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Guest Bio:

Bonni Goldstein, MD, is the medical director of Canna-Centers Wellness & Education, a California-based medical practice devoted to educating patients about the use of cannabis for serious and chronic medical conditions. She completed her internship and residency at Children’s Hospital Los Angeles, where she also served as chief resident. Over the last 15 years, she has evaluated thousands of patients for the use of medical cannabis and is recognized as an expert in the clinical application of cannabis therapeutics. She has a special interest in treating children with intractable epilepsy, autism, cancer, and other conditions. Her latest book, Cannabis Is Medicine: How Medical Cannabis and CBD Are Healing Everything From Anxiety to Chronic Pain, was published in September 2020 by Little, Brown Spark. Additionally, Dr. Goldstein recently co-authored two peer-reviewed articles researching the use of cannabis-responsive biomarkers to document cannabis treatment efficacy, guide clinical decision-making, and improve outcomes in children with autism. In June, Dr. Goldstein will be presenting at IFM’s Annual International Conference on the therapeutic use of phytocannabinoids, a talk which will also be available via livestream.

Transcript: 

Kalea Wattles, ND: Understanding medical cannabis, how it interacts with the human brain, and the current clinical applications is necessary for all healthcare professionals now that cannabis is available in most states and many countries.

Dr. Bonni Goldstein has been treating patients with medical cannabis since 2008, and in her plenary talk at IFM’s Annual International Conference, she’ll share the latest scientific and clinical information supporting use in common conditions like anxiety, chronic pain, insomnia, and neurodegenerative disorders. She’ll also present a concurrent session on the use of cannabidiol in the pediatric population for conditions including autism, epilepsy, and beyond. We’re looking forward to exploring this topic in preparation for our annual conference. Welcome, Dr. Bonni.

Bonni Goldstein:
Thanks so much for inviting me.

Kalea Wattles:
I thought it would be interesting to start our episode today learning a little bit more about how you became interested in this idea of using medical cannabis with your patients. Because I understand that you’ve been working in this area for over 15 years, and while it seems now like medical cannabis is pretty commonly accepted, especially in parts of the world like the Seattle area where I’m located, I imagine that the climate was a bit different 15 years ago. So give us a little introduction of how you became interested in using medical cannabis.

Bonni Goldstein:
Well, that’s a great question. So I trained in pediatrics, and then I worked in the field of pediatric emergency medicine, which as you can imagine is a little crazy. I worked a lot of night shifts. I had a young child, and after about 13 years in that field, I was just terribly burned out. You do see a lot of distressing things. A lot of it you can fix, broken arms and asthma attacks, but often you see very difficult things. And I think it was just wearing on me, the night shifts and the kind of trauma of the stress, and I took a little time off. And, you know, during that time, I had a friend that asked me about medical cannabis. In California, the law was passed in 1996. This was around 2007, 2008. And I was really intrigued when I read some of the scientific literature to try to help my friend. And then I witnessed what, you know, she had been diagnosed with cancer and was getting some chemo. It changed everything for her. It just made it more tolerable. She was able to sit at the dinner table with her kids as opposed to lying in bed all day. And I just thought, wow, you know, she’s such a reasonable person, and she’s using this plant medicine, and I don’t know it. I’m a doctor, and I don’t know anything about it. So I continued my kind of self-education, and I started working in the field and I just fell in love with it.

Kalea Wattles:
Well, it seems like the universe had a plan and put this friend in your life who got you started on this pathway. And I think for many of us, the term medical cannabis, maybe we don’t know what that means. Will you give us a little primer on what you mean with the term medical cannabis?

Bonni Goldstein:
Sure. So when we’re talking about medical cannabis, we’re referring to the use of cannabis to treat, mitigate, alleviate symptoms associated with illness or with particular conditions with the goal, of course, of making your life more functional, alleviating suffering. But with patients, remember their illnesses are sitting like a boulder in their path. It’s in the way of functioning, going to work, taking care of your kids, being a good spouse, just day-to-day function, getting out of bed sometimes. And what medical cannabis does is it kind of pushes that boulder over so you can continue down your path and you can function when you have chronic illness, especially an illness that’s refractory to current medical care, meaning you’ve tried everything and there’s really nothing working for you, you become, well, traumatized by it all, but more so you lose control over your life. And what I have found with medical cannabis is that patients gain control back. We may not cure them, but they are managing the condition instead of the condition managing them. That would be what I would sum up as medical cannabis. And I just would like to point out, there’s a wonderful researcher, Dr. Staci Gruber in Massachusetts, who’s doing research looking at the differences between medical cannabis use and recreational use. And of course there’s many people who use recreational cannabis without any issues. But the difference is medical cannabis patients really have that goal of just feeling better and managing their symptoms. There is no kind of intention to become, you know, intoxicated.

Kalea Wattles:
Beautifully said. When you were using this analogy of the boulder and the pathway, I can relate this to a naturopathic principle, which is to, part of your treatment plan should be removing obstacles to healing. And it sounds like you’re using cannabis as a tool to remove some of those obstacles, because in some cases, if someone is just not feeling well to engage in the parts of their life that give them meaning and purpose, I imagine that’s really detrimental to their healing process. So I was kind of painting that visual picture as you were speaking.

Bonni Goldstein:
Yep. That, I would say that that’s a great analogy. And again, it may not be curing; it moves the boulder out of the way.

Kalea Wattles:
Yeah.

Bonni Goldstein:
So that you can get on and participate in your life.

Kalea Wattles:
It sounds like there are so many different types of conditions that could benefit from medical cannabis. I think a common question out there in the ecosystem is, should we be aware of differences between THC and CBD?

Bonni Goldstein:
Well, okay. So the reason that cannabis can treat so many conditions is because of the underlying physiology that we have, which is the endocannabinoid system. This is a system only discovered in the late 1980s, early 1990s. But it’s a cellular mechanism that we all walk around with, and it’s like a feedback loop. When we tip in one direction from a trigger like illness, inflammation, injury, right? We tip, and the endocannabinoid system goes into action to kind of balance us back. That’s what its role is. And often chronic conditions, chronic sleep deprivation, chronic stress, I mean who doesn’t have that these days? And also medications, not being able to exercise, not eating well, that all can kind of mess up the mechanism of your endocannabinoid system.

And the concept is that our inner cannabis, like compounds called endocannabinoids, may not be able to do the job. So you take an external source of cannabinoids, which comes from the cannabis plant, whether it be THC, whether it be CBD, and then there’s a whole slew of others that I use in my practice, CBG, CBN, CBDA. There’s, you know, the whole alphabet. And the important thing to understand is that they can all be used medically. THC is not the bad cannabinoid and CBD is the good cannabinoid. THC is a very useful tool, especially if you know what you’re doing with it. And you know, we have this saying start low and go slow. And that’s so, in order to kind of protect yourself against side effects. But THC is the cannabinoid that comes from the plant that mimics your inner cannabis the most, okay? That’s been shown in studies. CBD has so many other interactions with, within… It enhances the way your endocannabinoid system works, but it doesn’t work directly at the same site that THC does. So they do have some different mechanisms of action, but they can result in some of that same end result, meaning like pain relief, decreased anxiety, for some people nausea. I find THC works better for nausea than CBD. For sleep, I find THC works better than CBD for most people, but each of them have their own kind of array of medicinal properties. And it’s important that if you’re not really familiar with them, it’s important to educate yourself on them or to see a practitioner who knows about them so that you can figure out what might work better. And I’m just going to point out recent research is showing that THC may be a little bit better for kind of chronic pain, neuropathic pain, sleep, and CBD kind of better for inflammatory pain, anxiety. And you know, that’s a very broad stroke. You know, that’s not really delving into the details, but that’s kind of what we’re starting to learn after, now, years of research.

Kalea Wattles:
It’s fascinating to hear you talk about all of these, the various cannabinoids that many of us aren’t familiar with. And so this raised this question for me of the mode of delivery. How are you giving these products? Is it a liquid, is it a chewable, is it a capsule?

Bonni Goldstein:
So in my pediatric part of my practice, the vast majority of children—so remember epilepsy, autism, cancer, some GI disorders, some teenagers with, you know, anxiety and depression—mostly we start off with the tinctures, which are extracts, which are liquids. And the reason we do that is because you can really be very accurate with dosing, right? If somebody makes a 25 mg CBD capsule, if my patient needs 13 mg, that’s not going to work, really, right? So I like to use the liquids. It gives accurate dosing. It allows you to titrate up in very small amounts. It allows you to use concentrated products if you get to high doses. So you could take less volume. So I find them very versatile and very useful. Some of my patients do take edibles like little gummies or sometimes the capsules if we know the dose and we’re dialed in on the dose. Some patients do like to inhale. So, for instance, why would somebody inhale cannabis? And I recommend using a vaporizer over smoking, of course. And the reason would be because it’s quicker onset. Most experts know that when people inhale, they kind of figure out their dose very quickly. It’s self-titrated, but it’s a more immediate… And if like, let’s say you feel a migraine coming on and you know in two hours you’re going to be, you know, on your knees in the bathroom or in the bedroom with the curtains drawn, it can actually abort or really significantly lessen a migraine if you get it in quickly. Also, patients who are having nausea with migraines or from chemotherapy find that it’s immediate relief. I mean I had a woman, if I could share a quick story, who came into my practice.

Kalea Wattles:
Yes, please.

Bonni Goldstein:
Yeah, an older woman with lung cancer, and she came in with her husband and her adult son, and she was a new patient. Her adult son had kind of visited the dispensary, the medical cannabis dispensary before coming. And he bought just about everything. He bought little vaporizers, he bought edibles, he bought tincture, he bought topical, all of them, because he just didn’t know. And he said he wanted to show me and actually say which one of these might help my mom, which was good forethought. Well, in the office she looked green around the gills. She had her head down on my desk. You know, I start off with people sitting at my desk and I said, “Do you want to lay down?” So she laid down on the exam table, and then she asked for the trash cans because she was going to get sick. And I just felt so bad. So we, I said, “Let me just see what’s in your bag.” So we go through the little bag, and there was a little vaporizer pen. She was very nervous about it, but being in a doctor’s office and being able to say, “Here you can, you bought it, you can take it,” she took literally one puff, and within five minutes, she was sitting up, the color was back in her face, and she was smiling, and the family’s kind of looking at me, and they’re like, “We have been suffering for so long, and that’s it? That’s all it takes?” And remember, it’s not magic, it’s not a miracle. She inhaled some THC, it went and found the cannabinoid receptors and told her brain to stop the nausea message. Simple as that.

Kalea Wattles:
So it’s clear why you would maybe need an immediate effect. If someone is doing more of an edible product, how long until we see the effects of that medicine?

Bonni Goldstein:
Great question. So for most people, somewhere between—depends on your absorption and metabolism, which is individual—but for most people, somewhere between 30 minutes, which is a very early onset all the way up to two hours. Although I have seen some people at three and four hours, which you know, for a chronic pain condition, that’s an awfully long time to wait for your medicine to kick in. So again, the really nice thing about cannabis is you can personalize to your needs. It’s a little bit different than a kind of a typical allopathic treatment. You know, if you get diagnosed with something, here’s the medicine and that’s how it comes. That’s it.

So with cannabis, you have multiple modes of action, so… And you can overlap, too. Look, I have some people who have really refractory insomnia, and they will take an edible a couple hours before bedtime. And then, because they also struggle, I’m sorry, they struggle with falling asleep and staying asleep. They’ll take an edible right at bedtime, but they’ll also inhale like a half hour before to feel the onset of sleepy when they are trying to go to sleep. And then the edible holds them all night. So because it does have a longer action, so be aware that when you take an edible, whether it’s a capsule, now there’s drinks with THC in them. So that, you know, is another option if you don’t want to take an edible, and then there’s capsules. Anything that ends up in the stomach, basically it’s going to take a little bit of time to kick in. Your liver gets involved and converts some of the THC to a slightly more potent cousin compound. So you have to be aware of that. So that’s why that start low and go slow is very important. We don’t want you to overdose. And then it lasts a little bit longer. That cousin compound kind of drags out the effects, which is great for nighttime because it gives people, you know, seven, eight, nine hours sometimes of being able to close their eyes and get that restorative sleep. And you know, it’s so interesting. There were no sleep studies on sleep until just recently. It was always a secondary finding in looking at people with fibromyalgia or other chronic pain or anxiety. It was never really the primary focus of any study on cannabis. And now we have a couple of studies that show that yes, there is no question that cannabis helps. And what was nice in some of the studies, which I will be talking about at the conference, is that they measured, they had the participants wear a wrist monitor so they could measure how many times they got out of bed, how much sleep did they get. So we have these wonderful tools to now be able to measure these things.

Kalea Wattles:
I’m really fascinated with this concept of personalizing the dose and the delivery method. And in your work with children on the autism spectrum, you have some research papers that note that each patient is on this unique medical cannabis regimen that’s determined by their specific needs, their specific response. And of course, in functional medicine, we’re all about precision personalized medicine. Could you tell us a little bit about how you personalize these treatments maybe for adults and for children and what the differences are?

Bonni Goldstein:
So the first thing, of course, is getting to know the patient. You know, where are they at in their course of illness? What do they need most in terms of relief, right? So do they need anxiety relief? Pain relief for a child, let’s say with autism? Are they very self-injurious or aggressive? They’re unable to go to school sometimes because the school can’t have them. It’s, you know, throwing chairs across the room. I have had people come into my office say that they haven’t slept in five years because their child doesn’t sleep at night. I mean, it’s really kind of crazy. So the whole thing is always to assess the patient, get a sense for who this person is. If you’re going to personalize the medicine, you gotta know who they are.

So after asking a bazillion questions, you know, part of the art of medicine is coming up with a plan to start trying to tackle some of the main issues. And, you know, sometimes we hit it out of the park and you get it right the first time out. It’s just like with any medical practice. And then sometimes it’s the fifth product or the eighth product. But basically, you know, I talk about in my book, rule it in or rule it out. So we start with a product, we start low dose, we titrate up, looking for the minimal effective dose with the least side effects. That’s the goal. And if, let’s say a child, I start a child, let’s say, on a combination CBD/THC, and the parents say “Wow, sleep is much better, but the daytime aggression is still not great,” we’ll titrate up on the dose, and then if the parent says, “Now, he is overly sleepy, and now he’s just not even, you know, participating,” we don’t want that either. So we back up to the dose that is of that particular compound that gave us a good result. It may not be the best result, but it’s got some benefits with no side effects. Then I bring in another product and we try to layer. So that’s how I ended up with it. And you’re talking about my research looking at these salivary biomarkers in children, and it’s really exciting, because it was the first objective data of the medical impact of cannabis on these patients correcting chemical pathways in children with autism. When I looked at that chart, I thought wow, they really all are on different regimens, and it’s really just, it’s a lot of labor. The clinician has to, you know, be connected with the parent, and the parent has to be willing to keep a log.

Same thing with adults. though I do the same thing. Let’s, you know, we may have to try a few different products to see what works best, but that’s really no different than any medical practice. When you think about people who, I’ve had people come in who have been on five different pain medications or five different antidepressants, right? It’s very similar. It’s trying to find, you know, with a plan, especially with cannabis, you’re trying to match the chemistry of the plan or of the product with the patient’s chemistry. And so I just think patience is the key, and because it is so safe, most people don’t mind trying a few different things.

Kalea Wattles:
That makes great sense. So what are the variables that you’re considering? It’s the dose, the method of delivery. Is it also the ratio of cannabinoids or is that too detailed? What do we need to consider in order to formulate an appropriate plan?

Bonni Goldstein:
Right, so first of all, you have to kind of know what’s out there in terms of the product. So if you’re interested in either treating patients with cannabis or using cannabis as a patient, you kind of have to break it into categories. So there’s what’s called CBD-dominant compounds, which is you’re going to get a CBD effect. Then there’s the THC-dominant compounds, you’re going to get a THC effect. A little one difference I’ll just share with you between the two. CBD has what we call a very wide therapeutic range. I’ve got patients taking 10 mg a day, I’ve got patients taking over 1,000 mg a day. It kind of depends on the condition. And of course, it depends on the person’s absorption, metabolism, excretion pattern, which when you think about personalized medicine, you must include that. We don’t all metabolize medications the same way. That’s why some people don’t get an effect from medicine and some people get too much of an effect from medicine. With THC, it’s a pretty narrow window. So you can usually find the dose pretty quickly, especially if someone’s what we call cannabis naive. And you can sometimes find that dose very quickly. With CBD, you have to be patient, because let’s say you’re a person whose dose is 200 mg; you might not get there because you don’t start out at 200, you start lower, and you work your way up. And then there’s combination THC/CBD products.

And then in terms of ratios, you know we have some understanding that lower ratios like four to one, four parts CBD to one part THC, one part CBD to one part THC, these combinations may work better for neuropathic pain. For some, certainly in pediatrics, we see that it works quite well for children with aggression and self-injurious behavior. Some studies show that only 50% of kids will respond to the CBD dominant, but then when you add THC in, another 30% will then respond as well. And that’s the point of personalizing is you are using that feedback from that patient to dial in on what will work. And so, you know, we give ratios, like when I talk about my epilepsy patients, the vast majority of them are somewhere between like an 18:1 and a 30:1 CBD to THC. So that’s what we call a CBD dominant. I do find having a little THC in the mix, THC is an anti-convulsant when used in low doses. Studies clearly show that. There’s a lot of misinformation out there that THC causes seizures. The studies do not bear that out unless you take a big mega dose right out of the gate. I actually had a patient who ate a whole THC candy bar many years ago and ended up having a seizure, but he ingested 180 mg all at once when the average dose is somewhere between one and 20 mg. 180 is obviously not indicated. So, but in general, most people don’t do that. So most people are, especially medical patients, I find them actually to underdose because they have a little… They don’t want side effects.

Kalea Wattles:
Right. I would love to ask you this question that I have wondered about probably for years. Can we develop tolerance to cannabis, and do we need increasing doses to get a therapeutic effect?

Bonni Goldstein:
So in general, it only appears, so what we know so far, it only appears that we develop tolerance to THC. Not everybody develops tolerance. In fact, there’s studies that show that low doses taken even on a regular basis over time, some people do not develop tolerance to that. Why would you develop tolerance? So understand the concept is that the cannabinoid receptor where THC binds to and where it acts, that receptor doesn’t exist for THC. It exists for your own natural endocannabinoid, your inner cannabis compounds. But if it’s inundated like over and over, you’re hitting those receptors over and over with larger amounts of THC over time, what’s fascinating is that those receptors kind of go, “Hmm, too much,” and they scurry into the cell and they hide, and then you don’t have as many receptors available. So then you have to escalate your dose of THC in order to get that same effect, which is the definition of tolerance, right? You need a higher dose to get the same effect.

What’s fascinating is the research shows that if you abstain, and they did this with adult chronic heavy users who they locked up in, you know, they compensated, but they locked them up in a lab so they couldn’t access cannabis, they checked their urine and so on and they did brain scans. Now looking at those, the number of those receptors and what we call, by the way, when those receptors hide inside the cell, we call that downregulation of the receptors. What they found was just abstaining for two days, 48 hours, allowed for those receptors to come back out to appear again, upregulate and be available. And they found no difference, no statistically significant difference between 48 hours of abstention in the chronic heavy users versus the controls who hadn’t used cannabis. So just after 48 hours, it’s really, when you think about it, our bodies are amazing in that they can do that. Now it’s interesting, a lot of people will, when I tell patients if they’re using THC and they’re starting to have tolerance, I’ll tell them take a day off if you can. Sometimes switching the product, you can kind of trick your body, you trick the receptors into not hiding out. But if you have to take 48 hours off, it’s about 48 hours. If you’re a person who really struggles, you might want to have a backup method.

One of the other things that I found is that when you, we know that when you have some CBD in the mix, like I’ve got patients who are on the same CBD:THC ratio for years with a reasonable amount of THC, and they’re not developing tolerance. It doesn’t appear that CBD has tolerance. The only other compound in the cannabis plant that we know may develop tolerance is one called CBN, which is cannabinol. It’s the breakdown product of THC. So that makes sense that it would cause you, you could build tolerance to it, but I really, I find a lot of medical patients don’t really have tolerance issues. Although sometimes, you know, pain can escalate, so you escalate your use. But this is why I encourage patients to incorporate some CBD, take a break one day a week, couple days a month, try to give your receptors a break so that you can continue to establish a good medical response. One thing I just will say is overuse, chronic heavy overuse has been associated with maybe some anxiety and issues over time. And the reason is if you don’t have those receptors, your natural inner cannabis compounds lose their site of action. We don’t want to shut them down, we want them to be there. Your own inner cannabis needs a site because remember, its role is to keep you in balance. You don’t want to take away the mechanism by which your brain and body function to keep you in homeostasis.

Kalea Wattles:
So interesting. So the THC that we intake from medical cannabis products, they’re binding to the same receptors as our endocannabinoids. Is that correct?

Bonni Goldstein:
100% Correct.

Kalea Wattles:
Mmm. So interesting.

Bonni Goldstein:
And so they’re augmenting the effect. They’re reestablishing the effect. Like when I meet someone with chronic illness who’s just like in that, I call it the deep hole of chronic illness.

Kalea Wattles:
Yeah.

Bonni Goldstein:
And they can’t climb out. They can never kind of get out, and they can take every single medicine under the sun. But if the endocannabinoid system is not functioning, that’s if we could just give them some ability to get that back into balance, they start to feel better. And I’ve seen that over and over and over again, and I’ve seen it with my, you know, my colleagues across the country and in other countries report the same thing. And we have now the science to support this, and that’s the whole basis of medical cannabis is that you’re augmenting this already existing physiologic homeostatic regulating system.

Kalea Wattles:
Well, it’s definitely clear that this is powerful medicine, and I’m sure that as you’re developing treatment plans, you’re including cannabis as part of a comprehensive treatment. Can you talk to us a little bit about how we can integrate medical cannabis into a treatment plan that might include some other components like lifestyle change? We do a lot of lifestyle modification in functional medicine, so would love to hear how we can integrate all of those factors.

Bonni Goldstein:
Right. Well with children’s, sometimes it’s a little bit hard, but one of the things I do talk to a lot of my families about is the food that their children are eating. You know, I recall a child a number of years ago who came in who the parents showed me this horrific video of him. He had autism, about seven or eight years old, acting out in the classroom and there were, it was so emotional, and it was such a big outburst. There were like four big adults holding him down. It was very… It was just awful to see that. And I know they were trying to keep him from hurting others or hurting himself. It was just really traumatic. But he comes into my office, and he’s somewhat obese, and he has one of these like, you know, Disneyland, mega-size lollipops, you know, not just a little lollipop but like that big one that’s the size of your head. And he is licking it, and I’m just thinking, you know, that’s probably not helping his behavior. I know they were trying to appease him to behave and kind of keep him distracted from a new doctor’s office, which can be traumatic for a child with autism. But we had a long talk, and you know, we started him on cannabis. I encouraged them to try to reign in the sugar in the diet, at least to start with that. And then, of course, you know, many of these kids are sensitive to gluten and to dairy and to other things. And so I really encourage to try to do an elimination diet and then, you know, figure out what works best for your child, because there’s no question in my mind about, you know, the gut-brain axis. And remember when you think about the endocannabinoid system, it’s dense in the gut and dense in the brain and dense in the immune system controlling inflammation, all connected. And the next time I saw him in person, he had lost weight, he was calm, and the parents were so excited to tell me, “We’ve changed everything about his diet.” So between the diet and the cannabis, we feel like we have really found what works well, and that just made me feel so good about that.

So, and it’s not always easy with children with autism because they have very restricted palates and sensory issues. So not an easy thing. I’m not saying it’s easy in any way. One of the things I try to tell adults is, you know, you must protect sleep, you know, turn off the screens, try to get a good night’s sleep, really work on that because that’s key. That’s a simple lifestyle change, especially if you have cannabis, because it does help with sleep and kind of that relaxation before sleep. So you can at least turn off the brain, you know, and not have all these racing thoughts. I also encourage people to exercise. And then often, you know, many of the people that come to me are conscientious about what they’re putting in their bodies. They often have supplements and so on. And so often I’ll go through those with patients. I think what happens with cannabis is you do get a skew of patients who have not responded to kind of the typical medical approach. So they’ve already investigated other things that they can do and cannabis kind of becomes one of those parts of their lifestyle. I mean, really, you know, I always joke around the whole thing with cannabis is much ado about nothing. It’s my patients, it’s just part of their regimen. The same way exercising is, the same way that preparing their own meals and not eating fast food is, right? And so all of those things matter. By the way, like things like acupuncture and yoga enhance the endocannabinoid system. Things like alcohol and opioids are not so great for the endocannabinoid system. So it’s important to really sometimes look at the whole picture so that you’re not, oftentimes they’ll say if we add cannabis, but you’re still having all these triggers, inflammatory triggers, you’re just almost, they’re negating each other, and you’re not really going to get the true benefits of cannabis.

Kalea Wattles:
Just like with any medical condition. Important to address all of those lifestyle factors and to bring us back to what you said in the beginning of our episode, removing some of those obstacles to healing, and oftentimes we can do that through lifestyle. I’m sure that in that pediatric patient you just described, the sugar intake was a real obstacle to healing.

Bonni Goldstein:
Yeah, there’s no question that it’s inflammatory. I mean, we’ve seen the studies that it lights up the part of your brain where you now, heavy drugs light up and that it creates inflammation. Of course we have obesity and diabetes and a terrible epidemic with those conditions, and it stems from the food that we put in our mouth. And so I think it’s important to, if you don’t want to be a customer of pharmaceuticals, you must look at what you are putting in your body.

Kalea Wattles:
Well you’ve taught us so much today about how medical cannabis can be beneficial in chronic conditions like anxiety and chronic pain and insomnia. But with the increasing popularity of longevity medicine, many of us are thinking about how we can protect our cognitive function. Would you talk to us a little bit about how we might use medical cannabis for the treatment or prevention of neurodegenerative disease?

Bonni Goldstein:
Yeah, that’s such a great question. You know, there was a recent article that came out looking at mice. Again, not in humans cause you would have to have a really long longitudinal, right, where people are using it and so on. And by the way, we have longitudinal looking at harms, and really, we have not found significant harms. I think people who smoke it may have some gum disease, but in general, the longitudinal studies show there’s no difference in terms of true medical illness between people using cannabis and people not using cannabis. However, there was this really interesting study in mice that showed that, you know, and in mice they have like a childhood and adolescence and an adult and then old age kind of very quickly. So you can look at them, they have a very short life compared to humans. And it’s interesting, because this study looked at the use of cannabis in kind of middle age and then what happens. And the study supports the use. Don’t wait till you’re 85 years old, that you should probably start in middle age if you’re going to use it, even if you’re not targeting a specific condition. This research kind of slants toward the idea of just enhancing your endocannabinoid system but starting before old age.

And one of the reasons too is you have to understand is your endocannabinoid system changes throughout your life. When babies are born, they have less cannabinoid receptors. And I find, and this is borne out by studies as well, that children under the age of 10 or 11 actually have less sensitivity to THC than adults. Now think about that, like that’s counterintuitive. You would think a child would have more sensitivity. Now of course, if they get into somebody’s edible and take a big fat dose, yes, they’re going to be sensitive to it. But in general, and when I work with young children who have, like, for instance, cancer or severe epilepsy and we give them low-dose THC, the parents will say, you know, it’s funny, my child’s taking five mg when I tried five mg and I couldn’t even get off the couch. I said, well your child has a different brain, right? We know the brains are different in children. Well, it’s the same thing on the other end of life is that as you age, your endocannabinoid system starts to not function as well. So augmenting that early on to help maintain the function of your endocannabinoid system seems to be borne out in the preclinical trials. I would love for some adult studies to look at this; that would be very helpful. But certainly, you know, it seems that cannabis just has this 80 years of propaganda against it that we’re constantly fighting. And you have to remember that when it was made illegal, we’re talking about the 1940s and then kind of reinforced by the Controlled Substance Act in 1970, nobody knew about the endocannabinoid system. It would be like, you know, handing an iPhone to somebody back in the forties. They would look at it and be like, whoa, I don’t know what that is, right?

We have to go with the science, and the science bears out that this plant has some amazing properties, and I don’t want to overstate it, but, you know, my practice has kind of become a practice of refractory patients, and I know that some of my colleagues who work in the field have found the same thing. And these are people who just don’t respond to conventional treatment, and it’s likely they have an endocannabinoid system dysfunction or deficiency that nobody’s addressing. But again, as preventive, it’s just a plant with some compounds in it that are biologically active. They’re using it responsibly. We trust people with opioids. We trust people with antipsychotics. We trust people with alcohol. There is no reason we shouldn’t trust people with cannabis that is certainly quite safe, that for sure has been borne out in the research and that might actually help them have a better long-term health.

Kalea Wattles:
Yeah. So as we’re thinking about the preventive piece, are there certain cannabinoids we should focus on? Or is it really about supporting our endocannabinoid system at large?

Bonni Goldstein:
It’s really about supporting your endocannabinoid system. Look, in the world we live in, we are surrounded by chemicals. I don’t know, I read something that said most women, by the time they do their hair and makeup and walk out of the house, they’ve been exposed to 400 chemicals. That’s frightening, right? Inflammation seems to be one of the largest causes of disease and illness. Cannabinoids have been shown over and over and over again to be anti-inflammatory. And there is an antioxidant neuroprotective as well as a list of other things.

So the way I look at it is, if you’re not a person who wants to use THC, what I tell people is use a little CBD with a tiny amount of THC, like one of those CBD-dominant oils or gummies or capsules or something. And again, starting low and titrating up. Now it’s a funny thing, people say, well I don’t really feel anything. Well, when you take your vitamin D, do you feel anything? When you take your other vitamins? You know, you’re kind of buying into the idea that your body, and often, you know, you’ve got blood tests to look at. But you know, even my own blood tests show some inflammatory response, right? I have some elevated inflammatory markers that I work on every day between my diet and my lifestyle. I think pretty much everybody can use an anti-inflammatory these days, and I don’t, again, I just don’t see any reason not to incorporate it.

And if you’re just, and if you don’t want to have some, you know, the quote altered mental status that comes with THC, there’s so many other compounds. CBG is a very, which is cannabigerol, it’s a very potent anti-inflammatory. And what’s interesting about it is it appears that you don’t need the same high doses that one would need for CBD. So that’s a great one to use. It’s also, and you know, one of my colleagues, Dr. Ethan Russo and a group, published a survey of people using CBG, and they found benefits for anxiety, depression, inflammation, pain, and sleep. Now who can’t use some benefits for those types of things? And for most of them, they had no side effects. They were people who were kind of self-medicating. But, you know, a lot of people do that with vitamins. And I just want to kind of make it, I just want to normalize this, it’s just, it’s so not a big deal. I understand that people struggle with THC and teenagers and so on and driving. I get that. And you know, every day I caution people about driving under the influence. I talk about teenage use in my book and anytime anybody asks me about it. But at the same time, certainly in adults, there is no reason to me not to incorporate a little bit of cannabinoid medicine to help with all the things that we all suffer with. And I just would like to point out too, there was a report that came out of Germany looking at cannabis, specifically THC in patients in hospice. And the patients that took cannabis lived longer, specifically too if you were elderly and if you were female. So it’s really interesting. And so that’s another area that I’m very interested in, which is hospice and palliative care, because cannabis absolutely addresses all the issues that people who are dealing with that. And it’s in a very benign way without side effects. And it’s a kind way to allow somebody to pass through.

Kalea Wattles:
Dr. Bonni, this preview has made me so excited for our annual conference where we’ll hear even more details from you. Without giving too much away, will you tell a little bit about what attendees can learn when they listen to your plenary talk on phytocannabinoids, which I’ll mention will be available livestream for those who can’t attend in person?

Bonni Goldstein:
Well, I’m going to talk about what I just talked about. So the endocannabinoid system, what these cannabinoids can do. And I will share some of the scientific literature in detail to show, you know, kind of what doses were used in studies, how the patients responded or the participants responded, also what the benefits were, what the risks were. So we’re just going to delve into the science a little bit more. I’ll share some clinical pearls. And then I’m also going to be speaking about pediatrics and specifically looking at the science behind that supports the use of cannabis for children with epilepsy and autism specifically.

Kalea Wattles:
Well, we can’t wait to hear even more details. You’ve given us so many clinical pearls today. I wanted to thank you for your thoughtfulness and your enthusiasm around this topic. I think we all are really thinking about some added tools we can put in our treatment toolbox. So thank you so much for being with us today.

Bonni Goldstein:
It’s been a pleasure. Thank you.

Kalea Wattles:
Did you know that IFM’s Annual International Conference is the largest gathering of functional medicine practitioners in the world? Expert clinicians and thought leaders in medicine convene to pave a new path forward for improving health outcomes worldwide. Come join the conversation this June 1-3 in Orlando, Florida, as we return to an in-person program. See you then.

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