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18 doctor focus cannabis patient care | vol. 3 no. 1 cannapatientcare.com The Doctor Who Changed Her Patient–Doctor Paradigm Through Cannabis B Y D A V I D H O D E S D R. MICHELLE WEINER, DO, MPH, is a pain man- agement physician and partner at Spine and Well- ness 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 chron- ic 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 depend- ence 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. Teaching Herself About Cannabis Dr. Weiner wasn't taught anything about cannabis or the endo- cannabinoid 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 dispensa- ries 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 pro- grams 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 actu- ally 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 decreas- ing 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. How to Introduce Cannabis to a Patient 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