RHR: Discovering the Potential of Medical Cannabis, with Mikhail Kogan

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The use of medical cannabis has been highly stigmatized over the years. There was even a ban on researching it for any medicinal use! But given the potential that this botanical medicine has and how well tolerated it is by most people, it’s becoming a huge asset in the integrative medical model. In this episode of Revolution Health Radio, I talk with medical cannabis expert Dr. Mikhail Kogan about the role of cannabinoids in today’s medical landscape, the stigma that surrounds them, and how to safely prescribe medical cannabis to eventually replace conventional medications.

In this episode, we discuss:

  • Mikhail’s background with medical cannabis
  • The role of cannabis in today’s medical landscape
  • The power and use of different cannabinoids
  • Navigating the stigma of cannabis use
  • How Dr. Kogan prescribes medical cannabis
  • Tips for beginners: where to start
  • The future of medical cannabis

Show notes:

 

Hey, everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. I’ve been a big advocate for medical cannabis for many years now. We use it in our clinic with patients in California with great success, and I think it’s a potent and very promising medicine for a number of different conditions, ranging from the conditions it’s best known for, like supporting patients who are going through chemotherapy, one of its longest-term uses in medicine, to Parkinson’s disease, to chronic inflammatory neurodegenerative conditions, to chronic pain, to insomnia, to depression and anxiety. And unfortunately, in the [United States], the use of medical cannabis has been highly stigmatized until quite recently. There was even a ban on researching it for any medicinal use, which is just insanity in my view, given the potential that this medicine has and how well-tolerated it is by most people.

Certainly, as with any other substance, there is potential for abuse. But when it’s used appropriately and strategically, it can be a huge asset in a wide range of conditions, as I just mentioned. It’s also not under the supervision or patent of Big Pharma, which is perhaps one reason why it hasn’t been as readily available as it might otherwise be. There’s not a big financial incentive for pharmaceutical companies in the case of this treatment, and I’m really excited to see that it’s now starting to get the attention that I think it deserves. A number of books have been published, there’s more research happening, and, in many states, medical marijuana is permitted with prescription, and, of course, in some states, you can get it without a prescription.

So today, we’re going to be talking with Dr. Mikhail Kogan. He is a leader in the newly established field of integrative geriatrics. He’s the chief editor of the first definitive textbook of this field called Integrative Geriatric Medicine, which is published by Oxford University Press as part of [the] Weil Integrative Medicine Library series. And he’s a frequent speaker at a variety of international conferences on the topics of integrative medicine, geriatrics, healthy aging, as well as medical cannabis, which is the topic we’re going to discuss today. Dr. Kogan’s main medical cannabis expertise is in treating older patients, the geriatric population, and in palliating symptoms at the end of life. He also treats a wide range of internal medicine problems from chronic [gastrointestinal] issues to cancers where the use of medical cannabis can also be beneficial. Dr. Kogan has a new book out in October 2021 called Medical Marijuana: Dr. Kogan’s Evidence-Based Guide to the Health Benefits of Cannabis and CBD, and that’s going to be the focus of our discussion today.

I hope you enjoy the interview, and I hope that you or someone in your life can benefit from this information because as I said before, as a clinician, I’ve seen huge benefits in using medical cannabis with patients [who] are a good fit for it. So let’s dive in.

Chris Kresser: Dr. Kogan, welcome to the show. I’ve really been looking forward to this conversation.

Mikhail Kogan: Thank you. Happy to join.
Mikhail’s Background with Medical Cannabis
Chris Kresser: I’d love to hear a little bit more about how you got interested particularly in using medical cannabis in general and then medical cannabis in the geriatric population that you specialize in working with.

Mikhail Kogan: In 2012, Andrew Weil asked me to join the new forum, American Board of Integrative Medicine, as one of the founding board members. And Donald Abrams was there with me. And then basically, exactly at the same time, GC passed the medical cannabis law, and in 2012, they started the process of registering patients. So, on one hand, I became pretty close friends with one of the grandfathers of the whole field, and also, it just kind of got pushed into doing this. And I always tell everybody, in geriatrics, unfortunately, the motto is de-prescribe. We’re all quite well aware that so many older patients are on so many medications, and I don’t really have any better tool than cannabis for probably a third of all geriatric problems. Not just symptoms. I’m talking about actual management of problems, too.

Chris Kresser: Yeah.

Mikhail Kogan: Yeah.

Chris Kresser: Yeah, that’s a pretty incredible statement on the surface, given I think the statistics are something like the average 65-year-old is on at least five medications, if I recall.

Mikhail Kogan: You’re exactly right. And something like 30 percent of people over 65 take more than five medications. Like think about this; it’s mind-boggling, right? Because even if they don’t take any other supplements or any other over-the-counter medications, still, the amount of interactions and potential side effects is crazy. And actually, [in] the last year, maybe two years ago, the medications, appropriately prescribed medications, became the third most common cause of death in people over 50.

Chris Kresser: Yeah, I’m aware of Barbara Starfield, when she was alive, was studying that at Berkeley and published a lot on iatrogenic events, as you just mentioned, being one of the major causes of death. Some, even in that paper you just referenced, I believe they suspected that if those events, because of underreporting, it may actually be the number one cause of death if those iatrogenic events were fully reported. Which again, I don’t think it’s an indictment of individual physicians who are largely doing their best. I think it’s more if anything, an indictment of the care model that we have.

Mikhail Kogan: Think of it this way: the conservative estimate, and as you said, it probably is way off, but [the] conservative estimate is somewhere around [a] quarter of a million people per year. So in two years, roughly, or three years, it’s basically the cost of the entire pandemic. And we don’t really talk about this every year, as if there’s this massive elephant in the room that nobody talks about. For everybody, it’s just the cost of doing business.

Chris Kresser: Right.

Mikhail Kogan: When I started practicing, I was like, well, I really want to learn tools that are, not that.

Chris Kresser: Yeah, I have experienced this personally with people in my life, my grandfather several years ago and then, most recently, my aunt, who is at the end of her life, and is taking seven or eight different medications and is suffering greatly. And as a clinician, myself, I know that a large part of her suffering actually is related to the side effects and the interactions of the medications that she’s taking. But the doctor’s response is generally to prescribe another medication to try to deal with those side effects, which, of course, becomes this vicious cycle where more and more medications are added, more interactions, more side effects, and it’s like this treadmill that becomes very difficult for elderly people to get off of, which I’m sure you know better than anybody else.

Mikhail Kogan: That’s probably half of the work we do in the hospital when patients show up with problems, half of what we do is what can we stop here?
The Role of Cannabis in Today’s Medical Landscape
Chris Kresser: So what, in addition to this issue that we’re talking about, maybe interactions of medication or overprescription and not adequate supervision, what are some of the other issues in the geriatric population that were not being adequately addressed with the standard of care?

Mikhail Kogan: Well, Chris, this is not a typical podcast, right? So I think we can talk frankly.

Chris Kresser: Yes, absolutely.

Mikhail Kogan: I’ve been following Dale Bredesen’s work, and actually, we co-published a number of papers together. And we know that the cognitive impairments, processes, whether it’s Alzheimer’s [disease] or others is basically completely unmanaged and any of the approved medications for Alzheimer’s disease are a joke. So when we have approaches in integrative Functional Medicine that are extremely effective, I mean, to the point that in our own clinic, we already have dozens of patients who have totally recovered from Alzheimer’s disease, and stay recovered for years, three, four, five years. And so, that’s totally untouched.

I’m personally fascinated [by] the role that cannabis can play in this smaller area of geriatric care, because we do know that for advanced Alzheimer’s disease symptoms, such as agitation, what we call neuropsychiatric disturbances, cannabis is very effective. Whether it’s effective as a part of a package for reversing Alzheimer’s [disease], we don’t know but really want to know because I think the potential is quite there, especially if you understand the endocannabinoid system; you’ll know that with aging, endogenous production of anandamide and other major endogenous cannabinoids drops and drops pretty quickly after the age of 50, 55.

Chris Kresser: Yeah.

Mikhail Kogan: So replacing it could make some sense for a lot of medical problems.

Chris Kresser: I’ve seen particularly remarkable results in [patients with] Parkinson’s [disease] and patients with similar motor dysfunction. I’m wondering what your experience has been with that.

Mikhail Kogan: It’s interesting; the experience is very heterogeneous, very mixed. And that’s part of the challenge. With certain conditions, let’s say insomnia, or even some intestinal problems, like constipation or irritable bowel syndrome, it’s extremely predictable. But for more complex issues, the results are kind of all over. I have some [patients with] Parkinson’s [disease] who would take some sublingual or inhaled, and all of their motor symptoms get a lot better, and then some for whom it does absolutely nothing. I think we’re just at the baby steps of understanding what’s what. And what’s interesting, or what’s really clearly interesting, is that cannabinoids have so many modes of action; [they don’t just] relieve a spasm or a pain. They’re anti-inflammatory and they’re antiviral, and they have so many regulatory functions in our body that I think we’re just dipping our toes into an entire new field of medicine; I can call it endocannabinoid medicine or something like that.

Chris Kresser: Right. And I know, you have an appreciation for this as Dr. Weil would, as well. But as an herbalist, myself, one of the things that’s often surprising to people with a more conventional medical background is the understanding that botanicals can have entourage effects. And they also can have adaptogenic effects where a medicinal might work in a certain way in one person given certain circumstances and it might work in a different way in a different person given other circumstances. I wonder if you’re sort of alluding to that where the impact and even the mechanism of action of cannabis might differ in different situations, and we really don’t yet have a strong understanding of this in part because of the research ban that’s been in place for so many years with cannabis.

Mikhail Kogan: It’s even different based on the route you take, based on what you ate half an hour ago, based on so many things that it’s fascinating. And I think it’s such a great example of botanical medicine in principle and not just how effective it can be but also how broadly active it is and how it interplays with our physiology and our biochemistry to the point where a lot of the things are not just partially predictable, but they have dependence on so many different things. And what’s even better, I think, for our entire field is through the medical cannabis, I think a lot of [doctors] and a lot of regular standard practitioners are starting to look at the whole field of botanicals a little different[ly], a little more open[ly], more accepting, because they’re finally realizing wait a second; it’s the whole plan that tends to work. They’ve tried giving Marinol or any kind of synthetic cannabinoids where impact is, I don’t know, 10 times or whatever it is, less potent. So it opens people’s eyes to say, wait, why is the botanical working but not synthetic? Well, because that’s how it works.

Chris Kresser: Yeah.

Mikhail Kogan: It took you 30 years to realize that. We have this very famous expression in the Russian language, “Better late than never.”

Chris Kresser: Yeah, maybe there’s something to this wisdom of plant evolution and all of these compounds that are these thousands of compounds that are in the plant or playing some role that we, with our human brains, don’t yet fully comprehend and that it’s better. We should endeavor to comprehend them and do more research, but in the interim, almost always, as an herbalist, I will defer to the whole plant for that reason because I think there’s so much more of a holistic impact there.
The Power and Use of Different Cannabinoids
Chris Kresser: And, as you alluded to, we haven’t even touched on the differences in strains, broad categories like indica vs. sativa and then even within indica and sativa all of the different effects that different strains can have and the different cannabinoids that have been recently discovered, [tetrahydrocannabinol] (THC) and [cannabidiol] (CBD) being the main ones that maybe most people have heard of and are familiar with. But there are other cannabinoids that we know of now that have distinct actions that are different from CBD and THC. And then, as you pointed out, the routes of delivery like edibles and topicals and vaporizers and suppositories all lead to a different subjective and even objective measurable effect.

Mikhail Kogan: Yeah, absolutely. I’m more fascinated now with some of the less common cannabinoids, two in particular come to mind. [One] is CBDA; it’s an acidic form or a cannabidiolic acid form of CBD, which comes from raw hemp. And that seems to be [a] very potent anti-inflammatory, specifically for things like arthritis where you need to have a COX-1, COX-2 inhibition. And for a lot of my older patients, I don’t even give them Motrin or Advil because it’s actually quite dangerous. They can have bleeding, they can have kidney problems, and CBD actually works quite well for a lot of those typical age-related arthritis, osteoarthritis we call it, right?

And then [cannabigerol] (CBG) is one of the newest ones, which seems to be a very good mood enhancer and appetite stimulant. So that’s one that I find quite often when the THC appetite enhancement is sort of unpredictable, plus you have to usually smoke it or inhale it, which is probably not the best route for a lot of older people.

Chris Kresser: Sure.

Mikhail Kogan: And so often, you want to give something that’s less psychoactive, although psychoactive is a bad word, I guess; intoxicating would be more appropriate.

Chris Kresser: How about [tetrahydrocannabinolic acid] (THCA)? I’ve seen some interesting research on its anti-inflammatory benefits and anticonvulsant and neuroprotective action. I was thinking of it when you were talking about cognitive issues and Alzheimer’s [disease] and even Parkinson’s [disease].

Mikhail Kogan: Yeah, absolutely. I’ve seen some work done where you would use what’s called a quadruple balanced strain like one-to-one to one-to-one THC, THCA, CBD, CBDA. Yeah, I think THC is a very potent anti-inflammatory. I think it’s going to take up its place. I know people who do a lot of neurology. I don’t actually do a lot of [work with] seizures, but I’ve heard people say that THCA and, to some degree, CBDA can be used as an anti-seizure quite effectively. Because if you use CBD for seizures, your doses have to be very high.

Chris Kresser: Right.

Mikhail Kogan: And the issue is also when the doses are very high, you also start wondering about drug-CBD interactions because they’re real.

Chris Kresser: Yeah.

Mikhail Kogan: And that’s a little bit of a, vs. CBDA, [which] does not have those interactions, or THCA.

Chris Kresser: Yeah, so that was going to be my next question, actually, is there research suggesting that very high doses of CBD inhibit cytochrome P450, and that can lead to higher circulating levels of medications; it could interfere with medication. At what dose of CBD do you typically become concerned about that?

Mikhail Kogan: I think it actually, at least in part, depends on the

. Let’s say [for] somebody who’s really frail in [their] 80s and 90s, I start getting worried over 100 milligrams per day. I think if somebody is a lot younger, 30s, 40s, mid-life or even younger, you’re probably not going to be, practically speaking, it’s probably not going to be that much of a deal until a [much] higher dose. Although I have actually seen opioid overdose when CBD was added at [a] high dose, like 200 milligrams, 100 milligrams twice a day. I saw that once, and the patient was not actually very frail. [They were in their] late 60s. It was a lot of back pain, and CBD was added by the neighbor’s suggestion, and there was that reaction.
Navigating the Stigma of Cannabis Use
Chris Kresser: Right. Tell me about your experience over the last few years in terms of the acceptance or lack thereof of medical cannabis, both within the medical community among your colleagues and also within the geriatric population that you’re working with. Because, of course, cannabis has been highly stigmatized for many years, and only recently, I think, the general public has started to gain an understanding of its medicinal value. So, what’s the typical response from a geriatric patient that you work with when you suggest medical cannabis? And how has that changed over the past five years, if at all?

Mikhail Kogan: Shockingly, I think it didn’t really change much. I think if you present cannabis as not a drug that’s going to cause other drug overdose or something like that, where you just normalize it, then you say, look, well, you have a chance with cannabis to get off some of the other drugs. I almost never hear an older person say absolutely not. In fact, think of it this way. Most people who are 65 plus probably have tried cannabis recreationally in their hippie years, right? So there is some experience there. And I actually find more resistance among kids. And then suddenly, [there’re] way more acceptance among grandkids. So it’s not an atypical situation for me to be in a room with two generations, with three generations, really. And then the grandkids [were like] I told you so. [You] should have started this years ago. And the kids would sit there with their mouths dropped thinking did you tell our 100-year-old mom to start taking marijuana now? Yeah, that’s exactly what I said. And she should be putting it in the rectum. And they’re like, what?

Chris Kresser: Yeah, I bet that’s over the top for them.

Mikhail Kogan: Yeah, but most of the time, [the] conversation is actually very easy. It’s very encouraging because they’re suddenly realizing it’s not a pharmacologic treatment; it’s going to have no side effects. And most people really want to try. The issue comes up all the time, and it’s less for me in the geriatric practice, more of a functional integrative medicine practice, because I do both, if somebody works for the federal government. Because there’s still a zero-tolerance policy, and I always, because our clinic is in [Washington,] DC, so I think [a] pretty high proportion of all of our patients at [the] Center for Integrative Medicine [are] working for the feds. So we have to ask, and we tell them, look, if something happens, [and] you get fired, we can’t protect you. I’m actually serving quite often as an expert witness in different legal cases on this topic. And if it’s not [the] federal government, believe it or not, on the East Coast, the tide changed a few years ago. And so most of the patients are actually winning now.

I even saw cases against the local jurisdictions, not just against some private company, but against the city of DC where the person was fired, because they thought she [came] in intoxicated, but she was prescribed the recommended [dose] correctly and was taking it for back pain. So it’s shifting. I mean, I think the whole field is shifting toward more acceptance, except, as you said, I wish our own colleagues within the western model would shift a little faster. I think a big part of it, first of all, there’s just not enough education, right? There’s no standard medical curriculum in any of the American medical schools that formally teach practical tools. They teach addiction, they teach side effects, they teach consequences of long use of cannabis and all that, but they don’t really teach students when they graduate and start working if somebody asks you, “Should I use it?” Students have no idea what to say to them. They don’t know how to recommend it; they don’t understand the basics. So that has to change, I think, before the whole future of the allopathic model will embrace it because you have no role models in standard institutions, and then you’re not graduating classes that can take that on. It’s going to be a gradual process.

Chris Kresser: That’s right, and if you don’t educate the physicians and medical professionals adequately, then they don’t feel prepared and confident to be able to make good recommendations. And they’ll just leave it alone and not recommend it at all. So yeah, I agree 100 percent with that.
How Dr. Kogan Prescribes Medical Cannabis
Chris Kresser: So I have my process in answer to this question, but I want to ask it to you: where do you generally start, let’s say a typical geriatric patient with medical cannabis? Are you beginning with CBD only? Or are you using ratios like four to one in favor of CBD as a starting place to get them to see how they respond? And [what] do you think about the ratios of CBD and THC in your patient population?

Mikhail Kogan: Well, generally speaking, THC always [has] to go first just in terms of the evidence-based and, more importantly, in terms of efficacy. The issue though why practically most people try CBD first is because they have to get a card, and in our area, DC, Maryland, and Virginia, you’re looking at say [a] four- to six-weeks wait period unless patients [are in] hospice. And if the patient is [in] hospice, they only really need mostly THC anyway. And so really, by the time they get the card, usually, I say why don’t you just try some over the internet hemp extract full extract first before and then see. Maybe say [a] person comes for insomnia, and I say why don’t you try 150 milligrams of CBD at bedtime, and if it’s enough and maybe you can mix it one-to-one with [cannabinol] (CBN), and if it works, great. And actually, then it becomes a lot cheaper, too, although frankly, it all depends on the dose because sometimes you can microdose THC and it ends up being way cheaper than even low-cost hemp sources.

So I think it really depends on the type of a problem, the type of a patient, and what you’re trying to do. If you’re trying to augment some other therapy, CBD can have a pretty decent role. But if you’re really trying to control [a] primary symptom, let’s say they’re coming in with cancer-related pain, I wouldn’t even think of CBD. I just go straight for THC. And [the] ratio there, that’s a good question. I usually start with one-to-one THC to CBD for pain mostly because if you keep increasing CBD, part of the issue is you actually may have a lower impact.

Chris Kresser: It offsets the effects of THC.

Mikhail Kogan: Exactly. So for some conditions, that’s a good thing, right? For some problems, you would want that. But for [others], you would not. So again, it’s kind of hard, and also what should be the first route of administration? I think that’s also a really big question. If somebody comes in with back pain, I don’t think I’m going to be giving them edibles. So I’ll just try suppositories as a first line. But if they come in with constipation, [small intestinal bacterial overgrowth], I will microdose a milligram of enteric-coated THC three, four times a day, and that is pretty much one of the most effective adjuncts that I have seen.

So it really mostly depends on [a] combination of [the] presenting problem and how strong the body is because I think that’s another thing. If somebody is really frail, you have to be careful with THC. It’s kind of easy to overdose, especially if they start, if they don’t know, and I have so many stories. I would write a card and then somehow would either not [be] able to talk to the patient or I didn’t write the card, somebody else did, and they end up in [the] dispensary, and a 90-year-old gets put on 10 milligrams [of] oral gummy day one, and then I get a call [that the] patient [is] in the emergency room. That happens probably once every few months, unfortunately. That’s just not understanding [the] basic physiology of aging or pharmacokinetics of an aging process, and I wish dispensaries, well, they’re actually getting better, I think, in a lot of states, including Maryland recently. They now require some kind of a medical educator to make sure that all this staff has some basic medical knowledge. Because often, at least in the past, a lot of the budtenders were high school kids; I’m not kidding.

Chris Kresser: Right. I’ve also seen the same shift when I was in California. Now I’m in Utah, which only has medical cannabis, but the general level of understanding in the budtenders is much, much higher here even than I would say in California because it’s only medical here. Whereas in California, you have recreational use. And so a lot of dispensaries were not even oriented toward medicinal use, and that level of education there was fairly low.

Some people are probably maybe a little overwhelmed based on the conversation so far because we’re throwing around a lot of terms. And as I’m sure the listeners can gather, there’s a lot of nuance here. We’re not just talking about [buying] whatever CBD product that your neighbor recommends or your friend or something that you found on the internet. There’s a lot of nuance in terms of strain, dose, route of administration, etc. And I want to come back to dose in a moment because I think this is an area where people really falter, just due to lack of education. Well, let’s talk about that now, and then I’ll come back to what I was going to ask. You said someone could take 100 milligrams of CBN for insomnia. Now [for] most consumer products you buy, the suggested dose I found is way too low. So [I’m] talking about on the bottle, it might say take five, take something that ends up being five milligrams. Or you might sometimes see 25 milligrams, and then the patient will come to me and say, “Well, I tried CBD or CBN or whatever, and it didn’t work.” And I’m like, “How much did you take?” And they’re like, “I took five milligrams.” I’m like, “That’s like a homeopathic dose of CBD.”

Mikhail Kogan: Well, I think the idea here is, I actually do start very low. Like you mentioned CBN. I don’t think anybody ever is going to need that high of a dose per day, although some people may. But I will typically start CBD or some kind of mix at somewhere between 10 [and] 15 milligrams of CBD equivalent and then go up. That does two things. One, you decrease any chances of any side effects. But two, you widen the therapeutic window. It’s a pretty unusual concept. If you take a medication, if you take [the] same dose day one, two, three, and four, you’re not necessarily expecting that on day five, there’s going to be a more significant impact from the same exact dose, unless the medication accumulates and there are some. But with cannabinoids, it’s interesting that often, if you give the same small dose, and then you start increasing the dose gradually, the increment of increase achieves a [much] bigger sudden boost of efficacy than you would expect, and that’s that widening of therapeutic effect. That’s why you start low, and you keep titrating until you hit the sweet spot, and then you stop. That’s another huge mistake. People often think, okay, so I got myself to 7.5 milligrams of THC at night for insomnia; well, I want to sleep an extra hour, [so] let me take 15 milligrams. And then boom.

Chris Kresser: Yeah, then they’re waking up.

Mikhail Kogan: [They have] headaches and they actually sleep less, not more. There’s also this principle of this U-shape[d] effect. So you have to find the most effective window and then stay in it. And if you do need to increase periodically, sometimes it does happen; you go up. But again, you’re titrating it very gradually. I would say the only exception to this rule is pain. And a lot of people come in with severe chronic pain. Sometimes we go up very quickly, like we’re not waiting for a week on the subtherapeutic dose of five days. We’ll go a couple of days of a low dose and then very quickly taper up by 50 percent, so each subsequent dose until they feel some pain relief. That’s probably the only exception I can, well, maybe severe nausea; it’s kind of the same, as well.
Tips for Beginners: Where to Start
Chris Kresser: The question I was going to ask was given all of this complexity, where should someone start? And I know the answer will depend on [whether] they [are] working with a clinician that’s knowledgeable in this area. Let’s assume for the time being that someone’s just listening to this podcast and they live in a state where recreational use is not permitted. So they’re going to be limited to products that you can buy legally on the internet that are made from hemp. And just to clarify for all the listeners, there are CBD products that are made from [the] cannabis plant, marijuana that you cannot buy online, and then there are CBD products that are made from hemp that you can buy online.

So maybe let’s start there because I think that’s probably going to be the majority of listeners who either don’t live in a state where they can get marijuana products on their own, or if they do, they’re not comfortable because they don’t have someone who’s guiding them. So what advice would you offer in terms of where to start with CBD products that you can buy online?

Mikhail Kogan: First of all, let’s just talk about general, right? Because there [are] so many CBD companies. I’m not going to single [out] anybody or say that this is my favorite. I think that would not be appropriate. But I would say that they must be organic; the brand, ideally, should really be somehow that you can figure out what it is. Meaning, if the product arrives God knows from where and you have no way of testing this product, you’re risking. So if you know the brand, and you know where they’re making the product, and you can figure it out, you know where they’re growing it, that’s probably best. Because unfortunately, as you pointed out, in hemp products, the amount of CBD compared to cannabis products is less. So they have to extract a [much] larger volume of [the] plant. And if the original plant had [a] contaminant, guess what? You’re going to concentrate the contaminant into the product you’re taking.

And unfortunately, there have been deaths from mold toxicity from poor-quality hemp where there was already several cases that have been reported. So you really have to be super careful with that. So that’s even before you think about what exactly should you be getting. I think after that, I would say if you’re going to try CBD, and you want to start somewhere between, say 10 to 15 milligrams twice a day and very gradually titrating up, the advantages if you’re not on any medications, or if you don’t have any kind of a severe life-altering illness, chances are, you’re not going to see a lot of side effects. And if you taper gradually say, maybe first two, three days, keep the dose let’s say 15 milligrams twice a day, and then start tapering after that, you can taper 30, 50 percent per day after that until you feel something. And if you get to a point where you’re, say taking more than 200 milligrams a day, and it’s doing nothing, you can probably say at that point, okay, well, it’s not working. We have to think of something else like combinations. So there should be something else.

Usually, I would, that’s a very general statement, because we’re not taking into consideration specifics of the patient, specifics of the problem. I would say if you have any rheumatologic conditions, so any kind of joint pain, whether it’s osteoarthritis or some other form of arthritis, like rheumatoid arthritis, I’d go straight for CBDA. And the advantage of CBDA you can taper it up as much as you want. And somewhere between I would say 100 milligrams to 300 milligrams a day, most patients are going to have a definite improvement. I wouldn’t say 100 percent, but way over 50 percent. And those are the patients that then can start tapering down some of the medications. And that’s another blessing. If you’re say, have rheumatoid arthritis and you’re taking some immune suppressants, there’s going to be no interaction there. So you can taper up CBDA, get a lot better, and then consider tapering things down. And of course, you and I know very well it wouldn’t be our only treatment, right? I mean, we would be giving the same patient so many other recommendations. But it’ll be part of it.

But so yeah, acidic forms, risk is pretty small CBG, CBN, CBC risk is pretty small in terms of interactions. I think the CBD is the one you have to worry about. That’s why I kind of typically, if the patient is old and frail, I’ll cap their dose at 100 milligrams, unless I know that they’re not on any medications that I’m worried about. Unfortunately, that’s a rarity.

Chris Kresser: Pretty rare, yeah.

Mikhail Kogan: So I always have to worry about something else. But everybody else you probably can go way higher two or three, 400 milligrams. I mean, the epidiolex given to kids with seizure meds, and they go up to 500, 1000 milligrams in combination with seizure meds. Most of those will interact with CBD and they’re not too concerned. I mean, they’re not seeing a lot of shift, but I actually question that. I wonder if we just, it’s just a matter of time before we see problems.

Chris Kresser: So let’s talk a little bit about THC and the therapeutic use of it. Because at least in some of my patients, they’re a lot more open to taking CBD than they are to taking THC because they’re concerned about the psychoactive effects. They either don’t have experience with cannabis products, and they’re worried because of what they’ve heard and maybe some of the stereotypes in movies and stuff like that, of just being stoned or they have had experience in the past, maybe it wasn’t positive because they weren’t using it in a controlled or regulated way.

Mikhail Kogan: Or they took a dose that was way too high at the start.

Chris Kresser: Way too high. Exactly. They didn’t have a, like, yeah, controlled doses. They were smoking and they didn’t have any idea how to titrate how much they needed. So I guess the first question is, how do you kind of broach that with patients? And then the second question is, for people who do want the therapeutic effect of THC, but maybe don’t want the psychoactive effects as much, particularly during the daytime if they’re working and have to function in a way where they don’t have that alteration of their consciousness, how do you approach that in your practice?

Mikhail Kogan: Right, right, that’s a great question. It’s a very, very important topic. So that widening of the therapeutic window, so starting sub therapeutics or starting at the dose. I mean, I would typically start between point five to one milligram per dose in that range. And with that dose, most people will not get to any kind of cytotoxic impact at all, and you’ll stay there for a few days and then you start tapering very slowly up until you hit the sweet spot. So that tends to work for a lot of people.

Now you’re absolutely correct, if you take a therapeutic dose in the morning, and it’s pure THC, you may feel like it’s really hard to function. So I think that’s what you mentioned. That’s when you try then to put much higher dose of CBD to sort of decrease the impact of the psychoactivity and kind of level it. And somewhere between four to one to maybe 10 or 20 to one most people kind of have that, they can’t function at that ratio. The problem is though sometimes that just not, doesn’t control symptoms very well. So if that’s the case then you really have to sort of figure out what would be their ideal ratio. That’s why I often start if it’s a pain with one-to-one. To me that often is that kind of, you take off the edge of the cytotoxic effect down a little bit, but it’s not that much of CBD to kind of cause a drop in the pain control of THC. That’s, to me that seems to work. Interestingly, sometimes you can do what I often love to do is a triple, either triple topical or triple preparations. They are very rare, though in my opinion. I haven’t seen a lot.

Chris Kresser: Yeah.

Mikhail Kogan: That’s the THC, CBD and CBDA. Because if you think about it, most of the pain is going to have some severe inflammatory component of some sort. And it’s not always, it’s very common to be some arthritic component or some cox. For listeners who don’t know this, this is just the type of inflammatory process.

Chris Kresser: The pathway.

Mikhail Kogan: It’s mediated red. It’s mediated through that and that’s where the non-steroidal anti-inflammatories such as Advil and Motrin tend to work well. So CBDA there could be a great substitute for the NSAIDS which I hate passionately.

Chris Kresser: Yeah.

Mikhail Kogan: Well, they’re just, I’ve seen so many side effects. Like I’m not talking about my stomach hurts, I’m talking about I’m coming in with bleeding ulcer or my kidneys shutting down.

Chris Kresser: Absolutely. Yeah, people are unaware. I mean, these things are sort of treated as if they’re completely benign. I am sure we both had lots of patients who have taken them every day for years, particularly in the geriatric population, because their aches and pains, they want to stay active, which is totally understandable. And they’ve gotten in the habit of taking two or three Advil every time before they exercise, and then they develop an ulcer, and they wonder why that happened.

Mikhail Kogan: So that’s a perfect example. For all of those people who pop a couple of pills of Motrin before exercising, take CBDA and it actually works a lot better. I mean, it also causes this, there is a little bit of, I wouldn’t say euphoria, but it does have some kind of an uplifting impact.

Chris Kresser: Yeah.

Mikhail Kogan: And it doesn’t have, not only no toxicity, it’s also, if it makes you feel a little bit better on not just the physical plane, but also the mental then why not?

Chris Kresser: Absolutely. And like you said, it’s quite a blessing to have something like this, that also doesn’t interact with the majority of the medications that people are taking, which can be really, really tricky otherwise to find treatments that don’t interact or cause additional side effects.

Mikhail Kogan: Absolutely. And if you take this interview say three years ago, we would have a much harder time talking about CBDA because the price was crazy.

Chris Kresser: Right.

Mikhail Kogan: Now, the prices have come down so much. And I think I’m pretty sure they will keep coming down slowly. I don’t think we’re anywhere near sort of the bottom of the standard price that I think it wouldn’t be surprising that will at some point reach the kind of a less than like a dollar for 400 milligrams.

Chris Kresser: Sure.

Mikhail Kogan: Somewhere in that range.

Chris Kresser: Yeah, supply and demand as m

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