The Medical Marijuana Guide Cannabis and Your Health

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Published by Rowman & Littlefield
An imprint of The Rowman & Littlefield Publishing Group, Inc.
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Distributed by NATIONAL BOOK NETWORK
Copyright © 2018 by Patricia C. Frye, MD
All rights reserved. No part of this book may be reproduced in any form or by any electronic or
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from the publisher, except by a reviewer who may quote passages in a review.
British Library Cataloguing in Publication Information Available
Library of Congress Cataloging-in-Publication Data
Names: Frye, Patricia C., author. | Smitherman, Dave, author.
Title: The medical marijuana guide : cannabis and your health / by Patricia C. Frye with Dave
Smitherman.
Description: Lanham : Rowman & Littlefield, [2018] | Includes bibliographical references.
Identifiers: LCCN 2018027684 (print) | LCCN 2018028117 (ebook) | ISBN 9781538110843
(electronic) | ISBN 9781538110836 (pbk. : alk. paper)
Subjects: | MESH: Medical Marijuana—therapeutic use | Cannabinoids—pharmacology
Classification: LCC RM666.C266 (ebook) | LCC RM666.C266 (print) | NLM WB 925 | DDC
615.7/827—dc23
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 Contents

Acknowledgments
Introduction
1 History of Cannabis: The Journey from Medicine to Intoxicant and
Back Again
2 Legalization
3 Cannabinoids, Terpenes, and Flavonoids
4 Laboratory Testing
5 Clinical Conditions
6 Adverse Effects Associated with Cannabis Use for Medical Problems
7 First Doctor’s Visit: Start with Your Provider
8 Ways to Medicate
9 Making Your Own Medicine
10 Hemp-Derived Cannabidiol (CBD)
11 Self-Care: Toning Your Endocannabinoid System

Appendix: Lists of Drugs by Metabolism

Notes
Works Cited
Index
About the Author
 Acknowledgments

I would like to say thank you to:

Mark, Ashleigh, and Chris, for introducing me to the world of medical

cannabis;
My agent, Diane, for bringing me this remarkable opportunity;
My husband, Rodney, who has given me the encouragement to stay on the
path, the time and space to get it done, and the meals to keep me going;
My son, Andrew, just because you are my shining star;
Tamika and Anne Marie, for everything you do to keep our office running
and making our patients feel as important as they are;
Lisa, Taryn, and Heidi, for your help with research, edits, and citations;
Dave, for your guidance and everything you have done to make this work;
Suzanne, my editor, for her constructive criticism and commitment to the
subject of medical cannabis;
Adam, Eric, and Franco, for sharing your knowledge and expertise;
Doctors Dustin Sulak, Bonnie Goldstein, Deborah Malka, John
McPartland, David Bearman, Jeff Hergenrather, Debra Kimless, and all
the cannabis clinicians who have inspired me and define what excellent
patient care is all about;
And all of my amazing patients, from whom I have learned so very much
about true art of healing.
 Introduction

In 1996, California became the first state in the United States to legalize
cannabis for medical use. I was practicing pediatrics at a large health
maintenance organization in the southern part of the state. There was
probably something about it in the news. I think that was the extent of my
awareness. I never gave it another thought—until 2015.
Now back on the East Coast and still holding onto my coveted California
medical license, I decided to look for some light, part-time telemedicine
work. I took my license out of retirement mode and farmed out my
curriculum vitae. The first solicitation I received was regarding a pediatric
job in San Diego. I explained to the headhunter that I was licensed in
California but physically in the Washington, DC, metropolitan area and was
not interested in relocating. I would only consider a telemedicine job,
perhaps an urgent-care or after-care position.
A few days later, I received another e-mail. It emphatically reassured me
that this was a telemedicine job with a new company based in San
Francisco. Great, I am interested and excited! As I am reading, looking for
the particulars, it goes on to state that the job is to evaluate patients via
telemedicine for medical marijuana evaluations. Skreech! What?
Marijuana? I don’t know anything about marijuana. I tried it a few times in
high school and twice as a freshman in college. It made me either goofy,
sleepy, or paranoid, so I never thought much of it. I certainly never
understood why my peers liked it so much.
So here I am faced with an opportunity to work a few hours a week from
my home office with patients in California, and I knew nothing about the
plant, how it worked, what it was good for, the possible side effects, or how
it was dosed; I knew nothing.
Not being one to run from a challenge, I decided to investigate. I
interviewed with the president and director of operations. They were clean
cut, well spoken, friendly, organized, and professional—not the sleepy-
eyed, counterculture stereotypes one might imagine. It was a brand-new
company, and except for their chief medical officer, I was their first medical
hire.
I spent the next few days reading the California Board of Medicine’s
guidelines on what conditions qualified and their assurances that I would
not get into trouble making these recommendations—via telemedicine, no
less. I started to review the illnesses and conditions that were on their list
and began a Pubmed search on cannabis and its role in alleviating the
symptoms associated with these conditions. (Pubmed is an online database
of journal articles from the National Institute of Health Library.) I searched
for marijuana, and lo and behold, there were more than 34,000 articles on
the subject; cannabinoids yielded more than 10,000; and endocannabinoid
turned up more than 11,000!
I started reading and eventually enrolled in an online course on medical
cannabis. I attended whatever conferences I could. Armed with a cheat
sheet and a strong internet connection, I began my journey into the field of
cannabis medicine. Over the course of the year, I evaluated approximately
3,000 patients. My California patients came from all walks of life and all
ages. There were college professors, truck drivers, professional chefs,
software developers, doctors, computer programmers, housewives, actors,
small business owners, attorneys, students, and retired grandparents. They
shared with me the reasons they used cannabis, how they used it, when they
used it, and how much.
I learned about applying salves topically to ease migraine or arthritis pain
and how to steep cannabis tea or milk to sip through the day to improve its
pain-relieving effects. Cancer patients with inoperable tumors that had
resolved with cannabis use shared their stories. Anxiety patients would
carry a vape pen that they could use in case of a panic attack. Patients with
sleep problems were getting the best sleep ever by taking a few drops of
cannabis oil at bedtime. And one of the most important things I learned
from my patients was how they used cannabis without getting stoned. They
could treat their symptoms with no mental impairment. I didn’t know that
was possible. It was an invaluable education.
We know that there may be long-term consequences for recreational users
or patients who self-medicate or who use high doses of cannabis over an
extended period of time. But these were patients who were using low to
moderate doses of cannabis over many years and who were motivated,
functioning successfully, and benefiting from its pain-relieving, muscle-
relaxing, antianxiety, and mood-stabilizing benefits. There were patients
who, much to many people’s surprise, had cancers that were no longer
detectable and pain patients who were no longer on opiate medication and
were managing their pain with just medical cannabis. At the end of that
year, I thought to myself, “This plant is pretty amazing. And more people,
patients, and health-care providers should know about it.” It was then that I
decided to call the plant by its scientific name and to drop the term
marijuana, which had been used to stimulate fear and racial bigotry in an
effort to make it illegal for financial and political reasons.
There are a lot of books on the market about cannabis—the science and
the medicine. Some are geared more for the doctors and scientists, some for
patients or consumers, and some for the horticulturalists and processors.
There is even more on the internet, much of it geared toward people who
use it for THC’s intoxicating effects, but some sites with a more medical
focus. There is some very sound information—and other information, not so
much. When researching cannabis, it is important to remember that most
people who blog or comment about cannabis can only speak for how it
affects them. They don’t have the experience of evaluating thousands of
people, so their perspective is limited and may not pertain to you and how
your body may respond.
Around the world, there has been a resurgence in the use of traditional
herbal medicines. In Japan and Taiwan, Kampo, a Japanese variation of
traditional Chinese medicine, is fully integrated into the health-care system.
By 2010, approximately half of the medical doctors in Japan were
incorporating herbal medicine into their practice. More than 70 percent of
German physicians prescribe herbs. People are looking for safer and more
natural approaches to health and well-being, and cannabis is at the forefront
of that movement.
Cannabis has been used medicinally for 5,000 years. It has been an illegal
substance for only 75 years. Are there risks to using cannabis? A few, but
none that are life threatening. The reasons to make it and keep it illegal at
the federal level are not based on science or medicine. There are
sociopolitical factors that have kept this very complicated and mostly
beneficial plant in the juke joints, back alleys, rock concerts, and college
dorms.
This book is written for the patient who has never considered using
medical cannabis as a treatment alternative and for the health-care provider
who has never considered discussing medical cannabis with their patients. It
is my hope that, after reading this book, providers (even those who are not
able to make official recommendations for their patients) and patients who
would otherwise not even think about the use of medical cannabis will be
more comfortable having the discussion and making an informed decision
on whether cannabis might help them. If you decide that cannabis might be
worth a try, read, ask questions, start low, and go slow, as you explore the
healing properties of this ancient, medicinal plant.
 Chapter 1

History of Cannabis
The Journey from Medicine to Intoxicant and Back
Again

There was a time when American doctors were able to write prescriptions
for cannabis extracts, called tinctures, and salves to treat ailments like
migraines, parasites, seizures, pain, and melancholy. It was not a perfect
medicine. Dosing could be challenging because no one knew exactly why
or how it worked, but most of the time it did work. Except for occasions
when a patient was given a vial of cannabis tincture that was stronger than
expected and experienced the effects of too much Δ-9-tetrahydrocannabinol
(THC), it was safe—so safe, in fact, that no one died.
It is important for both patients and health-care providers to have an
understanding of the history of cannabis as a medicine and intoxicant and
the series of events that led to every type of the cannabis plant, both fibrous
and drug type, to be declared an international public menace and relegated
to an illegal, black-market, recreational street drug. With some awareness of
the politically and financially motivated efforts to remove cannabis from the
physician’s toolbox, I think you just might have a better appreciation for
this effective and remarkably safe medicinal.

AGRICULTURAL BEGINNINGS
Although human beings emerged about 250,000 years ago, according to
archeological evidence, agriculture is a relatively modern invention, at only
about 12,000 years old, with some tantalizing evidence of plant cultivation
as early as 23,000 years ago.1 Prior to cultivation, humans were hunters and
gatherers, foraging wild berries and plants and following the migratory
paths of wild animals. Cultivation was one of the first things that set man
apart from other creatures inhabiting the earth. It was man’s first attempt at
manipulating the environment to suit his needs, and it was the necessary
first step toward many technological advances.
Cannabis is certainly one of the first, and perhaps the oldest, cultivated
plant, and it played an important role in mankind’s beginnings. Cannabis
hemp cord was identified in pottery in a Taiwanese village site dating back
at least 10,000 years. Cannabis seeds and oil were used for food in China as
early as 6,000 BC, and 4,000 years before the birth of Christ, hemp fibers
were used for textiles in China and Turkestan.2

ANCIENT MEDICINE
Cannabis, called má, is one of the 50 fundamental herbs of Chinese
medicine. Pharmacologist Emperor Shen Nung wrote a book on treatment
methods in 2737 BC, which included the medical benefits of má. The Pen
Ts’ao Ching, written in 1 AD, is based on traditions from the time of Shen
Nung and is the oldest known pharmacopoeia. Cannabis was recommended
for more than 100 conditions, including gout, malaria, poor memory, and
rheumatism.
Hua Tuo (140–208 AD) is credited with being the first healer to use
cannabis as an anesthetic. He mixed pulverized cannabis plants with wine
and acupuncture to locally and systemically anesthetize patients for wound
cleaning and pain control.3
In 1993, a 2,500-year-old mummy was discovered in the permafrost of
Ukok Plateau in the Altai Mountains of eastern Russia near the Chinese
border, an especially cold and dry region. With the inadvertent help of grave
robbers, whose disturbance of her tomb allowed water to enter and freeze,
the Siberian Ice Maiden (also known as the Princess of Ukok) was so well
preserved that even her elaborate tattoos were intact. Anthropologists were
able to ascertain what medical conditions she suffered from. MRI scans
revealed that the young woman had a malignant tumor in the right breast,
with metastasis to the right axillary lymph nodes and spine. The scans also
showed that she suffered from osteomyelitis, an infection in the bone, and a
skull fracture and other injuries, including a dislocated right hip, consistent
with possibly falling off a horse.
This 20-something-year-old was obviously a person of significant stature
and prestige. Her coffin was elongated to accommodate a three-foot
headdress. Also in the burial chamber (or kurgan, of the Pazyryk culture)
were two small tables with serving trays holding horsemeat, mutton, yogurt,
coriander seeds, a beverage—and a pouch containing cannabis.4 While we
don’t know for sure that she used cannabis to control the excruciating pain
she must have experienced, it’s highly likely that she did.
There has been much debate over a passage in the Old Testament in which
God gives Moses the recipe for holy anointing oil, often translated as
“sweet calamus.” Exodus 30:23–25 reads,
Take thou also unto thee principal spices, of pure myrrh five hundred
shekels, and of sweet cinnamon half so much, even two hundred and
fifty shekels, and of kaneh bosem two hundred and fifty shekels. And of
cassia five hundred shekels, after the shekel of the sanctuary, and of oil
olive an hin. And thou shalt make it an oil of holy ointment, an ointment
compound after the art of the apothecary: it shall be a holy anointing oil.
In 1937, Sula Benet, a Polish anthropologist and professor at Hunter
College who specialized in longevity and Eastern European culture, wrote
that the Hebrew word kaneh means both “hemp” and “reed.” I also spoke
with a physician from the Israeli Ministry of Health, who asserted that
Kaneh-bos (singular) translates to “aromatic cane” and that, indeed, the
Hebrew term kaneh bosem found here means “cannabis” and was an
ingredient in holy anointing oil.
Ibn Sina (b. 980), the Persian philosopher and scientist, is best known as
the physician who wrote The Canon of Medicine, probably the most
advanced scientific medical textbook available in its day. Written in Arabic,
the Canon was translated into European languages and was widely used as
a reference in Western universities until well into the seventeenth century.
The Canon of Medicine makes various references to “Kunnabis” in the
treatment of ear infections, skin rashes, and inflammation. In addition, it
warns of the problem of using too many leaves.5
Cannabis (vijaya in Sanskrit) is indigenous to India and is found in more
than 80 traditional Ayurvedic formulas. It is recognized as a powerful herb
with the ability to both heal and poison and is recommended in only very
small doses and always in combination with herbs that balance its effects. It
is used to treat pain, digestive disorders, and dysentery and to enhance
sexuality. It is known to improve digestion; relieve anxiety; and treat
glaucoma, swelling, and diabetes. Its dry, hot, and penetrating qualities are
said to have a long-term negative impact on reproductive tissue, and
“overuse can lead to dry, weak, brittle tissues.”6 In fact, excessive cannabis
use can affect sexual hormone production in both men and women and can
negatively affect fertility.
The Materia Medica of Indian Herbalism, published in 1841, notes that
long-term consequences of cannabis use can include indigestion, tissue
depletion, melancholia, and impotence. Excessive doses can cause “mental
exaltation, intoxication, a sense of double consciousness, memory loss and
gloominess.”7 It is known as a tamasic drug, which means that, if used in
excess, it could dull the mind, affect memory, and cause spiritual confusion.
In Ayurveda, the patient is discouraged from smoking because the qualities
of smoke are heating, penetrating, and drying. They are encouraged to use
cannabis as an edible and along with other herbs or foods to make it less
damaging. It is thought that milk balances the negative qualities of
cannabis. Traditionally bhang, a cannabis milkshake consumed during
certain Hindu festivals, is made by boiling leaves in milk with dates, sugar,
saffron, cardamom, rose petals, and almond meal.

WESTERN MEDICINE
Dr. William Brooke O’Shaughnessy (b. 1809) was an Irish physician,
surgeon, and chemist who, in addition to his work with cannabis, would
later lay the groundwork for intravenous fluid and electrolyte replacement
in the treatment of cholera. After graduating from the University of
Edinburgh in 1829, he joined the British East India Company in 1833 and
moved to Calcutta. There, he served on the committee of the Materia
Medica and later as chemical examiner, developing methods for forensic
studies to detect arsenic poisoning and other botanical poisons. He was a
member of the Medical and Physical Society of Calcutta, where he
published one of his first papers on the medical application of cannabis,
“Case of Tetanus, Cured by a Preparation of Hemp (the Cannabis Indica),”
in 1839. In 1841, O’Shaughnessy returned to England, where he introduced
the use of cannabis to Western (European) medicine.
 Dr. O’Shaughnessy wrote of his successful treatment with cannabis in
“On the Preparations of the Indian Hemp, or Gunjah,” published in the
Provincial Medical Journal, which included “Their Effects on the Animal
System in Health, and Their Utility in the Treatment of Tetanus and Other
Convulsive Diseases,” “Cases of Rheumatism Treated by Hemp,” “Case of
Hydrophobia [Rabies],” “Use in Cholera,” “Use in Tetanus,” and “Case of
Infantile Convulsions.”8 I have been particularly taken with Dr.
O’Shaughnessy’s account of the baby girl with infantile spasms. He
meticulously chronicled the condition of the baby and the devastating
effects of the constant seizing. His description of how he gradually
increased, or titrated, the dose until her body responded to the medicine
parallels much of what parents and cannabis clinicians of today have found.
In his article, the infant responds at first, but at a later date, the spasms start
again. Again, he administered the cannabis tincture, slowly increasing the
dose, but he had to give a lot more than the first time. He marveled that the
amount needed by the baby was on par with the dose a much older person
had taken during an experiment and that, while that amount was
intoxicating to the young adult, it did not appear to have any deleterious
effects on the baby. It so beautifully illustrates how each batch of medicine
may be slightly different, how younger people appear to tolerate much
higher doses than do older people, and how every person responds to
cannabis differently—all important things to consider when recommending
dosing.

THE NEW WORLD

Hemp was such a valued commodity and had so many uses that it was a
required crop in the 13 original colonies. It was used as food and to make
cloth and rope. In times of shortage, one could be jailed for failing to grow
Cannabis sativa.
It was also recognized for its medical benefits and was added to the list of
approved drugs and treatments, the US Pharmacopoeia, in 1850. Companies
like Eli Lilly, Park Davis, and E. and Wm. S. Merrell produced cannabis
tinctures that were commonly prescribed for migraines, melancholia, pain,
muscle spasms, and seizures. While it was widely used during the second
half of the nineteenth century, it began to fall out of favor with the advent of
pharmaceutical tablets like aspirin and morphine, which were much easier
to dose. Produced as a tincture (a plant extract in alcohol or oil), it was
impossible to know the concentration of the psychoactive component, THC,
so it was not uncommon for patients to take too high a dose and suffer the
adverse effects—dizziness, mental confusion, anxiety, and paranoia.

TWENTIETH- AND TWENTY-FIRST-CENTURY

MEDICINE, REGULATIONS, AND POLITICS

Pure Food and Drugs Act of 1906

During this period, excessive opium and cocaine use was creating problems
with addiction. These substances were used in products from Coca-Cola to
bogus patent medicines for coughs, pain, and discomfort associated with
tuberculosis to even teething medicine for babies. As the addiction problem
grew, medicines thought to be less addicting than morphine, like heroin
(later found to be more addicting), were developed and prescribed.9
As a result, there was an increased social concern that the public was
unknowingly using addictive substances. In 1906, the federal Pure Food
and Drugs Act was passed for the purpose of “preventing the manufacture,
sale, or transportation of adulterated or misbranded or poisonous or
deleterious foods, drugs, medicines, and liquors” and required that the
“quantity of any alcohol, morphine, opium, cocaine, heroin, alpha or beta
cocaine, chloroform, cannabis indica, chloral hydrate, or acetanilide, or any
derivative or preparation of any such substances contained therein” be
present on the label.10 With that, the bottles of cannabis tinctures identified
the variety of cannabis, the suggested dose, warnings, and sometimes a
skull and crossbones symbol, with instructions on what to do for accidental
poisonings. Quite naturally, this was cause for concern for some patients.
Around this time, there was also a growing sentiment against any type of
intoxicant, including alcohol, and the temperance movement was in full
swing. The Eighteenth Amendment was ratified in 1919 and remained in
effect for 14 years, until it was repealed in 1933.11

William Randolph Hearst and the “Mexican Problem”