Here, Dr. Michelle Weiner shares her journey to learning and practicing cannabis medicine.
Dr. Michelle Weiner, DO, MPH, is a pain management physician and partner at Spine and Wellness Centers of America based in South Florida, and was the chair of Florida’s Medical Cannabis Advisory Committee (1). Cannabis helped change many of her patient’s lives. Her patient’s experiences with cannabis furthered her understanding of how to use cannabis effectively for chronic pain. After she finished her residency and fellowship, Dr. Weiner had a large amount of patients that had chronic pain who were taking opioids.
“Honestly, that wasn’t what I expected after I had finished my training, because I really went into medicine to help people and empower patients to promote wellness,” Dr. Weiner said. “I found that there was a big problem with addiction and opioid dependence and chronic pain that wasn’t being treated properly.”
When cannabis became legal in Florida in 2016 (2), she thought it would be a great option to offer to her patients who had pain and wanted a substitute to help them decrease their opioid medication. Here, Dr. Weiner shares her journey to learning and practicing cannabis medicine.
Dr. Weiner wasn’t taught anything about cannabis or the endocannabinoid system (3) in her medical training, so she started learning on her own. “I started researching, talking to different physicians in other states, as well as going to the dispensaries and trying to learn as much as I could about the different routes of administration, the different cannabinoids, and learn as much as I could about the endocannabinoid system,” she said. “I was very curious about the plant.”
As she found out more about cannabis, she was amazed that her training had not prepared her for the importance of the human endocannabinoid system. “It’s like saying we’ve never learned about the sympathetic nervous system or the cardiovascular system,” she said.
She started integrating cannabis into her treatment programs for patients, offering the patient cannabidiol (CBD) or trying to help them with medical cannabis. “At that time, we had to wait three months for the patients to be able to actually purchase cannabis, which was really a ridiculous rule that has since changed,” she explained.
Her research revealed that there was a 40% reduction in overall opioid use (4) when cannabis was added to a patient’s treatment regimen. “I saw that not only were they decreasing their opioids, but they were also sleeping better,” said Dr. Weiner. “They had a reduction in their anxiety medications and antidepressants as well. So, I saw this huge substitution effect and I realized that this one botanical medicine could potentially be used for so many indications. For me, it really offered people hope, and it was this catalyst to say, okay, take your health in your own hands as opposed to just waiting for the answer or the magic pill.”
Over time, as she got more positive results from patients, she began using cannabis for different conditions such as neurodegenerative and psychiatric conditions. “It’s really just a wonderful tool to have in my toolbox,” she said.
Dr. Weiner explained that there are certain questions she will ask initially just to get a baseline so that she and her patient know where to start with cannabis treatment. “One question would be if they’ve ever used cannabis before and what their reaction was, and if they know the product and the dose that they were using,” she said.
“The other question is what conditions we are treating and what time of day they would want to use the medicine. You can give someone tetrahydrocannabinol (THC) while they’re sleeping and perhaps that’s not going to cause much fear, as opposed to maybe someone who can’t use any form of THC with the potential of psychoactivity during the day while they’re at work,” Dr. Weiner explained.
It’s a personalized treatment based on the condition they want to treat, like nausea or increasing their appetite, and their past experience with cannabis. “What I really like to learn is their tolerance to THC,” she said. “Some people take 5 milligrams of THC, and they don’t need any CBD to counteract that high. Other people need a 5:1 ratio of CBD to THC. So, it really is personalized,” she said.
Dr. Weiner normally has a patient write down in a journal what products they’re starting with. “I always give them an algorithm to start with. For example, I tell them to use a tincture during the day, or perhaps half an edible at night, and then we go from there,” said Dr. Weiner. “We go back and forth with email a lot. And then the nice thing is a lot of patients like the fact that they can personalize this, and they can understand and listen to their body, and see what’s working for them, and then make changes from there.”
But other people need more hand-holding, she said. In any case, it’s amazing how people respond differently to THC. “It’s not just about age or weight, but many other factors; hence personalized medicine,” she said. “I’ve had patients who are 80 years old, who can take THC and have never felt any intoxication. And then I have other ones who may be very young, who use cannabis often and still feel that intoxication.”
Dr. Weiner said that she treats chronic pain (5) by looking at the whole person. “We’re not just treating where their actual pain is, but also the emotional component behind that, and that’s really the benefit of cannabis,” she said. “Our cannabinoid receptors are in our central nervous system. They’re in multiple organs and muscles throughout our body. So, when you use it, you have more of this mind–body connection where people are really able to not just take care of the physical pain but understand that they are not their diagnosis. They are not their pain. It gives them a little bit of a tool to say, let’s change my perspective on how I’m living, and how can I relate to my pain.”
She has found that not just cannabis, but psychedelics come into play when dealing with chronic pain. “I think that the psychedelic renaissance that we’re starting on now is opening people’s eyes to understanding the connection between chronic pain and mental health,” she said. “I think we’re seeing that using ketamine (6), for example, which is a dissociative anesthetic. It’s used for pain management, but it also has this ability for the patient to dissociate.”
The problem is that different medical specialties are not seeing this as a way to help their patients, whether its cannabis or psychedelics. “A psychiatrist will address only emotional pain for example, depression, and a pain physician will discuss physical pain and not mental health,” she said. “So there has to be more of a collaboration going on among specialties.”
Patients who use cannabis as medicine are listening to their body, she said, and can also treat a lot of the physical pain that gets stored in their body by using other medications that open their mind and even alter their consciousness. “I have seen these medications transform people’s lives through the power of connection. It gives them a new perspective on how to look at themselves, their lives, and conditions,” she said.
Dr. Weiner pointed out that there are different considerations for older patients in treating their chronic pain. “Because the cannabinoid receptors are not in our brain stem, there’s no chance of respiratory suppression,” she said. “It’s very nontoxic. It’s a very safe plant. Age doesn’t really matter.”
However, there are some significant differences to consider between younger and older patients. “When we’re younger, we’re healthy. Our endocannabinoid system is functioning in an optimal way, assuming that our lifestyle choices are healthy,” Dr. Weiner said. “As we age, we make less of these naturally occurring cannabinoids, so we can’t regulate our endocannabinoid system in the same way. Also as we age, it becomes more difficult to maintain homeostasis or balance. We don’t know how to test the cannabinoid recaptor density and the endogenous cannabinoid levels. These values are also likely to vary based on stress, lack of sleep, or our diet.”
But either way, because they’re elderly, she always uses a high CBD dose first because of the risk of a fall or confusion in an older patient. “I’ll generally start them off on a high CBD product and then titrate them up on their dose and then switch them over to a 1:1 ratio so that the CBD can still negate some of the high from the THC,” she said. “But I’ve been very surprised. I had an 80-year-old patient the other day who came in and she was very frustrated because she tried CBD for two months and it did nothing. Then she just started using THC alone, and she got great results. So, every person’s a little different.”
“Older patients are at the point where everything that they’ve done to improve their condition has failed,” Dr. Weiner said. “They’re just so frustrated with their pain or their lack of restorative sleep or their tremor from Parkinson’s or their depression that they just want hope and an answer. So usually, they’ll come in with a daughter or son who is much more inquisitive and nervous for their mother or father.”
She said, given the history of cannabis, for some elderly patients it’s something they can’t really relate to. “You have to understand what their previous opinion is about cannabis culturally, and what the stigma is, and then give them a lot of education.”
Patients with chronic pain want answers and solutions now, she said. “But the evidence is slow to follow,” Dr. Weiner explained. “Most of that has to do with the fact that cannabis is a Schedule I drug (7). Because it’s a Schedule I drug, it makes it difficult to do research. Other countries are much further along than we are.”
The interesting part of cannabis as medicine for chronic pain treatment is that patients are teaching the physicians now, she noted. “They are using cannabis and then telling the doctors, ‘Well, I’ve decreased my medication. I’m sleeping better. My pain is more controlled.’ So, it really means that we’re probably missing the root cause of most people’s pain. Not just to give a Band-Aid and to numb the pain or to numb the person’s emotions or feelings, but to help them become aware of what’s happening and give them hope. That’s the biggest issue. A lot of times patients are just hopeless, and that’s not a way to live, either,” she said.
Dr. Weiner is working on a study with Florida Atlantic University (FAU) on chronic pain and cannabis with Dr. David Newman at FAU (8). They received $75,000 from the Consortium for Medical Marijuana Clinical Outcomes from the State of Florida to conduct a study looking at the elderly population with chronic pain and the use of medical cannabis. “What we were looking at was safety, if there’s any patterns, the efficacy and then the education the patients received,” said Dr. Weiner.
There were 131 patients in this study, with their pain score measured on a scale from one to 100. “There was a 52% reduction in the pain scores, which is definitely a statistically significant decrease in the patient’s pain.”
The most common side effects that patients reported was increased appetite, lethargy, and improvement in mood. The other thing that they said was that the physician spent less than 20 minutes educating them. “That was something else that we took from the study was the fact that we probably need physicians to be more knowledgeable and improve the exam that the physicians have to take to be qualified to recommend cannabis,” Dr. Weiner said.
She and Dr. Newman just finished the study and will be publishing results soon. They are considering continuing that research. “We would really love to do a study where we’re looking specifically at products as opposed to just overall use of cannabis, but really identifying what products they’re taking, the milligrams, the ratios, the route of administration, and getting a little bit more detail,” said Dr. Weiner.
Dr. Weiner also has two ketamine studies right now that are approved through the University of Miami (9) comparing two different routes of administration of ketamine—intramuscular route versus sublingual route. “We have patients that are having six sessions of ketamine and seven sessions of therapy for the different routes of administration,” she said. “Patients are having a microdose (of ketamine) during therapy, which is actually ketamine-assisted psychotherapy, comparing it to higher intramuscular ketamine doses with the therapy after. The point is really to show how chronic pain patients need therapy. It’s not just the fact that the ketamine is causing pain relief, but the fact that they need help dealing with how they’re relating to their pain.”
She has found out that when someone uses ketamine and they’re able to reconsolidate a memory, or have an experience, and no longer have the emotion attached to it, then the trauma is able to leave their body. “It shows up like less pain,” she said. “So, there’s such a connection going on here. I’m sure the endocannabinoid system plays a role in that in terms of glutamate being a neurotransmitter that’s hyper excitatory in this population.”
Her other ketamine study is a nano-botanical formulation that she worked on with therapist, Shari Kaplan, designed to mitigate the negative side effects of ketamine, which is usually nausea, dizziness, and fatigue. “Shari made a botanical formulation that can be poured into water. It’s water soluble,” Dr. Weiner said. “We give it to the patients after ketamine so that they don’t have any negative side effects when they’re going home.”
They did the study in group sessions. “We had six people in four different groups, and we looked at 24 people,” Dr. Weiner said. “One time, they got the placebo. And then one time, they got this nano-formulation.”
She and Kaplan are analyzing the data now.
Dr. Weiner had a female patient diagnosed with fibromyalgia who had been treated by another pain physician. She was on high doses of fentanyl, given as a transdermal opioid, and Percocet (10). She was also on Ambien (11) for sleep and medication as a muscle relaxant.
“She came to me and had the stigma about cannabis,” Dr. Weiner said. “But she was just on all these meds. For me, I look at someone who has something like fibromyalgia, which is a chronic pain condition. Opioids treat acute pain. So, when she goes back to the doctor every time, he just increases her medication, but that’s not really helping her at all.”
The woman was functioning completely fine, Dr. Weiner noted, but had the same pain issues. “It took me about three months to wean her off of her opioids,” she said. “As I started to use cannabis with her, I used it like a short-acting tincture to be comparable to her short acting opioid. Then we used long-acting forms of cannabis, like a capsule or an edible, to represent more of the long-acting opioid.”
Dr. Weiner was able to wean her off all her opioids. “The interesting thing is that she had no pain. Then she was able to significantly reduce her cannabis,” she said. “So, I think that’s an interesting concept, the fact that they don’t even realize that they have this opioid-induced hyperalgesia where the pain medications are actually making her more sensitive to pain. It’s like a wind-up phenomenon where once the pain starts, it’s not able to calm down. Cannabis really puts the body into this parasympathetic mode, but it also is treating this wind-up phenomenon.”
Dr. Weiner thinks that her clinic has changed in the sense that she no longer treats the patient in that patriarchal way—here’s a medication for the condition that you have—but becomes more of a conversation of understanding what’s going on in the patient’s life and treating the whole person.
“My clinic is very different now because I actually want to get to know the patient a little bit because there’s a lot of things that they’re not sharing,” she said. “Or if it’s a situational thing, perhaps they’re not going to improve. I think the algorithm for how I treat pain and how I look at the patient has changed. I talk to them about sleep hygiene. That’s an important one. I think people don’t put enough influence on getting a good night’s sleep. I talk about resilience to stress. All of that, I think, really has to do with lifestyle changes because I don’t want the cannabis to fail because other parts of their lifestyle are not really going in the right direction.”
She wants her patients to understand who they are. “I think that’s really the most special thing about cannabis is that it does have the ability to alter our consciousness and it can transform how we view ourselves,” she said.
Her experience with cannabis as a treatment option has led her to believe that medical professionals need to get away from this daily pill, pharmaceutical type of mentality. “We need to focus a little bit more and put evidence into looking at lifestyle changes, talking more about nutrition and movement. Also, really just to have physicians have a little bit more of an open mind. If they see that things are not working, don’t just increase the dose. If we don’t have good treatment options, then we need to go find better options and we need to be honest with the patient,” she said.
Dr. Weiner believes in the next five years a lot is going to change with mental health and chronic pain. “I think we’re going to really get away from the opioids to treat chronic pain and only give that for like three to seven days after an acute trauma or surgery. Patients are going to start to understand how to use botanical medicine and rely less on physicians,” she said. “I think as we modulate the endocannabinoid system, we’ll be able to decrease chronic conditions, which is really the goal.”
David Hodes has written for many cannabis publications, and organized or moderated sessions at national and international cannabis trade shows. He was voted the 2018 Journalist of the Year by Americans for Safe Access, the world’s largest medical cannabis advocacy organization.