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19 doctor focus cannapatientcare.com march/april 2022 | cannabis patient care Figure 1: Dr. Michelle Weiner, DO, MPH, a pain management phy- sician and partner at Spine and Wellness Centers of America. 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 al- gorithm to start with. For example, I tell them to use a tinc- ture 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 un- derstand 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 intox- ication. And then I have other ones who may be very young, who use cannabis often and still feel that intoxication." Treating Chronic Pain 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 be- tween chronic pain and mental health," she said. "I think we're seeing that using ketamine (6), for example, which is a disso- ciative 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 see- ing 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 phys- ical 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. Understanding the Age Difference 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 consid- er between younger and older patients. "When we're young- er, we're healthy. Our endocannabinoid system is function- ing 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 en- docannabinoid system in the same way. Also as we age, it be- comes 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