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Cancer Issue September|October 2019

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Cancer & Cannabis

An interview with Bonni Goldstein

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Bonni Goldstein is an M.D. and medical director of Canna-Centers Wellness & Education as well as Medical Advisor to Weedmaps.com. She is the author of “Cannabis Revealed: How the world’s most misunderstood plant is healing everything from chronic pain to epilepsy.” Dr. Goldstein studied medicine at the University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School, now Rutgers. It was during her clinical rotation in 1988 that she discovered her calling in pediatric medicine. 

When she was in medical school in the late 1980s, she was taught that cannabis is a drug of abuse. But, she’s a self-described science nerd, and her intense curiosity led her on a path to becoming a prominent pediatric cannabis specialist.

Goldstein didn’t start off bucking the system. She did her residency at Children’s Hospital Los Angeles. Then she stayed on the next year to help them run the residency program. She started working as a critical care transport physician. In this role, she would travel to area hospitals where seriously ill kids came in with dire medical conditions, such as cardiac arrest or breathing problems related to an undiagnosed heart condition. Her team’s job was to go to the area hospital, stabilize the child, and bring them back to Children’s where there were specialists who could care for them.

“Sick children make doctors nervous,” Goldstein says, especially when it’s a hospital without a pediatrician. “And there were a few times where I walked in, and we had to literally save the child’s life and make sure they were stable before we would even put them in the ambulance.”

Later, Goldstein transitioned from that job into pediatric emergency medicine, which she did for about 13 years. 

“I got a little burned out after I had my own son and was trying to be a mommy and a doctor,” Goldstein says. “I really enjoy being a doctor, so the way I did it was I worked graveyard shift for the first five or six years of my son’s life, and then was a mom during the day.”

Finally in 2006, she took a leave of absence to teach science, catch up on her rest, and to reassess what she was doing. A friend, who was struggling with an illness asked an innocent question that would send Goldstein on a completely different path.

“She asked me what I knew about medicinal cannabis,” Goldstein says. “I knew nothing.”

She did some research for her friend and was at once intrigued by the science of the endocannabinoid system—how cannabis interacts with the human system. She took a job in a medical cannabis doctor’s office in Southern California. 

“Within the first two months of working there, I just fell in love with the practice and delved into the science. That was 2008, and then in 2011, I took over the practice.”

She has a few adult patients who have been her patients for many years, but as far as new patients, she’s only accepting pediatric patients. The most common conditions she treats are cancer, epilepsy, autism, ADHD, some genetic syndromes, and gastrointestinal disorders. 

“I have pediatric patients that were having 40 seizures a day, and they no longer have seizures as long as they take their cannabis,” Goldstein says.

The science of the endocannabinoid system is what intrigued Goldstein. It’s is a system in our bodies that is made up of chemical compounds called endocannabinoids and receptors called cannabinoid receptors. Our bodies have all kinds of different receptors. Each one acts like a lock, and chemical compounds we make in our body act as the keys. For example, we have serotonin receptors, and we make serotonin; we have dopamine receptors, and we make dopamine.

“We make endorphins that fit in our opioid receptors. We don’t have opioid receptors for the pharmaceutical opioids. We have them because we make our own opioid-like compounds,” Goldstein says. 

It turns out that we make our own inner cannabis-like compounds called endocannabinoids. 

Goldstein says that the goal of these compounds is to balance messages that cells are sending each other. Take epilepsy and autism. These are both conditions that are neuroexcitatory conditions. The brain is over-firing and in a healthy brain if there’s over firing, the endocannabinoid system goes into action. It’s triggered by that over-firing, and it sends these chemicals—these endocannabinoids—out to tell the cells to stop over-firing. 

“It’s not magic. It’s not fairy dust,” Goldstein says. “It’s where are these compounds working?”

They’re interfacing with our endocannabinoid system. We also know that it’s more complex. CBD works outside on other receptors and systems other than the endocannabinoid system. Ultimately, our understanding of how cannabis is medicine is based on its interaction with the endocannabinoid system. For people who have an imbalance in that system, the compounds in cannabis can provide augmentation or supplementation to make the endocannabinoid system function better. 

It all comes down to where the receptors are located. So those cannabinoid receptors are dense in the brain, the immune system, and the gut. And so, when you think about those diseases that can affect your brain, immune system, and gut, there are a lot of conditions. 

“These receptors are also in our heart, kidneys and liver, our connective tissue in our skin,” says Goldstein. “So they’re everywhere.” 

Why Cannabis?

One reason why cannabis works for some patients might be because a patient suffers from a deficiency in their own endocannabinoids (endo for internal). Goldstein says there is some evidence to show that there is an underlying endocannabinoid problem in epilepsy and autism, two of the main conditions that she treats. 

She points to a study out of Stanford University last year that documented that children with autism have statistically significant lower levels of endocannabinoids. 

“The way I look at this is would you ever leave a child deficient in any other compound,” Goldstein says. “We don’t leave someone deficient in thyroid hormone. We don’t leave someone deficient in vitamin D. For someone with type 1 diabetes, we give them an external source of insulin.”

“Cannabis as medicine is not something to take lightly,” she says.

“It’s very, very important to me that people separate medical use versus recreational use. They are not the same thing,” Goldstein says. “Remember medical use is informed. It is supervised. It is controlled. And the goal of the use is to treat the medical condition.”

Referring back to the insulin example, she says she would not give insulin to someone who did not need it, because it could be harmful. The same goes for cannabis. Goldstein only sees patients after a prescreening suggests they might have an endocannabinoid deficiency or imbalance.

Goldstein says she’s a pretty conservative physician. She starts with low doses and titrates up, aiming for the lowest dose to get the desired effect with the least amount of side-effects. Her office also asks every patient if they have side effects and vast majority say ‘no,’ Goldstein reports.

And just like other medications for conditions such as high cholesterol or depression, patients often try different preparations before they find one that is both effective and tolerable. Fortunately, in California, cannabis is very regulated through dispensaries, and some companies have worked very hard to have a consistent preparation, Goldstein says. 

“I spend a fair amount of time educating parents on what they’re looking for. And the reality is that there is no one size fits all. And often patients try different preparations to find what works best.”

Cannabis and cancer

Goldstein points out that with cancer there are different goals. One is treating symptoms—symptoms from cancer itself and side effects of chemo, radiation, or other treatments for cancer.  The other goal is to kill cancer cells. She has treated patients with many types of cancer, including lung cancer, brain tumors, gynecologic cancers, leukemia, lymphoma, pancreatic cancer, prostate cancer, and breast cancer. 

Though Goldstein has had positive results, she says it’s really difficult to draw any conclusive results from these.

“People come at different stages in their cancer,” Goldstein says. “Unfortunately many people come at the very end, stage four and have been given two months to live.”

Still, she can say with confidence that patients can take cannabis for symptomatic treatment—to gain appetite, help with anxiety, sleep, and side effects from chemotherapy and radiation—that those patients benefit from cannabis. She also says that she feels anyone with a diagnosis of cancer should consider starting medically supervised cannabis earlier than later.

One reason is that she says there is clear-cut evidence that phytocannabinoids from the cannabis plant—when put in a test tube or even an animal with cancer—can slow the growth of the tumor and can cause the cancer cells to die and can block some of the signaling messages that cancer cells send to metastasize and to grow their own blood vessels. 

“The big question is, of course, what about humans?” Goldstein says. “Well there are exactly two clinical trials. Both have been in patients who have glioblastoma multiforme. It’s the cancer John McCain had. A very deadly, aggressive brain cancer that has a terrible prognosis. 

“The second clinical trial is being done by a pharmaceutical company and they have posted some of their results online. They took 21 patients with recurrent glioblastoma multiforme and divided into two groups. One group got chemo only. The other group got chemo plus THC and CBD. All they have reported at this point is that at the end of one year, the survival for chemo alone was 53 percent. And the survival for those that had cannabis added into the chemo was 83 percent. So there’s clearly something there, right?”

What evidence is missing?

There are more than 400 compounds reported in the cannabis plant. As a physician, Goldstein wants more research to answer critical questions, such as which compounds or a combination of compounds in the cannabis plant kill the cancer? She is pleased by ongoing research in Israel right now looking at this question. She wants to know how she knows her patient who is coming to see her is going to get the right combination to kill this specific type of cancer that they have? What’s the best way to take it? How much should you take? What’s the dose? How long do you have to take it? All of those questions remain for cancer. 

For now, most of the basic scientific research is happening abroad, because cannabis is still a schedule one drug in the United States. 

“We are so far behind,” Goldstein says. “We’ve lost 80 years because of prohibition.” 

Even so, Goldstein carries on. She has many success stories.

One patient I wrote about in my book was 15 when he came to see me,” Goldstein says. “He had stage 4 bone cancer called osteosarcoma. And he went into remission after three months of very high doses of cannabinoids. He was given about three months to live and had over 20 tumors in his chest. And now, he just turned 20 this year and remains cancer free. And there’s a handful of other patients too. I don’t see any reason not to use cannabis.” 

Goldstein cautions however, that cannabis can change how other medications behave by either increasing or decreasing their activity. 

“You have to be careful about that,” she says. “Being informed is the key.” 

“People say ‘cannabis cures cancer,’ but that is just a sweeping generalization,” Goldstein says.

“Cancer is not really one diagnosis. It is hundreds of different diagnoses, different processes. Cancers all are different. So I don’t want to call that a myth. It can have some effect on the cancer, but again we’re missing a lot of really important research.”

She also says that cannabis is not 100 percent benign or safe. 

“I would say that’s about 80 percent true,” Goldstein says, “but I have seen cannabis increase seizures in children. I’ve seen cannabis aggravate autism. You have to be cautious.” 

Goldstein works with other physicians who spend a couple of days to a week shadowing her. “The can see the real world use of cannabis, the way that I approach it, and the way that I help patients come up with a protocol or a plan. I’ve had a lot of doctors come from California but also doctors from New York, Maryland, Florida, Missouri all come out and spend time in my office to learn.”  

A few educational recommendations from Dr. Goldstein:

“There’s a wonderful book called “Cannabis Pharmacy” by Michael Backes. I haven’t read all the books out there, because I mostly read the scientific literature. There’s also a lot of nice information on the website projectcbd.org and Whole Plant Access 4 Autism at wpa4a.com—it’s a great place to start if you’re just starting to research cannabis.”

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The Magazine

Children’s Issue July|August 2019

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The Dis-List

Cannabis and Anxiety

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“What, me? Worry?” This iconic signature phrase was on the front cover of MAD magazine, emblazoned under the face of Alfred E. Newman. Anxiety, and the associated psychological and physical symptoms, is the most prevalent mental illness in the US—affecting approximately 18% of the population. Anxiety manifests differently in each person and it originates from a variety of risk factors including life events, genetics, and personality. And although the “What, me? Worry?” attitude is attributed to male archetypes like Alfred E. Newman, it is women who primarily suffer from anxiety disorder, twice as frequently as men.

There are traditional therapies that are used to treat anxiety and its co-associated disorders. The treatment protocols and success rates vary, just like the anxiety presentation itself varies from patient to patient. Patients respond differently to different treatment options, and some may do well with a combination of techniques such as cognitive behavioral therapy, meditation, other complementary treatments, and a pharmaceutical medication. This multi-modal approach is well-accepted by traditional medical practitioners even though it has varied success rates. 

So how does cannabis fit? It depends. Some physicians and other health care providers are suspicious of cannabis, believing it will cause more harm than good—and in truth, that is a possibility. The over consumption of cannabis products containing high concentrations of THC, the intoxicating molecule in cannabis, may actually mimic a panic attack. Patients who do not consume cannabis regularly, overconsume cannabis with high concentrations of THC, or who are completely new to consuming cannabis may be sensitive to some of THC’s effects. THC may cause a rapid heart rate, dry mouth, and an overwhelming feeling of fear or anxiety—which is similar to many of the symptoms experienced with a panic attack! 

However, there are many patients who use cannabis to help treat their anxiety disorders. How can this be if the effects of THC imitate a panic attack? Well, the answer is that not all cannabis is alike. Cannabis is like an entire pharmacy in a plant. Different cultivars and cannabis products contain varied amounts of THC and the non-intoxicating CBD (the second most predominant cannabinoid), as well as other constituents. The different combinations of chemicals can be used to discover which mix helps reduce anxiety for each individual patient. 

If you are considering using cannabis to see if it works for your anxiety, you may want to start with a cannabis product that contains all or mostly CBD. CBD is a non-intoxicating chemical that carries no risk of causing panic attack-like effects, as it works differently in the body than THC does. There are also animal studies which report that CBD does work on serotonin receptors—and these are the very same receptors that pharmaceutical drugs known as SSRIs target to treat anxiety. 

Another animal study showed that CBD helped increase the number of hippocampal nerve cells in the brain. (Hippo-what?) The hippocampus is a structure in our brain that is in charge of many things, such as regulating memory and emotions. This includes anxiety. Brain scans of people who suffer with anxiety show that they have a smaller hippocampus than people who do not have anxiety. Both CBD and SSRIs may help to regrow the hippocampal nerve cells to increase the hippocampus size and possibly reduce anxiety. 

What about terpenes? As we know, cannabis is more than just cannabinoids. There are over 400 constituents in the cannabis plant. Terpenes are some of the chemicals that give cannabis its scent and taste. They also have therapeutic effects. Cannabis products that contain the terpenes myrcene and limonene, for example, may create a sense of relaxation and may lessen the feeling of anxiety. Cannabis products that contain a lot of the terpene pinene may create an energized and focused feeling in some, but may make other people feel anxious. 

The upshot? Is THC the evil demon? Not necessarily. There are patients who require some amount of THC in combination with CBD to effectively treat their anxiety. It is just prudent to start at a very low concentration of THC or start with no THC and slowly add THC and titrate to higher concentrations of THC if needed. The panic-like feeling dissipates with continued cannabis use. 

There is no one cure for every person, whether it is conventional medical therapy, medical cannabis, or a combination. Risks and benefits of every treatment need to be weighed before starting any treatment. Consult your recommending physician and be willing to try different combinations, as every person responds differently.

Be well,

Dr. Deb

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