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20 doctor focus cannabis patient care | vol. 3 no. 1 cannapatientcare.com 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 de- pression that they just want hope and an answer. So usually, they'll come in with a daughter or son who is much more in- quisitive and nervous for their mother or father." She said, given the history of cannabis, for some elderly pa- tients it's something they can't really relate to. "You have to understand what their previous opinion is about cannabis cul- turally, and what the stigma is, and then give them a lot of education." The Other Obstacles 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 chron- ic 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 sleep- ing 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. Her Studies 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 Med- ical 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% re- duction 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 rec- ommend 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 tak- ing, 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 hav- ing 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 ac- tually ketamine-assisted psychotherapy, comparing it to high- er intramuscular ketamine doses with the therapy after. The point is really to show how chronic pain patients need thera- py. It's not just the fact that the ketamine is causing pain re- lief, 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 experi- ence, 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. Patients Report on Their Experiences 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 Per- cocet (10). She was also on Ambien (11) for sleep and medica- tion as a muscle relaxant.