How to Treat Pain in Seniors With Suraj Tandon, MD

For more information about Dr. Suraj Tandon please visit:
https://www.medexconsult.com/

Join John Malanca and Suraj Tandon, MD for a deep dive into pain management and senior care in this enlightening interview.

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Transcript

John Malanca  0:00 
Hey everybody, John Malanca United Patients Group Be Informed Be Well, and I have a special guest, not only as the colleague but a friend, Dr. Suraj. Tandon. How are you doing?

Unknown Speaker  0:12  
I'm doing great, John. Thanks for having me today. I'm very lucky and happy to be here.

John Malanca  0:16  
Oh, always, always good. We're I mean, we do we do quite a bit together. So I was I was excited to have you on here. So turret Suraj is north of the border, Canadians friends. So what's the cannabis laws up there? I know, they change they've been ahead of us behind us, you know? And so, you know, it's, I get a lot of calls from from your fellow Canadians. How would I go. And I know, you shared a list of locations as centuries that about a year ago. And so I share that with with my Canadian followers quite a bit. So thanks for that, too. So you're well rounded in the cannabis industry. And not only you're young, but you're you're very knowledgeable. And you had a lot of topics that you could that you speak on on a regular basis. And I wanted you to come on to there. We have a demographic that's, as I've shared before, 40 to 140. And, you know, and so a lot of the followers that we have are, again, you know, 40 5060s, but we do have a lot of elderly and they come to us and say John help. One How do I talk to my doctor? How do I find a doctor? Does it work for this does it work for that are the drug to drug interactions? And so I'm hitting different topics here we've had a colleague, one of our colleagues, Dr. Jordan Tischler, on we spoke about things elderly and anxiety, which I'm seeing in my my mom and some of her friends, and but with you, I wanted to talk about pain in the elderly, and most commonly, you know, associated with aging. So can you talk about the types of pain that are most commonly associated with aging for for all ages as we age, but, but with but with, with seniors and

Unknown Speaker  2:04  
elderly? Yeah, absolutely. So, you know, pain are the complaints of chronic pain are probably the most common complaint that I receive from patients of, you know, all age groups, but certainly within the elderly age group, I'm sure we've all experienced it yourself, myself, I don't think there's anyone that I've come across who's never experienced pain. And so really, it as we age, you know, it's sort of like there's a lot of wear and tear on the body. And so just like a car, you know, and unfortunately, as we age, things seized up a bit, we're more prone to various types of perceptions of pain. And that can often be musculoskeletal. So issues with either the muscle tissue itself, either from a sprain or just, you know, pulling a muscle strain. Others include, you know, down to the bone itself, and that can often be described as arthritis. So there's two types, there's, there's rheumatoid arthritis, which often is sort of an autoimmune condition, attacking the joint space. And then there are what we consider the the wear and tear of the joint spaces itself. You know, we're typically in the large bearing joints, such as the hips and pelvis, and that's what we call osteoarthritis. So naturally, I think the most common complaint of people in experience is usually low back pain. And that's what we see, in America. 50 million Americans actually suffer from chronic pain. So that's a large percentage of Americans. So it's very common. The other types of pain that we see, often are gouty arthritis, so you could have people suffer from gout itself. And then there's, you know, you know, the other types are diabetic neuropathy. So, neuropathic pains, which can be associated with other types of disease, such as, you know, diabetes, and there's a whole, you know, a variety of different types of pain. So, you know, those are probably the most common but typically low back pain, and then you can have joint pain, particularly within the hands, wrists, elbows and knees.

John Malanca  3:54  
You know, with cannabis, I'm the first to say it's not the Golden Pill, the golden ticket. And so take this in, you're healed or you're super Superman or woman. What, what are some common treatments for age related pain in non cannabis world, but also age related pain when incorporating cannabis that you're seeing with your patients?

Unknown Speaker  4:16  
Yeah, so typically, obviously, we're very excited about cannabis having a potential benefit in you know, you know, as an adjunct or an alternative therapy to treating pain and other types of diseases. Now, we still obviously have to look at where the strongest evidence is where we have the strongest studies to support any type of pharmacological intervention. So, you know, as a as a clinician, we look at evidence and we look at the standard of care and what's out there and you know, the what we sort of look at not see the Bible, but the who the World Health Organization does have sort of a protocol on how to address complaints of acute and or chronic pain. And typically what we're supposed to Do follow is using, you know two different types of modalities. One is non pharmacological therapies which can include CBT, or cognitive behavioral therapy, mindfulness, massage therapy, physical therapy, and also injections, which can be spinal injections or various injections to the joints itself using different types of medication, spinal cord stimulators, and then also what there's been a lot of validated evidence for is acupuncture. And acupuncture is really considered one of the first line treatments for pain itself. In addition to pharmacological therapies. So, it's always good to start off by thinking about non pharmacological therapies such as those, as I mentioned. And then, and again, the benefit is that there are no side effects really, from typically from those types of interventions, or if any, very, very minimal. The second then would be used to think of pharmacological interventions. And as I mentioned, the who has sort of, you know, algorithm that we're supposed to follow, which typically recommends non opioid medications first, as a first line treatment, and those typically include our cinnamon, offene, or Tylenol are NSAIDs so non steroidal anti inflammatory drugs, such as ibuprofen, and then considering other medications such as antidepressants, which can be used for off label use to treat chronic pain. And that can be some types of medications such as duloxetine, which isn't a very effective pain medication, aside from elevating and improving the mood. And then others include anticonvulsant, such as pregabalin, or gabapentin, and those medications target pain that is caused by a neuropathic mechanism. And I'll get to, when we talk about I'll get to a point as to how, and why it's important to differentiate the pain when someone experiences whether it's neuropathic versus nociceptive. And we'll get to that definition. And then other sort of what we consider you know, non opioid medications would be you know, now medicinal cannabis. And that can be in either taking it as an ingestible in a capsule formulation via a dropper tinctures, inhaling it through a vaporizing device. So using the flower itself, and harnessing its immediate effect by vaporization, which goes through the bloodstream quicker. And then the other which is sort of certainly growing. But we need further evidence is its topical use and applying it directly to the affected joint, which we typically see in patients with either low back pain, knee pain, or pain within their within their fingers. The next step after non opioid pharmacological interventions would then be to consider opioids, which again, as we see in the US and worldwide, there's a shift from using less of opioids because of its relative addictiveness potential for lethal overdose and so forth. But there are classifications of using either a strong or sorry, a weak opioid, and then followed by a strong opioid depending on the severity of the pain. So we always need to classify and determine how severe the pain is, once we've determined its etiology is to then consider first line treatments with non pharmacological therapies such as what we talked about, then considering non opioid medications like the Tylenol, aspirin, etc, combining both of those together is really the next step. And then if all else fails, and the pain is still bound to be quite significant, then adding an adjunct such as a weak opioid, or than a strong opioid for a finite duration of time.

John Malanca  8:40  
With with that, a lot it you know, we're 2022 now and a lot of people at all ages are saying, you know, I want to go to more of a healthier protocol, organic, natural protocol, and they're turning to and I'm a big fan of acupuncture, massage, chiropractic stretching, just moving and that's it helps me get through the day. I am a fan of cannabinoids on the outer part of my body as well as inside of my body working together. And so are you seeing more patients are your patients coming in, say, you know, Doc, I prefer not to go with an opioid I know. Pain is a big thing. And I'm very fortunate that I don't have pain. You know, one of our nurses who you know, she you know, she suffers from fibromyalgia. On the outside. She looks fantastic. So her family's like, Come on, hurry up. But she said John, I wake up every morning at four in the morning to get out of bed by six because my body is excruciating. And she she learned about cannabis probably about 10 years ago and I remember she said, My jaw dropped like what the world I've been how come I never knew about this in nursing school. So you're talking about a lighter opioid or weaker opioid is what you said, what she's able to do is mix and match, you know, she can take this opioid we grew up with add five milligrams of cannabis. And this opioid, you know, now feels like instead of five milligrams is a 10 milligram, so she's able to find that sweet spot. And so she does a lot with her, her patients, she works for a lot of pain pain patients, and she's a maid. She's a pain advocate for patients to get not only cannabis, but also opioids for the doctor, because I know a lot of the pain patients we work with on a regular basis. They're handcuffed. Yeah, even even she's handcuffed, you know, because they'll give her 30 pills for fibromyalgia. God forbid, she has an awful day, you know, day 26. And she has to take two. So she runs out now on day 29. She goes in there says, Hi, Doc, you know, can I get another prescription or pharmacist kind of prescription? Oops, sorry, you're one day early, your red flag. And so it's it's awful what pain patients have to go through on a daily basis. And so if opioids is their answer, then give them the opioids. I mean, Nothing's worse than beat. Right. And as you mentioned, you know, we've all we've all been in pain, but for the natural side, taking, you know, hurting your organs, your special your liver, you know, cannabis and other modalities to don't really have those side effects. You do share that with your with your patient base.

Unknown Speaker  11:29  
Yeah, so certainly there's a growing interest of seeking alternative therapies aside from opioids, there's been a shift again, from all sorts of clinicians steering away from using opioids as well. And really, again, it's consistent with where the data is about opioid use. So one is I think they were often handed out to patients suffering from all sorts of various, you know, pain complaints, and there's pros and cons of its use and start certain patients experiences, specific types of pain. So using opioids for less than six weeks duration, especially acute lead, either postoperatively, after they've had a surgery, or they have some sort of acute need for is we're really the evidence is using opioids beyond six weeks, and longer for one greater than three months or one year, really, there's no substantial data to support its continued use. And that's where we now see that we maybe need to stay away from using opioids because we see the potential of lethality. In the US alone, you know, there are annually over 40,000 Americans dying from opioid related deaths. That's about 136 Americans dying every day from opioid related deaths. And in Canada, we see similar numbers but small statistics. Now, we recognize Yes, in short term use, it might be beneficial, especially in patients who are suffering from cancer pain, or chronic cancer pain, that's where really the indication to use it is in patients who have arthritis or low back pain, really, then there, there is no real substantial evidence to support its continued use, again, acutely for post operative measures, yes, opioids can be used. But again, it should always be combined. And, you know, a combination with the other types of medications, as we said, such as you know, the non opioid medications, and also ensuring that we're including non pharmacological therapies as well, such as the massage therapy, physical therapy, you know, acupuncture and so forth. The goal ultimately should be if someone is on opioids is to use the lowest effective dose to find symptom relief, and then really have a target in mind to get them off that medication altogether. Because we know how addicting that substance can be. And anyone can develop addictiveness and dependency at any point. So it's not that you have to be on it for two days, or 10 days or a year to become addicted to it. It's all genetic based on ourselves as to what you know, we find, you know, can get us hooked on that sort of substance. So, in terms of patients asking about alternative therapies, I do get a lot of patients who I think now are becoming more receptive and willing to entertain the idea about medicinal cannabis. As you know, as a, you know, a different therapeutic agent. There's a lot of there was an has been a lot of stigma associated with cannabis. But now I see especially in Canada, since it's been illegal since 2002. And since recreational has been legal now since 2018, I see a lot more seniors coming to my practice interested about hey, you know what, I saw this commercial for it or, you know, my friend has been using it further their arthritis. You know, I don't know enough about it and they don't want to certainly go to a recreational store dispensary, but they want to talk about clinicians. I certainly welcome that and encourage that as well as to speak to your doctors, your nurse practitioners. You know, any healthcare provider about can cannabis maybe incorporate? Can it be incorporated into my current pain regimen? And certainly I think that's the first step is to have an open discourse about it. And then ensuring that there's no specific contraindications to its use in that one specific individual individual. And then sort of discussing about next steps, how can we sort of complement this as a new therapy in my existing regimen?

John Malanca  15:26  
You mentioned that more and more elderly and seniors are coming in asking this question, I applaud that. Because, you know, you know, I'm from the 80s generation where the stigma is still there, you know, and talking about my parents generation, and beyond, the stigma was really there. And so to have this conversation was funny. You know, my mom's friends over the years have started calling. And I've shared this story quite a bit where I have friends from high school, that call me up and say, Man, I just want to thank you. I said, Why See, my mom's using cannabis? Because you don't know me? They say, No. Sometimes it takes an outside family member to have this conversation. Well, you see, look at that. They're like, Mom, I've been telling you this for five years each other and so it's, it's, you know, it's not, you know, getting, you know, a lot of body obviously, I don't want to have this conversation, my kids are probably the anatomy, you know, this is your, your life. And the same thing with doctors, you know, I have a lot of elder that were speaking retirement communities before COVID on a regular basis. And I ask how many people have this conversation with a doctor and you'd have some of the room raise their hand? Others say, I'm afraid to ask or I did ask. My doctor said, you know, Mrs. Jones, I'm going to act like you didn't, didn't ask me I quite actually that happened. My aunt, you know, her doctor 30 years said that same thing. And she's like, Give me a break. And one time I was speaking at a Retirement Committee, and the lady was probably in her mid 80s. And she said, Yeah, my doctor said, You better not do this, I'm gonna have to find, you know, find other doctors, I go, would you choose? I fired my doctor and everybody laughed. But I applaud that because this is your health. It's not illegal in most countries. It's not illegal to ask the question about cannabis, even, especially down here in the States. If you live in a legal state, or not a legal state, it's still it's still legal to ask question. And if your doctor is not comfortable, or knows nothing about cannabis, or the endocannabinoid system, or cannabis with pain, ask him or her if he can give a referral, because clearly nowadays, I'm certain, you know, a lot of people in your Rolodex know, don't ask Dr. Jones, but don't go ask Dr. Smith. Here. She knows. And so, that's, that's, that's a question. And, you know, I want to continue with that confidence that the patients can have a relationship with their doctor and talked about what's going on here. You know, there's so many different conditions that are coming up nowadays, especially as we age, and even when I'm, I'm going to be 55 this year, and I never thought about this type of pain or this going on or getting a colonoscopy. And so now at this age where things are happening, you know, talk to my mom this morning, what do you do? And I'm go to my doctor, for what? Just checkup? You know, okay, you know, and so she's, you know, staying on top of everything. What are some conditions that you're seeing, and maybe you can share? Elderly, typical elderly conditions, that they are finding success with cannabis and how that is incorporating them bringing their body into not only pain free, but less lessening the pain?

Unknown Speaker  18:40  
Yeah, absolutely. So I think, again, as I mentioned that the most typical complaints that I see in elderly aside from insomnia, anxiety, and so forth, is really is again pain. So now looking at the types of pain, low back pain is often a probably the most common complaint pertaining to pain itself. And then patients again, with knee pain, typically joint pain, wrist pain. And then also what I've seen, and certainly found that to be quite effective, although the evidence is kind of sparse, just because we don't have enough data yet. Is really in post herpetic neuralgia. So individuals who are suffering suffering from shingles, and I've had a number of patients referred to me from, you know, they're they're very specialist to, you know, try and alleviate the pain that they're having. So, oftentimes, you know, this is pain confined to the, you know, to the ribcage or the chest wall. And they try, you know, opioid medications. They've tried the non opioids they tried, in fact, steroids, and I have a number of older patients, one in particular who's 103 years of age, female referred to me by her rheumatologist and again having persistent pain To the she was very sort of initially apprehensive about cannabis. And this was going back in 2018, just because again, it, you know, society hasn't fully accepted it yet, but we see a slow transition and a progression towards its acceptance. And but again to her what was what was most important to her was her quality of life. She could not sleep because of the continued pain. And we decided to, after having a long discussion again, that, that putting her on cannabis was not to get her high. And I think that's one of the fears that a lot of elderly people have is that, oh, if I take cannabis, I'm going to be intoxicated, I can't function they're going to be, you know, sitting on the couch all day, and where they can't continue with some of their other day to day activities, whether it's, you know, playing golf or, or driving. So I always have a discussion first, which is educating them about cannabis, and the various molecules that are found within the plant. And that the goal of treatment is not to get you high, but use maybe a specific type of cannabinoid or a molecule within the cannabis plant that could provide maybe some anti inflammatory or pain relief effect. And that's the first step is that once you educate them, they then understand, and they sort of kind of set aside all that stigma and the misinformation. And they feel a bit more comfortable with perhaps now how this might be incorporated into their existing pain regimen with the other medications are taking. So that's the first step I take. And I see that with this individual specifically, was to put her on a type of cannabinoid called CBD ear, which again, is a non psychoactive or non psychomotor, impairing substance. And the goal was to not get too high. But basically, she took that in form of an, you know, an ingestible. So she took a few drops by a dropper that she placed in her tongue and swallowed, and she took that once or twice, depending on how advanced her pain was. And then we also gave her a sort of, we had a discussion about considering topical use, but I wanted to just start her off with an adjustable, and to be honest, that ended up reducing her pain. Now, everyone, sometimes I think a lot of patients will be real with you with what their expectations are, for any patient who say they have a tenant attend pain, and their goal is to get zero pain. I don't often see that with my patients, my patients are very realistic, where they say, Hey, Doc, you know, if I can get my pain down from a 10 to a five, you know, that would allow me to continue to do what I love to do, which is gardening, walking, cycling, et cetera. And I say that's the first thing is to have realistic expectations, setting those expectations. And if we get your pain down to zero, absolutely great. But if we don't, we get your pain down a couple of points. And now this, this results in improved sleep or an improved quality of life, then I think that's what the main purpose of attempting to use cannabis is, is to try again, improve your quality of life, reduce symptom burden, and I think that's what clinicians need to look at. We're not they're not patients are not coming to us to take this to, you know, get high and have fun, even though that might be a good positive side effect. That's not their goal. Their goal was to really improve their quality of life, whatever finite number of months, years or days they have left, that's where we need to have a real discussion with and and talk about its potential benefit.

John Malanca  23:31  
You know, it's funny I had I when you were talking about getting back to their daily routine and hobbies. I had a gentleman he says all I want to do is be able to roll around the ground and play with my grandkids that's my goal. And so I think it's a great goal to have and you know, he wants to be part of His family. You know, you're talking about cannabinoids and you know, I'm glad you brought that up you know it's cannabis is not a one size fits all as as we do know what works for you know, Mr. Jones 85 Senior male might not work for Mr. Smith 85 Senior male and so you know, you look at few things age weight current health conditions, sensitivities, physical you know, being Are you are you you know, able to move I mean it just you know, on strength of the body, but I have a lot of patients say I want the medical part not the recreational part and I think that's where the media has really confused a lot of people you know, there's about 140 different cannabinoids you know, T c being one which is known for the cycle of psychoactive CBD which you're seeing everywhere nowadays. And so when they say medical they they're really they're talking about comparing that to the CBD where recreational is the not is THC. I don't want people to be afraid of that because they all cannabinoids play a you know important role in bringing your body back to balance. There are a lot of studies showing THC for help with analgesic pain and acute pain throughout the body. You know, it's like you know, I always use this example you know, being in California and my brothers in the wine business you know, you and I go wine tasting and take little sips perfectly fine. We drink three bottles of wine, we're going to be intoxicated not feeling too good in most cases. Same thing with THC, you can have success with one two milligrams three milligrams depending how you are with THC and a combination and or what is your general. You know, a few years ago, everyone talked about one to one wonder when someone did an article and everyone's into one to one ratio, 50% thc 50% CBD? What are you seeing with your patients? I know, it's not a one size fits all. But what is what is the starting kind of a dose or recommendation that you that you give your patients?

Unknown Speaker  25:58  
Yeah, so typically, again, and this is where there's obviously a difference in terms of how we practice medical cannabis management in Canada versus the US. You know, in terms of accessibility to products, testing, and government oversight, it's a bit quite stringent here. So the general consensus, and this has now sort of been evolving and changing into maybe considering different ratios of, you know, these cannabinoids, not because of not always because of their their lack of efficacy, but really, because of sometimes these medications can be costly. So in Canada, typically, and in the States is a little bit different. But in Canada, typically we start patients off on sort of a high CBD product, which again, what is the purpose with starting a patient on CBD as opposed to THC, or, or a combination of them to, really again, as you mentioned, THC is the one that can cause sort of the high, the intoxication has really more of the psychomotor impairing effects, which can limit your ability to drive or you know, work, and also has some degree of drug drug interactions with some of the medications that people are on. We do also see that, you know, to some extent in terms of drug drug interactions with CBD, but the stark difference between the two is that patients who are using solely CBD and less than 1% THC, for on a daily routine are not getting that are not getting this sort of intoxicating effects. And that's because the mechanisms are different. But CBD can provide relief in terms of you know, reducing inflammation, helping some instance with sleep promotion. But really, again, it's that it does have some analgesic effect. Now compared to THC, THC is a much stronger analgesic meaning it's a much stronger painkiller. But it does have some of the other side effects, including which we typically see in some degree or percentage of patients using THC is that typically get around above 12% and higher of THC product, they can get the sort of palpitations or the racing heart, they might get, they might get the cotton melt or the dry mouth. And then in some select patients, but not all patients, they can get sort of the the the paranoia. So that's why in elderly patients, I typically use CBD just because they're already often typically on a number of other drugs. And or also, they have some, you know, some other chronic disease such as a history of a heart attack, or a history of a stroke, or they're on certain medications, but in those individuals, because if they have a history of heart disease or heart attack or stroke, then I typically will, if anything will start them on CBD as opposed to THC, because of the cardiovascular effects that are seen with the TT itself. Yeah, so now the dose itself does vary. So typically, what we say is try putting a patient on a low dose, which can be anywhere from what I see, you know, starting off at even two milligrams and going up. There's no set dose for any individual, it typically it's just a finding, you know, a dose for that one individual is kind of like, you know, it's like, you know, you have a dartboard and you're trying to get a dart, you know, on the board itself, and you're trying to find, you know, you're trying to hit the bullseye. Well, with with patience, it's really trying to find that specific dose and no two individuals, as you said, have, you know, that could benefit from the same exact dose, there's a number of variables, but you know, typically what we do is we start low and go up in incremental effects to where we then observe some symptom relief, and if the patient finds a response at five milligrams, then we say was stopped. There's no need to go up on higher doses. Now typically, I find that anything above 50 milligrams of CBD, you know, A day or per dose. Typically, if we're going up way above that dose, and there's no effect that we're observing in terms of symptom relief, then we say, Okay, now it's time to add maybe a small amount of THC, in addition to that CBD to see if we can improve your symptoms. Some individuals if they're not, let's say they previously use cannabis, you know, regularly. Or, you know, and they're not what we consider cannabis naive, then those individuals, we might start off with having some degree of THC right off the bat. But there's a lot of things to factor in. And I usually ask patients, are they working? Are they driving? Are they working in a safety sensitive position? Because all these things matter, especially when they're in cannabis, you know,

John Malanca  30:44  
I'm a big like, I'm glad you said safety, because safety is a big thing for all ages using this, but, you know, my mom's a widow, my father passed away. So she lives by herself. And um, you know, and she was never a cannabis user. Now, all her girlfriends are doing unfortunately, a lot of widows out there now. You know, so they're all taking something different. A lot of them take, you know, an edible because they're used to taking a pill, you know, but I always share regarding safety is don't overdo it the first time, don't you know, sometimes, depending on how you want to get into the best I want to get into your best modes of of intake ingestion, after this question, but living by yourself, do you like you said, paranoia could come in, being unbalanced could come in? cotton mouth, heart property. I mean, I've had so many stories like I did this and I went to dispensary and I came back the next day and I'm calling the calling 911 thinking I'm having a heart attack. And so that's why I think education is really important. That's why I truly believe a medical doctor should be involved. So they can walk you through this. I'm not a fan of sending an elderly or anyone to a dispensary for the first time Hi, what do I owe you? What's wrong, the asleep is anxiety. Pain, and they come out of there with you know, 15 different products. It doesn't need to be that way and that's the part that this industry that frustrates me when when doesn't matter who you are you what age you get, you get oversold a bunch of items, which you don't really need me sometimes. It just takes this and it's a domino effect of everything else falling asleep. You need to get your sleep oh my god, I don't feel any anxiety. I don't feel any pain. I don't feel any inflate inflation, inflation, inflammation. So, let's talk about prevention. Before I get into the prevention, you know, you were talking about when we started off with arthritis and rheumatoid arthritis. And so a lot of times inflammation in the body can lead to disease, dis ease and also with with pain. And so are you a fan of like I have my mom on, you know, sublingual tinctures for health and wellness mom take this, you know, and she it's a CBD product. And so are you still a fan of that? I know Doug Jordan is not a fan of tinctures. Are you? Are you a fan of tinctures?

Unknown Speaker  33:18  
Yeah. So I would say again, I look at in terms of any decision I make about recommendations to a patient about incorporating cannabis, I look at really where the evidence is. And obviously, I think we're still lacking in terms of, you know, we still certainly need higher quality, better quality evidence to look at other sort of types of delivery mechanisms, particularly, let's say topicals, for example. So aside from tinctures topicals is something that I have a lot of patients who are have either made their own topicals at home with using, you know, legal, Health Canada approved products.

John Malanca  33:57  
And throw that disclaimer there, didn't you? Well, no, it Well, the thing is,

Unknown Speaker  34:02  
I think what what the companies have determined now is that and I'll give you an example. So I have a lot of patients at times who just have pain within like one aspect of their of their finger, or their knee or for their foot. And they don't they're a bit afraid to either ingest something because they're afraid of getting high, but if they think if they apply it locally or topically, it's just going to provide a medicine directly. They're just like boltaron gel or those other NSAIDs that people commonly use. Yep. So what I've seen is some patients make their own and there's obviously risks with making your own, especially if you're not mixing the product, you know, thoroughly and so sometimes you have you can waste a lot more product than needed. Or you might not get any relief because when you do apply it you're just not getting any the medicine with the other sort of, you know, with the other cream that the cream base sets in there. So then they say Oh, I don't I didn't get any benefit. So companies now in Canada specifically are developing their own topical kits. So basically, they have the, you know, the ointment, and then how to combine oil to it, and then they give you all the mixing materials. And but one of the, I think, as we've learned, and so have the companies that elderly patients, you know, have, you know, some struggles with, you know, doing certain things, I've had, you know, a number of patients who couldn't open the bottle of their, you know, their, their cannabis oil. And that's because they had such advanced arthritis, that they couldn't even open the bottle. So, companies are learning physicians are learning practitioners are learning about, okay, how to make things easier, so that they can make use of their products. With topicals. Just specifically, again, I you know, although the evidence right now is very sparse, because we don't know how its distribution is throughout the body in terms of, you know, when they apply it, how much are they actually absorbing, does this potentially cause any drug drug interaction if they are on their medications, but I have seen just, you know, it, you know, in my office, the number of patients who have disclosed that, you know, hey, Doctor, I've been, you know, going to be honest with you, I've been taking it, and it works wonders, and they apply, I do believe there is likely some benefit, I just caution them, because then I can say, Oh, I recommend it, because I don't know what the data is. But if they're using it, they find that it is relieving their pain, then certainly, you know, I'm all for it. Again, making sure that they're under my supervision and monitoring, you know, their blood. And, you know, they're that there are no other potential harms between the other medications they're taking, then that's the main goal is that and that's why again, encourage patients not to go and self medicate by themselves, but to work with your your health care provider, because ultimately, we care about your well being, and who knows if we can get you if you find relief with cannabis, we might be able to get you off the other 1235 10 medications that you're on. And so sometimes cannabis itself can help reduce polypharmacy. So, you know, no one wants to take more than one drug if they need, you know, wants to take any drugs. But if you're on 10, and you know, now you're on cannabis, and you find that, hey, you know what, I don't need that opioid anymore. I don't need that ibuprofen. I don't need that Tylenol, then that's better. We have that. That's a great goal in mind. And what was the second part of your question? I'm just in case I almost forgot to

John Malanca  37:23  
shave it. You know, you know, you know, and I always share too, when I when I talk with patients that live with their spouse or or widowed or live alone. Do you have any family members around? Do you have a son or a daughter? You know, and if you are gonna do that, make sure you have that conversation with them. And maybe for the first two nights, have them come over you go there so you're not okay. Cuz I know. You know, my mom has tried it. It was funny. And I know we're we have I don't want to take up your take up your morning here. But, you know, my mom one time I've had I've shared the story. It's a great story. But I remember walking into her house one time and I see this big, beautiful bouquet of flowers on her on her diner. I'm like, sending you flowers, Mom, you know. She said, Oh, it's it was her girlfriend. I said what she does, she goes, you spoke to her and she's sleeping better. And she's doing this and she sent me flowers. Say thank you for introducing your to. So I think how cool is that? You know, you're seeing seeing these success stories. You know, my mom has an arthritic finger. I should try this top. She does it like you were saying that 111 area. She's like, Oh my god, I couldn't do this before. Now I can do this. And so it's neat to see to see that, you know my mom to Corinne, who you didn't get not to get to meet my wife who passed away from from cancer. I had talked to my mom. Good morning. Good afternoon, good night. And this one evening, we were saying goodnight to her and my mom says, Can I ask you a question? I'm thinking. She says, I've been taking all my friends are taking taking some stuff and I was taking a little gummy. I think it was or popcorn. I forget what it was then. This is probably about seven, eight years ago. And she says Does it help with sleep as well as pain? You know, she was like, you know, she's a tennis player, oral tennis forehand played for years, but she was I don't have pain. You know, and I was silent to hear my mom. I mean, if it wasn't for my dad, I think my mom would have been a nun. So to hear that I was saying and I remember cringing hits me, she's like, Be supportive, be supportive. And I said, yeah, she's like, Wow, it's amazing that it does that to the body. She was I think if if I knew about this when your father passed, I would have, you know, help with sleep and stuff like that. And so it's nice to see, you know, hearing their stories not only because my mom, but even the retirement communities, you know, you know, my husband passed away and I was in my room just sad and depressed and you know, my kids brought this over and next thing you know, I'm down having dinner with my Fellow. They call them inmates, what they call me retiring and my fellow inmates, but, you know, but it's neat to see that that the success of this plan is not for everybody. But it's neat to see that that there are some not getting paged patients or anybody false hope we're giving, giving, giving them hope. You spoke about drug to drug interactions? And can you talk about some drug to drug interactions and what to look out for and what maybe some medications to stay away from or cuz I'm a fan, when you're battling something as severe as cancer, so I get having a whole arsenal, you know, and and, you know, let's let's do this, let's do that on different modalities of chiropractic. Acupuncture, may be conventional, if you're going to do chemo radiation, but also incorporating cannabis in there to help as much as you can. But there are some drug to drug interactions. Are there things that you would say, hey, timeout, let's do you know, I prefer you not doing this or Yes, it is okay to combine?

Unknown Speaker  40:57  
Yeah. Okay. So and I'll comment on two things. One is, for remind me, the first thing I'll talk about the drug drug interaction. The second is I do want to get back afterwards, about the the reducing, or, you know, the harms with cannabis use, particularly in, in mitigating the, you know, the potential harms. And you touched on some of that already about, and I think, Jonathan, you must be a doctor, because the fact that you said that you have, you know, having someone there, you know, for the first two nights, if someone is starting cannabis, especially in older patients, that's what I typically recommend for patients is that if they have a family member, for the first couple of nights, it's good to have someone there, you know, in the house, just to be there, as you know, as a backup, again, we know that elderly individuals, as we age, we have, you know, some decline in our gait stability, or muscle strength, we're at a higher risk of falls and imbalances, our vision is a bit weaker, we get a bit more, we get a bit more disoriented, especially when we get up out of the bed. So now, if you combine cannabis, then you know, there isn't a significant harm, but it's always good to be cautious. And again, that's why it's important with with overlays, I often will recommend them starting the medication at bedtime, because, you know, they're typically at bed and they're going to sleep for, you know, five, six hours if they're lucky. And so you're allowing the medication to take effect, whereas during the daytime, you know, it might be a bit you know, a bit more cumbersome. So I had always, I always advise individuals to take the medication at night, have someone around for the first couple of days, especially if they need assistance with going to the bathroom. So So toileting is also a concern. And they you know, a lot of individuals unfortunately, have to go to the bathroom at night. So as you mentioned, I think that's always good is to have someone there at night for the first couple of days. And then basically, we get used to it in terms of drug drug interaction. So I would say the only drug that I would ever consider sort of an absolute contraindication. And again, there is some debate about this is really in terms of immunotherapy drugs. So there's these are specific drugs that are used to treat specific types of cancer. Now, really, the concern about the drug drug interaction is usually in younger individuals who might be on this medication, if there is an intent to cure their cancer. And what we know with one of these drugs or the class of immunotherapy, so not the traditional anti cancer drugs, such as you know, the platinum based chemotherapy agents, there isn't any drug drug interaction with those, but the ones that we are sort of right now on the radar, and there's some evidence that shows that there is a potential drug drug interaction and can reduce the benefit of the cancer drug is in immunotherapy agents are good enough Oh, in those specific patients who are on that drug, I make sure I have a a full discussion not only with the patient, but their oncologist who whoever is prescribing them that medication that they're aware that they've come or they have been using cannabis or they want to use cannabis, then I say that. And then I've had a number of oncologists here in Canada, especially who were not aware that have the potential drug drug interaction despite recommending cannabis to their patients. So you take a step back and I say, Listen, it's not to say it's absolutely you can't ever use cannabis. But I say, let's first look at what the goal is. So right now, if you have a cancer, and the goal is to treat and cure your cancer, then let's say let's hold off on the cannabis for the time being until you complete your cycle of the medication, and then we can maybe consider incorporating it. That's really the approach I take with patients whose intent is to cure their cancer. Now there are some patients as a palliative care physician who I know who have metastatic cancer or stage four cancer and they are sometimes still prescribed these immunotherapy drugs, then the discussion is what is the goal of including cannabis and what is the goal of the immunotherapy drugs. Is it to reduce symptom burden or not. And typically those patients with advanced metastatic cancer, the goal is not to cure their cancer at this point. And we know that the immunotherapy, the immunotherapy drug is not going to cure their cancer, but it might have a role in reducing the pain that they have or the the spread of disease that might affect their breathing or so forth. That's when I have a discussion with the patient and the oncologist and say, okay, there may be a potential drug drug interaction where it might benefit reduce the benefit of that cancer drug. But if the goal is to try and alleviate your pain or improve your sleep, then this might be a safe, acceptable reason to incorporate cannabis use. Okay, that's, that's really the only drug that I typically will avoid. And or sometimes with patients who had a recent heart attack, let's say within the last six months, and they are what we call on a antiplatelet agents such as like Plavix. So, when you have a heart attack, sometimes these patients are prescribed one of these antiplatelet drugs to reduce the risk of them having a subsequent heart attack, there is some evidence to suggest that shows that the interaction of cannabinoids with antiplatelets can reduce also the efficacy as well. So again, I have a heart to heart discussion. I say, Yeah, let's hold off for six, you know, let's hold off for another six months or wait beyond six months before we consider cannabis. Because there are again, many traditional drugs, other drugs that we can utilize. But and then we can have a real discussion about maybe incorporating cannabis. Yeah, the other ones typically is Coumadin or warfarin, which a lot of patients are on for blood clots or heart valves.

John Malanca  46:41  
Yeah, cuz those are the ones I've always heard is blood thinners. heart medicine, you covered both of these. And I did not know about the immunotherapy with for cancer patients. You know, I heard with chemo radiation, you can incorporate cannabis, and it not zeroing out negating the benefit, I guess if you must say benefits of of other conventional case, you know, and I've never tell anybody not to do. You know, I've seen it work. I've seen it not work. I've seen cannabis work. I've seen cannabis not work. And so I would never tell anybody not to do and that's a part where I said so you know, say chemo, chemo pain. You know, I think cannabis is very beneficial for not only for pain relief, appetite, stimulation, mood, nausea, you know, all of the above. And so those are the parts where I think, you know, one having discussion with your doctor. And, you know, people always come to us and say, does it work for this? Does it work for that, and I and I don't want to say it's like duct tape with 1,000,001 uses. But when you really get down to it, it's amazing. All the benefits this plant has to offer and it doesn't work for everybody. You know, like I said it didn't you know, how we got started, United Patients group was my father in law with stage four lung cancer metastasized to his brain. We didn't know the benefits, they gave us two weeks, all we wanted was appetite stimulation, well, his eating got him healthier. And the cannabinoids not only got them healthier, but also we're attacking the cancer cells. So coming out of the gate, we hit a grand slam with my final law. You know, let's fast forward, you know, eight years later, fast forward eight years, which is now going to be five years shoot, you know, my wife, who had the most, you know, perfect healthy lifestyle diagnosed with pancreatic cancer. And, you know, she passed and so I you know, we tried everything from stem cells to you know, worked with a lot of functional integrator men, even cannabis. The pain, I remember, she had tears in her eyes, like, how come this is not helping my pain, John, you know, and so just just killed me that everything that we've learned, and it just shows you that it's not a one size fits off, you know, maybe it can maybe cause most pancreatic cancer patients. Unfortunately, you've been diagnosed and 48 hours later or two weeks later, you know, I had four beautiful months with Korean and she wasn't really into a lot of pain until towards the end. And so I don't know. And that's why I think more studies need to happen for for for all patients and in all ailments.

Let me actually have one question here, too. This come happens all the time. John, is in cannabis covered by insurance. And it's not covered by insurance yet down here. What about up in Canada?

Unknown Speaker  49:39  
Yeah, so great question. I'm hoping especially for the states just like in Canada. So I hope that as we see as the federal government as the insurers realize that this is probably a better alternative than opioids it's safer. It's going to cause less harm, less direct cost. us to the American health care system that they will consider subsidizing the cost of their patients. And I hope that they do. In Canada, were a little bit ahead. We it's not, again, not fully, it's not covered by the government per se. It there is some nominal coverage by third party insurers under what we call a health spending account. And there are a number of, you know, insurance companies, insurance companies that cover, you know, a couple of $100. So it doesn't cover the overall cost, but it's a starting point is my point. I'm hoping that also, that the Canadian government with time will recognize that this is a likely much more cost affordable medication than the other prescription medications that Health Canada does have on the formulary that they allow for coverage for patients. So again, in Canada, we're slightly ahead with some insurance companies covering the cost of this. But again, if patients are taking this regularly, then there certainly is a bit of a cost to it. But I think in the States, there will be that that same follow up and I think just like, you know, Canada, the US, we're neighbors, so we often look, you know, look at each other as to what we're doing. And I think, you know, the US and hopefully they will make you know, some of the same recommendations,

John Malanca  51:15  
but hopefully did to add on the on the on the insurance thing. It's funny. That was years ago, I was interviewing we did a whole thing on vet Veterinary and pets and families. And this family said, Oh, no, on our pet insurance, we write cannabis, and they reimburse us. I don't know what the cost was. And the funny thing is, it's illegal for vets to recommend cannabis to their patients or dogs. But pet insurance will cover it. Whereas humans, it's in most cases in states, it's legal to recommend medical cannabis at the state level to your patients humans, but insurance won't cover and it's I hope, I hope, you know, everyone will get on board somewhere. I mean, it's it's it's amazing. Some states down here, you're requalified conditions or other states over here, sorry, pains on a qualifying condition. Pennsylvania just made pain a qualifying condition in the last year two years ago, cancer in some states, you know, no, you don't have cancer, but will will allow you to have pain as a qualifying condition or epilepsy or etc, etc. So, you know, it's unfortunate, all states have different laws down here. And hopefully, they'll have an idea about across the board, not only with qualified conditions, but safety and products. So to our listeners, ask questions, ask questions. Don't be afraid to ask questions about the safety or product, make sure all your products are tested. And when I say tested, it's not up to you. It's up to the dispensary or whoever you're purchasing from, to have an up to date. I guess lab report, certificate of analysis, also known as the CE O A. And if you have questions or they can't submit that to you go to another company. There are so many companies out there and if you still have questions, you're always welcome to reach out to me here United patient group, as well as Dr. Tandon up there, and I'll put all your information up there Suraj for that, I can go on and on and on. But I maybe this will be a part two. You know, I just I appreciate you as is incredible doctor but human being and what you you're doing for this industry and in the work that Suraj and I are doing together with with Dr. Dr. Tischler is is pretty amazing what we've accomplished so far and and still doing it. Do you have any closing words for Yeah,

Unknown Speaker  53:45  
absolutely. So John, first, I want to, you know, just commend you on having this platform for all your listeners. I think it's an excellent platform for the listeners who out there to get succinct, accurate evidence base information. And I think that's what's truly important. And then to have John and his organization to really support patients, to be a strong advocate on your behalf, I think is absolutely vital. And you're doing an excellent job with connecting with people, leaders within the industry who can comment on this. And I think that's what's really most important for patients is to get, you know, credible information, to remove the misinformation the disinformation, and to speak to experts in the field. And really, my last vital point that I would give to all the listeners out there is to, you know, encourage you to have open discussion with not just your, you know, your doctors or nurse practitioners, but your family members. You know, I think we're at a stage where we're evolving the there's a lot of D stigmatization now which is, which is a good thing. We're looking at the potential benefits of cannabis and cannabis. Again, I'll remind you is not a new substance. It's been around for 1000s of years, used all across the globe. Again, All for medical purposes. So I think that's the first thing is looking at the history about it. And that will remove a lot of the stigma that you know, or, and the biases that we might have about it, but have an open discourse with your doctor, your nurse practitioner about, you know, whatever complaint you have. And maybe if there's some benefit, it's always better to speak to a health care provider, because our goal, again, is to improve your quality of life, reduce your symptom, and disease burden. And if we can find a substance that is maybe better, newer, has less side effects, and can meet all of those goals for you, then we're in a we're all in, that's what we want. And you're doing this under the supervision and, and the care of a provider who can ensure that, you know, there aren't any major harms, there aren't any drug drug interactions. And that's what medicine is, that's what the beauty about providing health care is, is that we want to work with patients. We want patients to sometimes teach us as well. So you know, teach your providers, if you have a doctor who doesn't know about it, then this might be a way to educate them as well, right? We don't doctors don't know everything. And now with the advent of technology and the internet, you can really encourage us to learn more. And that's what medicine is we're constantly learning, we want to help our patients. And and that's really the main thing I encourage all of you guys, do not be afraid, you can't get in trouble for having a discussion about it. And again, it's your body and your life. So why not look at alternative ways to really improve that?

John Malanca  56:30  
Beautiful? Well, well said, I want to add to that too. I'm a fan of journaling. Write down what you're experiencing, what your pain level is, what you've eaten, how you slept. And then what if it's chiropractic, acupuncture, even a pharmaceutical and or cannabis, write it down to see what your, how you're improving day after day, week, after week, month after month is, et cetera. And another thing I was like doing this as well, a lot of times Raj, you know, a lot of patients out, refer them away from cannabis. Try this first, try this first. And one thing that I'm a big fan of, in an old colleague share this many years ago, what he does with his patients is sit there, it doesn't matter if it's pain, anxiety, depression, or whatever, but take a deep breath and take a full body check. How do I feel? Am I in pain? Am I level of one to 10am I and 11. And then incorporate cannabis, or whatever you're doing. And then go back and do another full body scan. Take that breath, inhale, let it out. And go okay, is my pain now? A 10? Or is it a two or a five or a three. And again, write that down and you'll know and that kind of helps you guide engage where what what works best for you, we're all made differently. But we all have that sweet spot that we that works perfect for us as well. So Suraj my friend, always great senior and, and look forward to doing many more things together in this industry and beyond. But I appreciate you and all you do and hope our audience enjoy enjoys you as much as I have. So thanks, everyone, and thanks to Rogen, and again, John Malanca. United patient group, be informed and be well and we'll see you soon and how do they reach you get? I'll put your information below but I'll put the information there for everyone. So anyway, have a great day everyone. We'll see you later stretch. Take care. Bye bye