see. Maybe it's because those interactions are theoretical but not practical, and that's what I actually believe.

 

I think some of those interactions are going to occur at such high doses that it's just people are not going to take that much, at least not yet, for now. I think the other big issue is are we worrying about quality of the products and are we sure that what our patients are buying is safe from other perspectives? I mean, right? Because it's an extract. If it's not well regulated, if it's not well checked, how do you know they buy what they pay for? How do you know there's no toxins? I'll give you one example. I don't know. You guys probably don't know this, but in U.S. we have this delta-8 THC craze, have you heard about that?

 

Geoff Allix (39:30):

No.

 

Dr. Mikhail Kogan (39:32):

Yeah. It's basically a metabolite or isolate of the cannabis. You can actually make it from CBD or from hemp. You can start with a non-cannabis... Well, hemp is cannabis, but little THC in it to begin with and you can make this product called delta-8 THC. It's not as potent as THC, as delta-9 THC, which is an actual THC, but it causes a lot of problems because it seemingly works identically to THC in terms of recreational use. It's just not as potent.

 

But to make it, you have to extract it from large volumes of hemp and almost every product that's been researched, looked up out there in the U.S. market, has toxins. We're not talking about some mild toxin. We're talking about heavy metals, we're talking about organic pesticides, residues and all kinds of stuff. So how do you control it against that when the market itself is like a wild horse running out there, you can't even catch it anymore? You constantly retract.

 

Congress here in U.S. is trying to say something about it because delta-8 is... Okay, for full disclosure, I tried it and I'll tell you, yeah, it's not as potent, but it's potent enough that if you take enough, you're going to get pretty much a similar effect as THC. I bought it. Like I walked into the store during a holiday with my 13- and 15-year-old kids trying to buy... Like I wanted to buy CBD tincture oil for my dog and I saw the delta-8 and they sold it to us. My kid was right next to me. I said, "Wait, go back. Let's see what..." He went back and they would've sold it to the 13-year-old.

 

Geoff Allix (41:20):

13-year-old.

 

Dr. Mikhail Kogan (41:22):

13-year-old. They would've sold delta-8 because it's a hemp product. They don't even think of it as a something, but it should really be just like THC, controlled and dispensed appropriately. We have this kind of government legal logistical nightmare in U.S. Sounds like you guys are not anywhere near that yet, but it'll reach you. It'll reach you. It's interesting to see how all of that evolves because now there's delta-10. Now there's this THCV, THCO.

 

There are all these other new molecules. They're not really new. They're new to market. They've been known, but they haven't been sold out on the market. A lot of what's happening is wild experimentation if you will. Certain pearls will come out of it. I'm always worried that this will negatively impact the field in the long run because it'll trigger some kind of a negative, large backlash because we're going to have some problem.

 

Like right before COVID hit, we had this epidemic of EVALI. It was basically bootlegged cartridges for vaping that were causing this massive lung inflammation and some people, kids, young people died. It wasn't from the actual cannabis or the tobacco. It was some kind of a preservative or something in that concentrate that activated this inflammatory cascade in the lungs. It's growing pains for the industry and for the patients, it translates in the U.S. into a logistical nightmare because doctors don't know anything about it.

 

That's actually a really big point. Most of the neurologists are clueless or what they do know is so little that it's completely irrelevant to their patients. They just know like, okay, maybe they shouldn't smoke or something, but they really don't understand the details at all. Patients have to go find the cannabis experts on their own usually. By the way, that was one of the main reasons why I decided to write the book.

 

The whole story here is that my patient connected me to a professional writer, Joan. Joan approached me first and said, "Hey, let's write something." I said, "Sure." We went to the publisher. I wanted to write the book for the older adults on this topic. They said, "Ah, forget it. We need a general book. It's too small for..." I said, "Okay."

 

But it was Joan's idea. Say, "Look, you have to write it in such a way that there's an actual protocol so that the doc could buy it or the patient can give the book to the doc and say, "Here, this is what's working for people. Can I try it?" I know that it'll get outdated in no time, but at least for time being, it's going to actually help a lot of providers because they're going to read this, and it's pretty simple to read, and they're going to understand at least some basics. Now, of course there are textbooks on the topic and bigger texts with a lot more detail, but often physicians they're not going to learn a whole brand-new branch of medicine just because they're just going to follow their patients.

 

Geoff Allix (44:40):

There's links in the show notes to the book. Yeah, just released called Medical Marijuana. You said a little bit about it, but so is it useful for both doctors and patients as well? You'd recommend?

 

Dr. Mikhail Kogan (45:01):

Yeah.

 

Geoff Allix (45:01):

Is it worth a read for everyone?

 

Dr. Mikhail Kogan (45:05):

It's worth a read for everyone. I mean, of course, if you're already more than an expert in cannabis this is totally too basic for you. But if you are curious about this topic, if you have a condition which you think... MS for sure, if you think that this may be helpful, the book is really for you because it's written in a way that a lot of cannabis books are not written. A lot of cannabis books are written either as desk references, which are very hard to read and their protocols are really not there.

 

They would summarize the studies, they would say, "Okay. Well, this study showed this." For patients, that's not relevant. Patients want to know, what should I do today? I don't care about the study. I want to know what works and what doesn't. This is what we did. This is a book written by a clinician for patients and his colleagues. That's basically what I did. I took only conditions where I felt evidence is sufficient and my knowledge is sufficient to give specific recommendations.

 

I avoided some controversial topics, but I also avoided topics where I simply don't have enough expertise, so of course the book is superficial. But it's deep enough for those conditions that I covered that I think people who have those conditions who are going to open the book are going to find it useful.

 

Geoff Allix (46:24):

You mentioned wider integrative medicine. Would you say that it fits as part of that jigsaw? Because certainly Overcoming MS encourage healthy lifestyle, so healthy diet, mindfulness, taking medication as necessary and so on and so on. You'd say it's one of those pieces?

 

Dr. Mikhail Kogan (46:45):

Yeah. I mean, absolutely, and the beauty of MS, if there is such a thing, is in contrast to Alzheimer's and Parkinson's, the chances of a complete cure are much higher. I have seen a lot more patients with MS get rid of their disease completely or put it in a permanent remission. We can't really say cure here because I think if you stop doing what you're doing, it'll probably come back, but it's a permanent remission.

 

As long as you're gotten better and what you did that’s integrative with lifestyle and other things worked and you keep doing this, the disease is basically non-present and you're living a normal life. That's the goal. It's a lot harder to do for Parkinson and Alzheimer's, I'll tell you that. But yeah, and it fits perfectly because, well, it's botanical... right? It's already a natural product, so to speak, but it also fits perfectly because it provides me a set of tools that certain things don't.

 

Generally, integrative medicine does not have a lot of immediate relief. Certain things like acupuncture for spasticity, for example, have some evidence, but generally it's a slow medicine. We give tools that gradually make people better. But if they come to me and they have pretty bad spasticity and pain, I can't really work with them unless I help them to get at least that a little better, otherwise they won't be able to exercise. They won't be able to eat.

 

All they will think about all day long is how do I get my pain improved? Right? But the cannabis offers that too. It's often that bridge between I would start the cannabis for certain things and say, "Okay. Once you're a little bit better, that's when the work begins. That's when I'm going to put you on a better diet, that's when you're going to start exercising, that's when you're going to start meditating and doing other things."

 

It takes time but I find that my practice improved so much because when I do it that way, patients start trusting me and they actually stick longer, because the big problem with our approach, I’d say people tire out. They're not really seeing immediate result and they just give up. That's-

 

Geoff Allix (49:00):

Yeah. It's a difficult one. You sort of say to people like, "Improve your diet and exercise and mindfulness." They say, "Well, I've been doing that for a week and I've not noticed any difference." You're like, "No, you're looking at like six months or give it a long time before you [inaudible 00:49:18]."

 

Dr. Mikhail Kogan (49:18):

Yeah. Yeah. Yeah. Because cannabis can cause shifts rapidly. I mean, I find... And I used to talk a lot about pain control, but I'm actually now talking just as much about sleep. A touch of THC with some CBD, or just pure low dose, you can have profound shifts in the sleep improvement. You can take somebody who has been sleeping poorly and because of that their energy is down, their pain is worse and everything's worse.

 

You start them on a touch of THC at night and you massively improve them within a week I'm talking. I mean, I'm not talking about months and months. That sometimes gives people so much instant cognitive and overall boost, the energy boost to start doing more things. That's what I find because the motivation is critical. Often, especially in neurodegenerative conditions, motivation is a huge problem. Because people already are coming in, they may have been sick for many years, they don't believe that they can get better.

 

They're just in the existing mode of operation, but they can't think of a better something. You shift them suddenly and they're like, "Oh, wow, I actually can feel that much better? Okay. Well, I better listen to this guy because he just did this." I think it shifted my practice significantly because of that.

 

Yeah. I find it a little ironic and often funny how five/six years ago, even more close to 10 years ago, I would have very difficult conversations with experts, with like neurologists, for example, who would say, "Oh, cannabis, you're going to make my patient addicted. They're dying anyway. How could you do this?" Now conversation's like, "Oh, when can you start them on this stuff?" Because they're also seeing the shift.

 

They don't do it themselves just yet, but they're realizing the value and they're sending me patients. I mean, they're like, "Well, what should I do with this particular patient?" It's really interesting how I'm seeing the shift not yet on the level of everybody knows how to do it, but everybody's trying to find somebody in the community who knows how to do it, which is great. Our next big step is to actually train every medical student.

 

I think they all should come out of medical schools, and not just medical students, nurses, and everybody, to say, "Look, I know a little bit about it. I can do some basics." That would be the day. Now, of course sounds like you guys are a little behind, but I have no doubt you'll get there. I think places like Israel, for example, or there are several countries, Canada, Israel, that nationally approve the cannabis. They're a bit more ahead of the game because they actually have larger groups of providers who've been in this for a long time.

 

But the U.S. is definitely on top, and definitely top three because we have so much business interest in this and so much patient interest that there is just a market for people who can call themselves cannabis docs. I don't call myself a cannabis doc. If you go to my clinic sites, either of them, you see a little bit in my bio, but we're not advocating that we're just giving cannabis to everybody. It has more to do with the fact that I use integrative medicine as a concept.

 

I try not to just substitute things. This is really important. I mean, we have a term for this called green apathy. When you take people away from the drug onto the botanical, it's okay. It's actually a good thing for certain things, but it's the principle that matters more. You want to simply teach patients to take care of themselves better. That's really the biggest aspect. If that means that cannabis has an exit strategy there to help them get off of something so they're onto something else, I'm all in. Yeah.

 

Geoff Allix (53:31):

With that, I'd like to thank you so much for being our guest on Living Well with MS, Dr. Misha Kogan. We're thrilled to learn about the amazing work you're doing to help people navigate the intricacies and benefits of medical marijuana. I would encourage everyone to learn more about you and your work by checking out the link in the show notes. The book is available from all major... Well, there is one massively major book resource on the internet, which everyone knows of, but I'm sure it's available in all the others as well. I checked out that one.

 

Dr. Mikhail Kogan (54:02):

Yeah.

 

Geoff Allix (54:03):

I'm sure it's widely available.

 

Dr. Mikhail Kogan (54:04):

It is available in Audible and I'm proud of the person who recorded it, so [inaudible 00:54:10]-

 

Geoff Allix (54:10):

Is it you or not you, or?

 

Dr. Mikhail Kogan (54:13):

No. No, no, no, no. No. English is not my first language. There was a professional actor who did the recording. It's really well made actually.

 

Geoff Allix (54:23):

Okay. With that-

 

Dr. Mikhail Kogan (54:23):

So listen in.

 

Geoff Allix (54:24):

Yep. Thanks very much for joining us. Thank you for listening to this episode of Living Well with MS. Please check out this episode’s show notes at www.overcomingms.org/podcast. You'll find all sorts of useful links and bonus information there. Do you have questions about this episode or ideas about future ones? Email us at podcast@overcomingms.org. We'd love to hear from you. You can also subscribe to the show on your favorite podcast platform so you never miss an episode.

 

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The Living Well with MS family of podcasts is for private non-commercial use and exist to educate and inspire our community of listeners. We do not offer medical advice. For medical advice, please contact your doctor or other licensed healthcare professional. Our guests are carefully selected, but all opinions they express are solely their own and do not necessarily reflect the views or opinions of the Overcoming MS Charity, its affiliates, or staff.