Oncologists Should Recommend Cannabis-Based Medicine for Palliative Care
Earlier this June a review was published that encourages oncologists to recommend cannabis products to their patients as a safe and effective method of palliative care. The opinion piece highlights how cannabis is a useful treatment for a variety of illnesses (nausea, vomiting, sleep, mood, anxiety), and encourages practitioners to prescribe cannabis for their patients so that they can appreciate the safety and effectiveness of the product.
Dr. Caplan and the #MDTake:
As Dr Abrams makes abundantly and eloquently clear, the reasons for oncologists to RETURN to recommending cannabis (as clinicians were accustomed to doing in generations past) are many. Weighing the safety profile of cannabinoid medicines and the long list of potential benefits for those battling cancers, against temporary adverse side effects (some of which, like appetite stimulation and sedation, can also be advantages for oncology patients), it is almost unethical for modern clinicians to NOT recommend that patients consider cannabis supplementation. The historical sociopolitical war on drugs was never founded in scientific rationale, nor supported by rigorous inquiry that has borne out half a million scientific reviews on the topic. It is high time that physicians return to a practice style that prioritizes patient well-being first, and emphasizes self-education about areas of medicine about which the providers may be less informed.
Year 2019 was an up and down year for the cannabis industry. As the year comes to a close, let us take some time to reflect on what transpired during this transitional period for the cannabis industry. Hopefully, a detailed look at what happened may shed some light on what is ahead in 2020.
First, public opinion on cannabis has continued to rise. For the first time, poll results suggested that more than two-thirds of Americans support legalization. Such a pervasive, bipartisan, agreement for a fundamental change in the law is rare, and is a true reflection of the state of the industry now, and where the industry is headed.
Riding along with public opinion, Congress saw more movement towards full legalization than in any single year prior. The list of cannabis-related bills that were introduced in Congress this year tops 15, covering topics from banking to immigration. Most noteworthy among those bills are the MORE Act, a comprehensive legalization bill that passed its committee in the House, and the SAFE Banking Act, which passed the full House by a landmark 321-102 bipartisan vote. At the same time that these provide an optimistic outlook for the federal regime, no actual progress has been made in Congress, largely because the Republican-led Senate remains staunchly opposed to reform (google “Mitch marijuana machete” for an idea of Mitch McConnell’s recent activities relating to drug policy reform).
The executive branch has not been without movement either. President Trump does not have the traditional hard-lined anti-cannabis stance that some Republican leaders espouse. He campaigned on a platform of not interfering with states’ ability to manage their own medical and adult-use programs. He has publicly stated his support for the States’ Act, a bill that would essentially codify the same, leaving enforcement up to the states. Under Trump, the FinCEN continued its policy of allowing banks to do business with the cannabis industry, assuming that the Suspicious Activity Report (“SAR”) requirements were being followed. There are also no known examples of DEA or other federal law enforcement actions taken against operators lawfully operating under state law.
At the same time, the executive branch has made moves against the legalization movement. In 2018, then-AG Sessions rescinded the Cole Memorandum, signaling that the feds were looking into increasing enforcement against cannabis businesses (Thankfully Sessions is no longer a part of the administration, as his views are notoriously more anti-legalization than Trump’s). Just last week, as Trump signed the yearly spending bill into law, he attached a vague statement reserving the right to enforce federal law even in the face of full state-law compliance. Overall the federal government has progressed, albeit slowly, in the right direction.
Many states had significant progress towards legalization in 2019. Illinois became the 11th state to fully legalize adult-use, while Hawaii, New Mexico, and North Dakota decriminalized. We now stand with 33 states having passed a robust medical program, a full two-thirds of the union. Bills were proposed in more than two dozen states, some to expand existing frameworks, and others to create new ones. Just this week Alabama’s legislature’s commission recommended legalizing for medical purposes, a stark shift from the traditional views thought to be widely-held in the deep south. Overall the trend is clearly moving towards more states joining the legalization team, some quicker than others.
Though 2018 set a high bar for the hemp/CBD industry in terms of significant reform, Year 2019 arguably topped the significant progress of the 2018 Farm bill. In October, the USDA published its interim final rule, providing much-needed guidance to the hemp community. It created a federal framework for hemp farmers, creating registration, licensing, and testing requirements. It also allowed states to create their own systems, and many of the largest states for hemp farming are doing just that. FinCEN, the same treasury bureau that regulates banking for marijuana businesses, announced in December that banks may do business with the hemp industry without having to adhere to the SAR reporting requirements like those doing business with marijuana.
At the same time, the hemp/CBD industry skyrocketed in 2019. We saw an explosion of CBD products, and the industry is now estimated to be worth $4 billion. Tinctures, edibles, lotions, balms, you name it, someone has put CBD in it and made money this year. There remains so much uncertainty about the legalities of the market, and many have taken advantage of this “Wild West” atmosphere to quickly seize market shares, without guaranteed continuity once enforcement occurs. Year 2019 was not without foreshadowing of enforcement, however. In November, the FDA sent out warning labels to several companies that were selling CBD products. The letters go into detail regarding the various items being sold and analyzed how each company was violating various laws. Although the FDA hasn’t actually seized anyone’s assets or froze any bank accounts, they are clearly watching and thinking about doing it.
A really interesting piece of news swept the nation this year. At the beginning of November, the NYPD posted a picture of two officers posing with “106 pounds of marijuana that was destined for our city streets”, bragging about its success. Only one problem… it was all legal hemp, with certifying papers and all. The NYPD quickly dropped all the charges, and recently returned the hemp to the owner. This incident also highlights a significant issue with the hemp industry, in that it comes from and has all the outward appearance of marijuana, leading to confusion and enforcement problems. Until law enforcement agencies are properly trained, this type of incident is likely to repeat itself.
Year 2019 also took its toll on many cannabis companies. Large companies like Eaze and MedMen had to lay off many employees, as the actual returns were less than what their projections anticipated. Many stocks took big hits in 2019, for the same reasons. The projections for the industry have been huge, and are likely accurate, but are also likely skewed because of the nature of the industry. There is still a large “traditional” market in existence, which continues to dwarf the legal one. While some have come out of the shadows, progress remains slow because of the monumental taxes, regulations, and difficulties associated with being a fully-legal operating cannabis company.
WHAT ABOUT 2020?
The year 2020 is upon us. The cannabis industry is not going anywhere. It will continue to grow and mature as the year goes on. We aren’t going to see any reversal of the general trend towards legalization. At the federal level, I don’t believe that 2020 will see a single cannabis bill passed and enacted into law, and certainly nothing like full legalization. The country is not ready for it yet, as many of the industry leaders remain staunchly opposed for two reasons. First, there remains distrust and skepticism that is leftover from the reefer madness days. Many politicians still feel that marijuana is a gateway drug to other substances, and until they are convinced otherwise will stay opposed. Second, and more sinister perhaps, legalization denotes trouble for industries like alcohol, tobacco, and pharmaceuticals, all of whom stand to lose significant market shares once cannabis replaces these vices as people’s substance of choice. Lobbyists for these industries continue to work tirelessly to oppose legalization, and members of Congress are still forced to follow. Until these issues change, we must wait for full legalization.
At the state level, change will happen, and rapidly. Already several states seem poised to have recreational programs on the ballot, in states where it is almost certain to pass. These include New Jersey, New York, North Dakota, Minnesota, Vermont, and Pennsylvania, all of whom will pass legalization by years end. More states will join the medical bandwagon, leaving perhaps one or two states with absolutely no cannabis legalization framework.
Public opinion will continue to positively increase and have more of an impact on the industry. If in 2019 we finally hit 66%, I predict that Year 2020 will have us hit 75%. As the younger generation grows up, and as the older one retires and fades away, the numbers will continue to rise. At the same time, science continues to develop, as new studies are coming out nearly every week showing another beneficial use of the cannabis plant. At the same time, organizations like CED Foundation and The IJCA continue to run awareness campaigns and spread the word, adding to the number of people who are exposed to ideas and understanding of the plant’s many uses. More studies and more awareness, reaching even more people, means more backing for legalization.
Hemp is poised for a huge gain in 2020. With the federal regulations in place, the industry now has definitive guidance on the government’s position. While CBD as medicine remains a tricky subject, certainly hemp’s use as a tobacco alternative, a plastic alternative, textiles, fabric, and other industry uses will skyrocket. I also believe that 2020 will see the FDA, DEA and USDA will work out some of the kinks with using CBD as an active ingredient, providing helpful guidance to an industry running around like a headless chicken. Once that occurs, again, the industry will expand rapidly, as more certainty from the government will allow more companies to enter the market.
Lastly, I think 2019 brought some valuable lessons to the industry. The way the projections did not turn into reality, and the hits that many businesses had to take, give us some really important lessons. Caution is urged when investing in an industry plagued by burdensome regulations and strong financial incentives not to join the legal market. The “traditional” market remains the elephant in the room. The likelihood of real enforcement crackdown is low, because of limited resources, sheer numbers, and the probability that any enforcement would result in really bad press. Because investors have now been warned, the industry’s growth will slow. We will continue to see startups join the market, but perhaps on a smaller scale.
I hope that this discrepancy between projections and sales will also be a lesson for our legislatures. They need to come up with solutions that create subsidies for those coming out of the shadows so that states can see the actual revenues they hoped for. They may have to accept several billion in illegal sales as water under the bridge. They may have to lower tax rates to incentivize people to legitimize their operations. They may have to lessen the licensing requirements, making it easier and cheaper for those interested in joining to actually do so. The specific decisions are theirs to make, but they need to get creative about solving this problem.
Overall 2019 was a successful year for the industry. Even the downsizing and financial hits taken will prove to be valuable in the long run. Just like getting out of bed too fast can result in injury, an industry that expands too rapidly can result in harmful consequences.
Benjamin Caplan, MDWHAT 2019 HAS TAUGHT US ABOUT WHAT 2020 WILL LOOK LIKE: PROCEED WITH CAUTION
As with all elements of the aging process, the human endocannabinoid system loses tone over time. Whether it is a reduction in the numbers of cannabinoid receptors or a slow waning of the machinery used to create the signaling molecules that bind to the receptors or the natural senescence of the system that supports all of these normal signaling processes, the fact remains that adults over 50 are best-suited for external support for the endocannabinoid system.
Indeed, the average age at dispensaries is surprising to most who are not familiar with the modern medical cannabis arena. Baby Boomers, perhaps more than any other age group, tend to dominate the medical cannabis dispensaries. This is no new phenomenon, however. Through the ages, across cultures and around the globe, cannabis has been consumed primarily by older adults. Whether by tribe elders, wise councilmen, spiritual leaders, or the educated elite, cannabis has been an integral part of human aging for as long as we have recorded history.
Here, a review out of Israel followed at 184 patients over 65 (average age was 81.2) beginning cannabis treatment. 63.6% were female. “After six months of treatment, 58.1% were still using cannabis. Of these patients, 33.6% reported adverse events, the most common of which were dizziness (12.1%) and sleepiness and fatigue (11.2%). Of the respondents, 84.8% reported some degree of improvement in their general condition.”
Appropriately, the authors advise caution for older adults related to those adults who may be consuming multiple pharmaceuticals, for potential medication interaction effects, as well as nervous system impairment, and increased cardiovascular risk for those who may quire the concern. Wisely, they recommend that “Medical cannabis should still be considered carefully and individually for each patient after a risk-benefit analysis and followed by frequent monitoring for efficacy and adverse events.”
Dr. Caplan and the #MDTake:
At CED Clinic, we have long seen that the average age of medical patients is over 50. Whether for concerns related to sleep, pain, mental or physical health, it seems as though Baby Boomers have either weathered enough politics to have developed a healthy cynicism for the misinformation campaigns of the 1930s and 1970s, or they have direct or indirect experience with cannabis to have learned of its safety and efficacy. Either way, it is quickly reclaiming its historical place in the care of older adults, although oddly… it seems to be a demographic skipped over by the marketing systems of most establishments in the cannabis arena, at least for now.
Sudden cardiac death associated to substances of abuse and psychotropic drugs consumed by young people- A population study based on forensic autopsies
A recent study out of Spain has revealed alarming trends among cases of sudden cardiac death associated with substances of abuse consumed by young people. Half of the 15-36-year-olds who suffered sudden cardiac death were found with illicit substances in their bodies, primarily cannabis, tobacco, and cocaine. Researchers found that although cannabis was the most common substance found in the deceased systems, cocaine and tobacco are known to have a stronger impact on the cardiovascular system and lead to ischemic heart disease, which is often the more acute causes of sudden death. It was also mentioned here that the duration of cannabis is far longer in the body than that of either tobacco or cocaine, and this duration may easily confuse people to associate it as a trigger for sudden death.
However, on the other hand, there are several tragic cases of young, otherwise heart-healthy individuals who have died with cannabis as the only substance discovered. Fortunately, these cases are extraordinarily rare, but unfortunately, no reproducible association has been established, so the mysterious concerns are not easily relieved or forgotten.
Dr. Caplan and the #MDTake:
While the return of medical cannabis to modern medical care seems to bring with it a return of appreciation for more naturalistic care, it is critical for us all to recognize that we still have much to learn. The tools and high standards of scientific evaluation have only recently been applied to cannabis, and there are reasonable arguments that the usual tools may not actually apply (for example, some are suggesting that the placebo effect, a cornerstone of randomized control trials may be a facet of effects related to the endocannabinoid system.)
For these, and a great many other unknowns, it is important for the discerning consumer to consult with trusted resources, including friends, family, scientists, and where possible, doctors, to ensure the appropriateness of use on an individual basis.
“Short- and Long-Term Effects of Cannabis on Headache and Migraine “
There are many headache and migraine medications on the market that advertise how they can make you feel better. But what happens when they make you feel worse? Medication overuse headaches occur in 15% of patients taking conventional migraine medication, so it’s no surprise that people are looking for alternatives that bring them relief without reduced risk.
A team of physicians from Washington University wanted to see if cannabis could be a contender. By reviewing data from about 2,000 patients who logged the details of their smoking sessions with the app StrainPrint, researchers were able to see if inhaling cannabis Flower or concentrate could be a solution for headache and migraine relief. They learned that there was, in fact, good reason to be hopeful for the herb.
While concentrates did have a larger reduction in severity rating, there haven’t been enough studies to say it is certainly better than Flower. Overall, inhaled cannabis reduced the severity of migraines and headaches by 50%. Some patients did report needing to use a larger dose for future sessions, indicating the development of tolerance, but the severity of the headaches or migraines wasn’t getting worse or more frequent like what can happen with conventional medications.
In a time when plant-based and all-natural medicines are becoming more sought out, it’s exciting to see medical cannabis is being considered more seriously as a contender. With the positive results from this study, and similar related work will hopefully encourage more physicians (and patients) to explore this centuries-old option.
What: Laws and regulations about growing cannabis in MA
Cannabis has earned the name “weed” for good reason. While careful allotments of light, humidity, soil, and nutrients affect its health and potency, cannabis is a resilient plant, built to thrive even in the harshest conditions. With its natural flexibility, cannabis growth can be an enjoyable hobby for people who are interested in growing their own medicine, either for the pleasure of attending to a growing plant or the joy of saving from the costs of dispensary products.
There are regulations and firm restrictions in place for how many plants can be grown in a home and any potential impact on visibility to neighbors. In Massachusetts, each adult may grow up to six plants, themselves, and no more than 12 plants per household with more than two adults. The plants must be grown in a secure, preferably lockable location, and they may not be visible from a public place.
It’s also important to know that just because it is legal for adults to grow cannabis, landlords and private living facility operators like nursing home or assisted living facilities often have the final say on the cultivation of cannabis on their property.
In general, gardening has been associated with reducing stress, depression, and anger. Considering these benefits, and the positive effects that cannabis medicine offers, once the crop is ready to be cured, cultivating one’s own cannabis is quite an attractive option.
Of note: Cannabis consumed from a home grow should still be lab-tested. Cannabis is a plant especially skilled at absorbing micronutrients (and micro-toxins) from its environment. Even when grown in “organic” soils, undesired contaminants can seep into the plants. Lab testing facilities exist and are easily accessible in all states with legal medical cannabis, and typically cost anywhere from $0 to $100 dollars for basic testing of final plant products.
The security camera footage has been watched thousands of
times. Breaking in through a skylight in the ceiling, dropping a ladder down,
and methodologically getting away with dozens of bags of finished product. The
video clearly shows that this was a professional job carried out by serious
criminals. The estimated value stolen was over $1M, meaning an estimated tax
revenue loss for Oregon of about $230,000. The culprits remain at large, and they
may never be found.
This isn’t the only incident either. A quick internet search
highlights several other high-profile incidents, with varying degrees of
professionalism, danger, and dollars lost. While each of these incidents have
differences, they all share something in common. The legal industry is known
for having large amounts of cash on hand, surplus product lying around, with
varying amounts of security in place. The industry is susceptible to these kind
of targeted robberies, a fact which is unlikely to change in the near future.
Why is this the case? The answer starts with the fact that
cannabis remains illegal at the federal level. The government classifies
cannabis as a Schedule 1 drug, meaning it is considered to have no medical
benefit and a high potential for abuse. Because that is the case, financial
institutions have been hesitant to open accounts and do business with MRBs
(Marijuana Related Businesses), because they fear financial penalties, asset
forfeiture, as well as civil and criminal repercussions.
Beyond the fact that the government considers MRBs to be
illegal drug trafficking operations, several related details make banks
hesitant. Bankruptcy courts are (almost) completely closed to MRBs. That means
that if a company goes under, the bank has no recourse to get its money back.
Section 280E of the tax code means that MRBs pay exorbitantly high taxes,
making them significantly less profitable, solvent, and viable as account
holders. The industry also still carries a stigma that makes some banks
concerned about their other clients, who may close accounts upon learning that
the banks have been doing business with MRBs.
It’s not all bad news, however. This issue has been talked about for years, and as the number of states with legal cannabis industries grows, banks have become more willing to get involved. The federal government hasn’t been silent either. The well-known Cole Memo, put out by the Obama administration, essentially stated that as long as businesses were operating legally under state law, they were a low priority for enforcement, as federal resources were better spent elsewhere. Subsequently, the FinCEN (Financial Crimes Enforcement Network, a bureau of the Treasury) announced that banks doing business with MRBs should follow the Cole memo’s guidelines to determine whether their customers were operating legally under state law.
When the Trump administration took over, AG Jeff Sessions
rescinded the Cole memo, stating that prosecutors already have discretion as to
how to use their limited resources, and there was no need to single out MRBs
for special treatment. This suggested to some that the DOJ was going to start
going after MRBs even if they were operating legally under state law.
Thankfully, this didn’t happen, at least not on the large scale that some
feared might happen. However, doubt and uncertainly remained for financial
institutions, most of whom refused to bank the money from MRBs. Earlier this
year, FinCEN announced that they still expected banks doing business with MRBs
to be reporting suspicious activity using the Cole memo guidelines. In a
backhanded way, this was an announcement that it was ok for financial
institutions to do business with MRBs, and many have begun or continued to do so.
As long as cannabis remains illegal at the federal level, there will be fear and risk that comes along with doing business with MRBs. This means that many companies choose to keep large amounts of cash on hand, created the obvious incentives that thieves look for when picking a target. If we don’t want these incidents to continue, we need to redouble our efforts to push legalization so that the financial, security, and investment opportunities catch up to the rate of business growth. Two helpful and relevant bills are currently making their way through Congress, though neither seems likely to become enacted. The MORE Act, a comprehensive overhaul of the cannabis laws recently passed the House Judiciary Committee. However, the bill is yet to be brought to a full House vote, and the Senate is even less likely to bring the bill to the floor. Then there is the SAFE Banking Act, which passed the House 321-109 earlier this year, in a landmark bipartisan victory. But that bill seems to be dead in the House, as Mitch McConnell positions himself as opposed to any movement in the field. As such, the immediate future for the industry does not seem to hold significant change, and these problems will persist. While I certainly do not want to see more of these incidents, we likely have not seen the last one.
Benjamin Caplan, MDTHE $1M HEIST OF CANNABIS PRODUCT IN PORTLAND HIGHLIGHTS SECURITY PROBLEMS IN THE INDUSTRY
Recommendations for the medical management of chronic venous disease- The role of Micronized Purified Flavonoid Fraction (MPFF)
A recent review has affirmed that treating chronic venous disease with Micronized Purified Flavonoid Fraction (MPFF) therapy is safe and effective. After reviewing 250 papers, the authors have found a large body of supportive evidence that the MPFF treatment, known as Diosmiplex, is effective for healing venous ulcers on its own or in combination with compression therapy. Diosmiplex, the only MPFF prescribed in the United States, as of 2017, is derived from orange rinds and favorable among patients due to its high safety rating.
Dr. Caplan and the #MDTake:
Flavonoids are one of the categories of natural compounds produced in nature, including within the innate production system of the cannabis plant. Several patients have reported using strong cannabis topical agents to help venous insufficiency and disease, including conditions such as varicose veins, phlebitis, and post-surgical venous incompetence.
Oncologists Should Recommend Cannabis-Based Medicine for Palliative Care
Earlier this June, a review was published that encourages oncologists to recommend cannabis products to their patients as a safe and effective method of palliative care. The opinion piece highlights how cannabis is a useful treatment for a variety of illnesses (nausea, vomiting, sleep, mood, anxiety), and encourages practitioners to prescribe cannabis for their patients so that they can appreciate the safety and effectiveness of the product.
Regulators and mechanisms of anoikis in triple-negative breast cancer (TNBC)- a review
Researchers are always exploring new methods to treat highly aggressive forms of breast cancer. As the scientific culture opens up to cannabis as a natural pharmaceutical factory, eyes have been drawn to the individual chemical components born inside cannabis, namely cannabinoids, terpenoids, and flavonoid compounds. Recently, a group stumbled upon a promising synthetic flavonoid derivative. This derivative, named GL-V9, has been found to have an inhibitory effect on the growth of triple-negative breast cancer (TNBC) tumors and has shown other anti-metastatic properties. The growth-stopping and anti-spreading effects would address two of the central aspects of TNBC that have thus far made it difficult to treat. The growing understanding of flavonoids and their potential therapeutic benefits seem all but sure to enshrine its place among future research regarding cancer treatments.
Dr. Caplan and the #MDTake:
In scientific and medical circles, it’s not uncommon to hear the phrase, “everything causes cancer.” It’s often repeated contemptuously, a tongue-in-cheek expression that calls attention to unknowns associated with the spawning and growth of cancers but also bends to the hurricane force of nature’s impact on living organisms. As living biology, cancers are born and thrive while provided sustenance by particular inputs and supports. Because of this fact, there are also innumerable opportunities to stifle or prevent the birth of tumors and many avenues to interrupt its growth or end the life of cancer cells.
The human cultural history has taught all cultures that sleep, exercise, fruits, vegetables, fiber, and water are all required ingredients for sustained, healthy growth. What is it about fruits and veggies that is healthy? They have fiber that is healthy for the human digestive tract, but they also have natural components, terpenes and flavonoids, which support wellness, healing, and the normal cycling (features of both living and dying) of our cells. Cancer represents the inappropriate over-replication of cells. In a sense, the body’s natural ability to end the cells which are not responding to normal signals is lost. If we know that the cannabis factory happens to produce many of the same compounds that are found elsewhere in vegetation and fruits, is it so surprising that we would see cancer-fighting effects?