Medicinal marijuana may provide anti-inflammatory, immunomodulatory and pain reducing benefits. Fortunately, one can obtain this benefit without ‘getting high’. Today we speak with researcher and clinician, Dr. Chris Meletis, on how we can safely and effectively utilize medical cannabis.
Dr. R’s Fast Facts Summary
What is CBD?
CBD stands for cannabidiol, cannabis without the psychoactive effect. The medicinal and therapeutic effects of CBD are becoming more widely known and studied.
Cannabis Sativa is the same name for marijuana or hemp
- Hemp by legal definition is less than 0.3% THC
- Used more from a historical standpoint than THC
- CBD is derived from Hemp
- THC (tetrahydrocannabinol) – is what makes you “high” (impairs motor function and cognition). The legality of Cannabis is dictated by THC content.
How does CBD and THC help from a mechanistic standpoint?
- Everyone has an Endocannabinoid system
- Receptors CB1 and CB2 which capture naturally created endocannabinoids within the body.
- Everyday we make natural cannabinoids, they’re called anandamide
- Receptors CB1 and CB2 which capture naturally created endocannabinoids within the body.
- From CBD standpoint – it binds on to both receptors (along with others) and modulates them. It controls inflammation in a very unique way.
Key Mechanisms of CBD
- Anti-Anxiety (stage fright)
Does the source of CBD matter? Marijuana vs Hemp
- Depending on how it’s sourced, there are other cannabinoids that come along with it
- The CBD from Marijuana is going to come with THC and other unique chemicals
- If it has been processed heavily, understand which solvents it has been processed with?
- The CBD from Hemp is going to have 0.3% (or less) of THC so you have less risk of psychoactive effect. It will also have other unique chemicals that support the CBD
What to look for:
- Where is it from?
- How organic is it?
- How clean was the processing?
Benefits of THC
- THC may be favorable over CBD for those with oncological involvement
Cannabinoids and Autoimmune Disease
- Summary of Cannabinoids and autoimmune diseases: A systematic review can be found in the May 2017 edition of our Future of Functional Medicine Review. Abstract found here.
Cannabinoids may provide aid in:
- Inflammatory bowel disease IBD – preliminary data is promising
- Irritable bowel syndrome IBS – speculatively, may be more helpful for those with IBS – D (diarrhea)
- MS, Dementia, Alzheimer’s, Parkinson’s, Nerve pain
- Rheumatoid arthritis , pain
- THC – do not take THC if you are prone to or have dizziness, anxiety, fragile psyche, or cardiovascular disease
- Either CBD or THC – they are metabolised through the liver, may impact certain medications (check with pharmacist or doctor)
Quality assurance is important
- Look for 3rd party certification of analysis, testing for toxins and pesticides
- Look for GCMP
- Recommended brand Full Spectrum Hemp Gummies
Side Effects of CBD
- When taken orally – alters other drugs you may be taking
- Paranoia, much more so with THC
- CBD has minimal impact
- THC has more of an impact
- Potentially, increase susceptibility to infection – internal note; more to follow in follow up email from Dr. Chris
- Side effects can also depend on your genetics
- “Start low, go slow”
- CBD 5-10mg of CBD, dosed once per day
- Re-evaluate after a few days to a week to assess impact
- Once you have reached 100mg per day for 1 week, if you have not improved after 1 week here you may not respond to CBD
Where to find out more:
- Get help using this information to become healthier.
- Get your personalized plan for optimizing your gut health with my new book.
- Healthcare providers looking to sharpen their clinical skills, check out the Future of Functional Medicine Review Clinical Newsletter.
Cannabis Defined … 00:03:50
Strength of Marijuana … 00:07:30
Key Mechanisms … 00:09:50
Endocannabinoid System … 00:10:00
Does the Source of CBD Matter … 00:15:20
Benefits of THC … 00:18:25
Conditions … 00:26:26
Cannabinoids for IBS or IBD … 00:29:00
Cannabinoids for Neurological … 00:33:20
(click gray Topics bar above to expand and see full outline/time stamp)
Cannabinoids for Joint Pain … 00:36:20
Side Effects … 00:44:20
Susceptibility to Infection … 00:47:46
Dosing … 00:53:00
Episode Wrap-up … 00:58:41
Download Episode (Right click on link and ‘Save As’)
- Louie CK parody
- May 2017 edition of our Future of Functional Medicine Review
(click green Links bar above to expand and see all links/references)
- Cannabinoids and autoimmune diseases: A systematic review
- Full Spectrum Hemp Gummies: enter the code “Divine” and get 15% off
- Hemp ICCT Facebook Page
- Dr. Chris Meletis Laboratory Testing
- Just Thrive Probiotics
- Healthy Gut Healthy You
Please note: I transposed CDB instead of CBD a few times in this discussion. It has been corrected in the transcript below.
Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. Today, we have a special guest, Dr. Chris Meletis, who is going to help us explore, in a cautious and careful way, the world of cannabinoids, or said more bluntly, medicinal marijuana, and what benefits it may have. But also, we’ll be cautious to make sure that we discuss the side effects and provide you with what will hopefully be some very rational and pragmatic recommendations.
Chris, welcome to the show. Very excited.
Dr. Chris Meletis: Thank you, Dr. Ruscio. Very much appreciate your opportunity to visit with everybody.
DrMR: Well, this is something I’m sure that I’m not alone in hearing more about this both through the pings I get from studies published in PubMed, but also patients asking questions, and things that you see, more anecdotal reports flying around the internet or what have you. And it is certainly something I would like to provide people with a more experienced clinician’s opinion on. And the fact that you’re really involved with some of the research and education regarding cannabinoids makes me excited. And, I guess, with that as a prelude, could you tell people briefly about your background and your involvement in the field?
DrCM: Well, certainly. So I’m a naturopathic physician here in Oregon, been doing it for the last 25 years. So we’re primary care here in Oregon. We have a DEA number. We do all the primary care type stuff. But we focus on addressing the cause, like all good functional medicine providers do.
I have written 16 books, couple hundred national articles. As we’re talking right before the interview, when I was younger, I used to cross the country lecturing 400 to 1,000 sitting room only medical doctors and providers about the science behind natural medicine. And there’s a lot of science as you and I both know.
So now I’ve gotten my focus on—just for the same reason you did—cannabinoids, both the hemp side of cannabinoids as well as the marijuana side. But I focus on the hemp side, because that’s legal; versus the marijuana side, which is a state-by-state thing. And there’s still even an argument now, is even hemp legal? And, of course, the federal government’s trying to figure that one out.
DrMR: And that’s actually a great lead in. Because one of the questions I was going to ask you was, how does one delineate between—you have your typical marijuana, people may picture the little flowers, as they’re called, that people may have flashbacks to high school parking lot, Ziploc bag full of this marijuana flower. But now you’re hearing about “legal” hemp cannabinoid derivatives or I’m not even sure if I can call them hemp cannabinoids. But I know you can get a CBD oil that’s derived from hemp only, and that’s legal. Apparently, you can send it across state lines.
And so, can you help us with a very broad stroke overview of cannabinoids versus marijuana versus hemp? And how do we separate all these things out, so the listener can keep this all straight?
DrCM: It’s actually a brilliant question. And it’s probably the question I get the most from, even health care providers, is, “So are you saying cannabis and are you saying marijuana?” Or “You’re saying cannabis and are you saying hemp?” Well, I’m saying both. Because Cannabis sativa—that’s the Latin name, as you and I both know—that’s the same name for both marijuana or hemp. The differentiation point, hemp, by legal definition, is less than 0.3% THC. So I’ll repeat that, less than 0.3% THC then it is categorized as a hemp.
So it’s the same plant that is kind of like if you have a poppy, some produce opium, some don’t produce opium. Well, it’s the same kind of thing with the cannabis plant. It actually has unique qualities. Industrial hemp versus the thing which we’re familiar with, whether it be from high school or watching too many crime shows about marijuana. And so, of course, its marijuana, which got a lot of the war on drug attention. And in the 1930s, there’s Reefer Madness and this whole backlash against marijuana. But really, the hemp has been used more in historical perspective than even marijuana as we talk about it.
So if I say, cannabis, I could be talking about hemp or I could be talking about marijuana. But my point of education is on hemp, because that’s where you’re going to get the CBD with such a miniscule amount of THC, is considered—and I’m not an attorney—“legal” in all 50 states. Though the DEA’s is splitting hairs on what that really means.
DrMR: Got you, got you. And please, correct any of these comments that I’m making, because I certainly am not an expert on nuance here. I’ve got a decent handle on some of what the big picture clinical trial or outcome data shows. But some of these nuances—please feel free to correct me.
So it seems that the psychoactive, the high that people will probably be stereotyping-ly—associating to marijuana, that’s the THC and that’s what really dictates what defines something as legal or illegal, even though it’s legal in some states. That typical stereotypical line of legal/illegal is typically dictated by the THC content, is that fair to say?
DrCM: That is exactly the issue. So that’s why, when you’re even taking a CBD product, which you’re saying, derived from hemp CBD, you want to make sure the manufacturing process is such that if you’re dispensing in one’s clinical practice or you’re taking it, it has such a low amount of THC that if you got pulled over and it was tested, it wasn’t 0.4% THC, it’s 0.3% or less THC. And that’s a very fine line that we now count on more than ever in our nutraceutical supplement herbal world. We’re counting on quality. But now, we have this legal aspect of, you go over that 0.3%, theoretically, you got marijuana.
DrMR: And again, for the audience, the head high that you get that can impair things—again, loosely—perhaps motor function or, certainly, cognition or the ability to feel like you could participate in the activities in daily living or if you are working, do your job in a competent way, is the THC?
DrCM: Yes, yes.
Strength of Marijuana
DrMR: And what’s interesting—and this may be getting us a little bit far afield, but some people seem to claim that THC almost enhances their ability to do work. I can picture a friend or two growing up, who would say, “Oh, if I get high, and then x, I feel like I’m really focused.” Which seemed odd to me, because all my experiences were the exact opposite. Is there something to that? Do some people have anti-ADHD like effect from THC?
DrCM: And the question is, is it merely the THC? Because, let’s say, when I was in high school in the ‘80s, marijuana was much less potent. It was a weaker strain. They’ve now strengthened it to such a level that there’s so much more psychoactive THC in it. So they basically parleyed two to three times higher percentage. And CBD and THC, when in proper ratio, offer a teeter-totter, yin-yang, tick-tock kind of approach. But we’ve now, once again, through better farming and chemistry, got into such high levels of THC that we have a problem.
But a lot of people express that they feel more creative. They feel liberated. But at the same time, there’s a lot of argument around which is worse, to drink alcohol and drive or to do marijuana and drive? And both are impaired events, which could get you into trouble. So once again, about the ratio. And if you use the whole plant as a marijuana side, which is not the nature of my expertise, I really focus on the hemp, we’re looking for what are we doing within the body and at what consequence?
So when I have young people come in to my clinical practice, I live in middle America, in terms of the middle class. And I have some kids saying what are called ‘waking and baking’. They are smoking in the morning. They’re smoking in the middle of the day. They’re smoking at night. And they’re not allowing their brain to ever just have a natural, normal foundation. And they’re altering their brain chemistry. There’s no question about it. Just like if you did too much caffeine—not to make an exact comparison—or too much of anything, too much gaming on the computer. It alters brain chemistry. So it’s not a good thing. And in this case with being high too often, it takes an emotional amount of serotonin, dopamine, these are neurotransmitters, to experience that high, which ultimately is going to leave you depleted.
DrMR: Got you. And I’ll see if we can find a link to this very funny Louis CK skit, where he was talking about how he—I guess he hadn’t smoked marijuana for years and years since he was in high school or college. And then, he was outside in one of those comedy shows and some of the people in the audience wanted to smoke with him. And he smoked. And he said, he essentially got put on his butt because now they’re designing marijuana to be able to cure cancer. Back when I was a kid in the ‘80s, you can smoke a whole whatever and barely feel it. And so, to your point, we’ll see if we can find it. It might be a funny quick watch for the audience.
So let’s start identifying a couple of the mechanisms, in terms of how do these things help? In case the audience hasn’t heard, for example, there’s a lot of discussion about an anti–inflammatory and potentially an immunomodulatory impact. So can you tell us more about how these cannabinoids help? And while you’re doing that, if you can break down, if this data is available, is it more so THC? Is it more so CBD? Is it both? Do we not really know? Just to help, again, give people some clarity on—okay, let’s say we see an anti-inflammatory benefit from smoking marijuana, have we shown that same anti-inflammatory benefit from CBD, specifically, which is something that a healthcare consumer may be using on a habitual basis for pain or inflammation or whatever?
DrCM: Brilliant question. So let’s go back to 1963. 1963, it was discovered by an Israeli scientist, Mechoulam, that THC existed. They were wondering why were people using cannabis. So there’s the THC side of things.
And then, late ‘80s, early ‘90s, they discovered that yourself, myself, and everybody listening have, within their bodies, an endocannabinoid system, which means we have receptors, CB1 and CB2 receptors, which actually are like a catcher’s mitt for outfielders, softball or baseball. And they’re actually going to capture naturally created endocannabinoids within the body. So every day, your body and my body, everybody’s body is listening is making natural cannabinoids. They’re called anandamide. Ananda in the Buddhist Sanskrit means bliss. So there’s ananda and there’s 2-AG, along with a couple others which we won’t go into because of detail.
And so anandamide and 2-AG are made in our body every day. And they are binding on to these receptors. And so, when we take either THC—which is, once again, not the area of my education and my webpages and my lectures; I lecture on more the CBD side of things. And answering it from the CBD side of things, which is the cannabidiol, that’s the abbreviation. CBD stands for cannabidiol. It actually binds on, to some degree, to both the receptors in our body, CB1 and CB2, along with other ones called TRPV1 and a whole list of them. And they modulate them. But they’ve actually shown that it controls inflammation in a very unique way.
Like for example, when a person takes ibuprofen, which is a nonsteroidal anti-inflammatory drug, we call it a COX-2 inhibitor or known also as cyclooygenase, as you and I both know. Well, they used to say, “Well, this is how it works.” Well, now we understand that NSAIDs actually work on the endocannabinoid system within our body helping protect and sustain anandamide—naturally made in our body—and allowing it to activate the receptors a little bit more. And the same thing with the acetaminophen, also known as Tylenol, one of the mechanisms now is also through the endocannabinoid system. So when we talk inflammation, we’re actually in part modulating the endocannabinoid system with drugs—OTC now, over-the-counter. But we’re also finding that these same pathways actually down regulate autoimmunity, help bolster immunity when appropriate, and I always have a saying from food and drug administration and FTC, ‘this has not been approved by the FDA, but this is what the research shows’.
And if you go to, let’s say, my Facebook page, facebook.com/hempicct, I have all these medical journals from PubMed, which you and I live on PubMed, seen all these research. There’s like, wow, look at neuropathic pain, epilepsy, all of these things, which MD, Ph.D., and other researchers are studying. And I just report the data, making no claims on anything other than, if our bodies are innately wise enough to have these receptors, if we gently nudge them, might we nudge them in a more healthy balance, which we of course call homeostasis.
DrMR: Sure, sure. So would it be accurate if we were to try to get people a summary of the key mechanisms or three of the most key—and feel free to add any: anti-inflammatory, immunomodulatory, and then anti-anxiety. Would you alter that at all?
DrCM: Anxiety, I would add sleep, pain as other big ones. And of course, we know it’s due to Charlotte’s web, and the little girl, which was having all these seizures, and the Colorado brothers, which came up with this high CBD product. Seizures, I mean that was its claim to fame that really got hemp and marijuana in the conversations of nighttime news was, she was having such seizures, nothing would control it. And the brothers in Colorado, which will go unnamed, actually created a charlotte’s web product, high CBD. And, actually, one of my faculty members for my professional educational program, her child suffered from intractable seizures. Actually, he had part of his brain resected. And he is controlled on a hemp CBD.
Does the Source of CBD Matter
DrMR: Okay. All right. So it’s a pretty impressive list. Does the source of CBD matter? If you derive it from hemp compared to marijuana, does that seem to matter?
DrCM: Well, the substance itself, CBD, cannibadiol, is exactly that. Now, the question is what else comes along with it? There’s something called ‘the entourage effect’. And the entourage effect means, of course, like with all plant material—and I’m going to give you a simple example of a rose hip. So if you have a rose in your front yard, when all the petals fall off, there’s this little nub there. It’s called a rose hip. Well, it’s high in Vitamin C. It’s high in bioflavonoids. So you’re not just going to get vitamin C from that rose hip. You’re going to get other bioactive substances that allow the vitamin C to work better in your body.
Well, the same thing happens for either marijuana or a hemp, is there’s terpenes, other cannabinoids, and whether it be THC or CBD. If you’re getting it from marijuana, unless you’re chemically processing it, the CBD from marijuana is going to come with some THC and other unique chemicals. Whereas on the hemp side, because of that rule of less than 0.3% from a cultivation perspective, you have less risk of that psychoactive effect. But you still get a wide variety of other terpenes like limonene, which makes you think of lemon; or pinene, which makes you think of pine bark. Once again, there are all these different substances, which, in and of themselves, have a bioactive effect.
So I think the big concern with getting it from marijuana is, hey, is it coming with a THC? And if it’s been processed heavily, which solvents has it been processed with? That’s a big problem in our industries. Butane, which can be toxic; propane, which can be toxic; acetone, which can be toxic are being used to process these products. And we wouldn’t think of using fingernail polish remover to get more flavor out of our next juice that we’re making in our blender. But once again, they’re using this to process natural things to make them stronger.
And that’s a point of concern. Where is it from? How organic is it? And how clean was the processing?
DrMR: Got you. Got you.
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Benefits of THC
Certainly, there seems to be this opinion forming almost of an anti-THC, which I understand because the psychoactive effects are something that precludes it from being a habitually used treatment. But are there some unique effects to THC? And I ask this, because I’ve done some of my own experimentation with this. As I’ve been following the literature, I’ve been experimenting with it for pain. Not that I have much pain, but occasional joint/muscle pain from working out or getting knocked around in indoor soccer or what have you; also for some of the anti-anxiety effects. And what I have noted personally—and again, that’s just my experience. I certainly don’t want to inflate that to be the rule for what we would find broadly through the scientific literature. But I have noticed that a small amount of THC tends to really help me not worry about work, life, other things that are happening. But if I go over a certain threshold, I’m fairly prone to have a paranoia-type reaction, which is quite unpleasant. But there does seem to be a small benefit, at least from my brain chemistry. And I’m talking, maybe a milligram or two, not much more than that of THC when accompanied in a high CBD formula. So with that long lead in, are there any benefits to the THC component?
DrCM: Well, there’s no question. In fact, with patients which have cancer or different challenges, including schizophrenia and some other things, a small amount is fine. And I like to give the example of, as a naturopathic doctor, we do something called naturopathic manipulation, which is kind of similar in some regards to chiropractic adjustment. And as we both know, when we get things lined up just right, it takes a nudge to bring things to alignment. It doesn’t take a whole lot of force. It’s about finesse. And I’m assuming you agree with that concept.
DrCM: And so, when it comes to, like you said, a milligram of THC, that’s great. That’s a respectful nudge. Knowing that our bodies are naturally producing endocannabinoids, we can actually shut down our receptors if we overdo it. So the nudge is great. Sounds like there’s an oral dosing that might have been tried. And of course, there’s also the topical side of both THC and CBD. In fact, this whole day is committed to creating a lecture series for medical providers—which we offer through icctcertification.com—on actually, I’m talking about the delivery mechanisms and how do you make things more bioavailable?
Like for example, when you’re doing that 1 mg of THC, which has unique properties, because it has a greater affinity towards the CB1 receptor. Whereas, the CBD has a greater affinity—all things being equal—a to the CB2 receptor. But it’s not so simple because we know that both of them also modulate—and we hate to use that word in science, because modulate, what does that mean? But they actually help balance out the already existing natural substances that anandamide and 2-AG that our bodies are making. So it’s like, they’re having direct effects. They’re also regulating these two other substances made by our body, anandamide and 2-AG.
So I think, a little THC is fine. Of course, depending on your state and the laws. Of course, unless we’re a select medical doctor, we’re not allowed to prescribe a marijuana. But the fact is, I think, a balance of THC, when appropriate, is a wonderful addition when needed. Most of my patients do fine just on CBD. However, I have some metastatic patients, which are using some THC. And they’re also doing unique deliveries. They’re doing transvaginal and transrectal delivery to avoid some of what’s called ‘first pass from the liver’. So when you take things in orally, then we’re losing some of that because our liver inactivates it, which comes up to the side effect. Because one of the side effects of either THC or CBD is it can actually alter the drugs that you might be taking from your prescribing provider, which actually are also being processed through the liver.
So you have to kind of put the toes in the water. It’s not like Shark Week on television. You want to kind of be gentle and see, “Is this going to be altering one of my drugs?” Which are CYP3A4, another liver enzyme metabolite. So we want to be careful because we are altering the State of the Union, so to speak.
DrMR: Got you. Okay. And it appears to me, anyway, that there’s—the broadest clinical applicability to CBD—and I want to get in some of the details in terms of conditions that have been shown to have a favorable impact from CBD. But just quickly, while we’re on this topic, would you say there are any conditions, in particular, where having at least a small amount of THC would be worth considering?
DrCM: And I think that most of the research that’s kind of compelling is on the immune side of things, where there’s some immunological challenge, which is grave, and there’s some balance point. It comes down to also how active does one have to be in their lives in terms of functionality. And you brought up an example of somebody that hadn’t been to or using marijuana for a long time. They have became, as a result, a naive user again, for a lack of a better word, a virgin user again, whereas a chronic user gets habituated and can therefore have a working tolerance.
And so, I would say that, honestly, the thing when I would use THC would be actually for things like immunological challenges, which I won’t use the “C” word, but things like that. And then, you need to find that balance. I work with a medical doctor, down in California, which all he does is just consultation for healthcare providers and their patients on the proper dosing of THC to CBD. And once again, outside of my scope of practice. I’m going to be very clear on that.
DrMR: Got you. Now, when you say immune, are you including autoimmune conditions like inflammatory bowel disease in there, or more so for cancerous type or cancer specifically? Is there a delineation there?
DrCM: The “C” word. Of course, the FTC and FDA doesn’t like the “C” word, so I’m just going to say the “C” word. Yeah. I would think that’s the time when, if it was me, I would definitely consider personally going that direction. But I will say that I have patients that find that a little bit of THC does allow them to relax. And a research on another lecture that I give is talking about how a standalone CBD is used for stage fright and social anxiety. A little THC can help. The only thing is, we want to be in control of our faculties.
So the question is, I would say, if they’re driving behind you, do you want them on THC and CBD, or just CBD? Because you want them to be in a clear focused mind. And it depends on how each person responds. It also depends on how they are liver metabolized, how toxic their liver is, whether they have a methylation defect. I find patients with an MTHFR—which is a mutation of the ability to convert folic acid into folate—they tolerate THC differently and they metabolize it differently than a person without that polymorphism or mutation.
So some of this comes down to genetics. And same thing with the enzyme called catechol-o-methyltransferase, which makes all of us more prone toward anxiousness if we have it. And they’re more likely to have that racy heart and the anxiousness from THC. Where somebody else might be really mellow and stereotypical like, “No worries, man.” And on the other side, they’re like, “Ughhhh” because the THC has spun them a little too tight.
DrMR: Okay. That makes sense. So let’s get into some of the conditions now, where we have the most favorable data. And I want to cite here a paper entitled, Cannabinoids and Autoimmune Diseases: A Systematic Review. I’ll link to the May edition of the Future of Functional Medicine Review clinical newsletter for our subscribers if they want to access a full summary and write up and images from that study. And anyone from our audience can also join to access that. And I’ll also link to the abstract.
But in this study, they found inflammatory bowel disease. There was at least one randomized control trial, two cohort studies, and one observational trial. And also some favor for MS, RA, pain in this summary. So why don’t we start with digestive? From a digestive perspective, where do you think people have the most area to gain from use of cannabinoids?
DrCM: Wow. You bring up the microbiome and the GI tract; that’s a few hours of conversation. Well, interesting, I’ve given four lectures about seven hours of lectures on this topic, all uniquely different hours and minutes. It’s very extensive.
First off, our natural endocannabinoids, once again, our endocannabinoid system naturally works in our body, are modulating our CB2 receptors within our intestinal lining. And they actually interact with the mu opioid receptor. So there’s research showing that CBD receptors and mu opioid receptors, they cross talk. And they also communicate with Lactobacillus, as well as Bifidobacterium within the gut. And all three, the mu opioid receptors, the CBD receptors are communicating and actually interacting. In fact, it’s called the endocannabinoid ohm. So endocannabinoids, and then the ohm of the microbiome.
And so, there’s a little party going on down there. And so, as a result, anti-inflammatory. And of course, it affects GI motility. And so we know, there’s IBS-D, that’s irritable bowel syndrome with diarrhea. There’s IBS-C, irritable bowel more constipated. And then we get, like you point out, the inflammatory bowel disease, the Crohn’s disease and colitises. And once again, these are autoimmune conditions. And we always have to ask the question from a functional medicine perspective, what lead to the manifestation of that condition?
Cannabinoids for IBS or IBD
So you’re plugging along, you’re symptom-free, and all of a sudden, you have symptoms. Usually, there’s a stressor, either internal psychological stressor, drugs stressor, or a dietary stressor, which we call epigenetics. Genetics loads the gun. Diet and lifestyle pull the trigger. And then all of the sudden, it’s like, well, what changed? Well, research shows that when we’re stressed and we all talk about adrenal burnout, adrenal fatigue, and how the adrenals and the thyroid play together, well, the endocannabinoid system actually also gets worn out from chronic stress. And therefore, our immune system is getting wonky. And then, we’re more likely to get susceptible to self-attack. Because after all, as you and I both know, autoimmunity is just auto – self-attack. Our immune system says, ‘hey, let me poke on that joint, that index finger, or let me attack the thyroid, Hashimoto’s disease’, or whatever the condition might be.
So it’s actually the down regulation and wearing out of the endocannabinoid system along with the adrenals and the other dietary and lifestyle challenges, which make us susceptible. So I would say, all the time with Crohn’s and colitis, CBD is a consideration. But realizing it’s a plant. And if they have an allergy to that plant, that would be a bad thing.
DrMR: Got you. Got you. Now, what about IBS? I was not able to come across—perhaps there’s one or a few floating around out there—any clinical or cohort or observational, any decently high quality data looking at cannabinoids for IBS. Again, I have not done a comprehensive search for that. But wondering what data do we have there in terms of outcome studies for cannabinoids with IBS. And does it break down, to those who have diarrhea do better than those who have constipation? There’s this—and again, please correct me if I’m wrong in this. But as I understand it, the impact on motility is more one to slow down motility rather than speeding it up. So one would suggest if you have diarrhea, then you may be do better from cannabinoids. But what do we know in this area?
DrCM: Yeah. I found, both clinically as well as in the literature, that if you have IBS-D, it’s more helpful. Of course, back to why does one have irritable or irritated bowels? And is it food allergens? Is it sleep apnea and hypoxia? Is it? Is it? Is it? So once again, supplementing, already working on diet and lifestyle, considering using something like a hemp-derived CBD would be a consideration, more with the diarrhea side. But once again, even the constipation side is altering things. And the problem with the constipation side, as we know, is if you’re not having your bowels move two to three times a day, which as I tell my patients, “That’s our goal.” And they’re saying, “You got to be kidding, two to three times a day? You’re eliminating muddy water, otherwise, your stool’s harder. What happened to all that moisture?” I said, “You reabsorbed it. You’re soaking in your own muddy water and we’re being kind.”
And so, once again, that alters your microbiome. And instead of having a nice compost pile, we have a septic tank in our GI tract. And so I look at that from, once again, the microbiome being altered with constipation. And that’s why, you see these commercials on television, “Work on your regularity, eat our yogurt.” Once again, they’re talking about probiotics.
DrMR: Sure. Okay. All right, that makes sense. And what about diverticulitis? I’ve not read anything in the published literature here. But I’ve seen a handful of cases that have sworn by the aid from cannabinoids for diverticulitis.
DrCM: I have zero experience in that, to be honest with you. I do a lot of work with diverticulitis. Once again, we’re now thinking about a diverticulosis, which is now infected and these little pouches have festering stuff in them. It can maybe palliate the symptomology a little bit. But I’ve had so many patients, which actually have had ruptured diverticuli from not treating it properly. That’s a tricky one. But I have not seen anything in the literature saying it’s a panacea. Once again, it’s a tool. But once again, why are the diverticuli becoming ‘-itis’ or inflamed? So it helps with the inflammation but not the infectious part, would be my guess.
Cannabinoids for Neurological
DrMR: Got you. Got you. Okay. So, that’s digestive. Well, what about neurological? I’ve read one study showing at least some preliminary favor in MS. And I’ve read some—and this sounds a little bit counterintuitive—that may indicate that cannabinoids can be neuroprotective, meaning they can protect your brain and your nervous system, which seems a bit ironic noting that one of the side effects may be memory impairment. But this may be solved by parsing out the THC from the CBD. But what about neurological conditions?
DrCM: Yeah. I mean, there’s research on Alzheimer’s disease, different dementias. I mean because we have a lot of CB1 receptors within our central nervous system. We used to think the CB1 receptors were only in the nervous system. Now, we know that was a misnomer. So we have to stay humble as we look at this burgeoning field. But, I mean, Alzheimer’s patients can respond often very well to a combination CBD to THC. Once again, talk to your healthcare provider. I’m not recommending that.
And in addition from perspective of just overall feeling better or de-stressed or post-traumatic stressors, research on both the THC, CBD side, as well as just CBD alone. And there’s enough evidence that, as a clinician and having done this for 25 years, I always start with CBD to start with. And then if I have to work with a provider that can help offer that from a legal perspective, the THC, we’ll incorporate that. But usually, the CBD by itself, 80%, 85% of the time, does the trick without any of the other sequelae. But MS, yes. Also, my Parkinson’s patients, I often incorporate it as well.
And so, I would say, Parkinson’s, the MS, little evidence on Huntington’s and definitely Alzheimer’s and other neural cognitive issues. I’m also very intrigued with amyotrophic lateral sclerosis. And there’s clear evidence about neuropathic pain and how it help with neurological issues. So I’ve had patients with stenosis of the spine and other things that have transdermally or topically used either CBD as the standalone or CBD and THC.
And so, from a clinical perspective, lots of research. My Facebook page which is, once again, facebook.com/hempiict has all these medical literature, oodles of it, lots of hemp. There are full articles that if a person is so inclined, they can read the medical gobbledygook. And it’s like, wow. And what’s fun about reading the whole article, as you and I know, is all that background information that the researchers provide out there saying, “This is why we’re thinking what we’re thinking.” So it’s not just the outcome of the study, but all these extra little tidbits they bury in there. Like you haven’t seen ever before and have a reference for it. It’s very exciting.
DrMR: Yeah. I know. I can totally relate to that. So I appreciate the fellow geeking out on PubMed. It is fun to uncover those little academic morsels.
Cannabinoids for Joint Pain
What about joint paint? Clearly, there seems to be some evidence for anti-inflammatory and analgesic or pain reducing, which, again, at least one study in rheumatoid arthritis. But for joint pain, muscle pain, there seems to be some evidence here. Would you agree?
DrCM: Well, there’s no question. And I think both you and I would agree that inflammation’s killing America. It’s probably more dangerous than cholesterol, because cholesterol—I would give the example of a non-stick pan. Butter doesn’t stick to a non-stick pan until there’s a scrape or damage to the pan, much like the lining of our blood vessels. So inflammation is going to be an accelerant for Alzheimer’s, premature aging, all kinds of immunological problems.
So, not only do I use it for the aspects of helping a person with their aches and pains, either transdermally or as an oral CBD/hemp-derived product. It just works wonderful on a daily basis to balance things out. Once again, a little bit goes a long way. And there’s that saying in CBD land or hemp land, “Start low, go slow.” Because if a little does the job, A) it’s more cost-effective; and B) you want to be respectful to the body. You want to take a whole lot of something else if you didn’t need it. So why would we take more of this? It’s not necessarily a panacea. It’s nudging and working within your body.
DrMR: I think it’s a highly tenable position to have. And I would agree with you there. What about the least helpful conditions and/or contraindications?
DrCM: Well, contraindications would be obvious. If you’re taking THC and you have a fragile psyche to start with, it might not be something you want to do. If you’re prone towards dizziness and you’re taking THC, not what you want to do. If you have cardiovascular issues, the THC side of things is definitely not what you want to do. On either CBD or THC, I would point out that they are metabolized through the liver. And if you’re on a medication and it’s metabolized through that same liver enzyme pathway, having a gentle conversation and a confidential conversation with your pharmacist is about, “Are there any contraindications with this?” And if they’re wise, they’ll say, “Well, let me take a look.” And they’ll say, “Okay. Well, this drug is metabolized this way. That’s metabolized another way.” But I say, you start low, go slow.
But I have saying that I have used when I lecture at the local MD medical schools, “Just because it’s natural, doesn’t make it safe. If it’s strong enough to help, it could cause disharmony in the body.” And that sounds very counterintuitive for a holistic provider to say. But it’s honest. If it’s strong enough to help, it’s strong enough to harm.
DrMR: Yeah. I think that’s also very, very reasonable. Okay, so liver potential—using this term loosely, liver toxicity and checking in that any medications that someone is taking won’t be impacted in terms of their metabolism by cannabinoids. Any other area where people may not want to bark up this tree in terms of it’s not very effective for this condition? Or any other contraindications that are worth noting?
DrCM: Well, in so much as human body makes these natural endocannabinoids that modulate your receptors, I think it has such broad effect within the human body that it’s probably pretty limitless in terms of the potential of health. But just because everybody else is thirsty, and there’s a pitcher of water out there, that doesn’t mean that your 2 gallons of water that you already drank today. You just keep on topping it off.
So, I think it comes down to need and really working with the healthcare provider that can guide you. And making sure that the product you’re taking actually is delivering what it’s claiming to, because CBD is not an inexpensive item. It’s a more premium item. And when there’s—
DrMR: Yeah. You’re actually right about that. And not to cut you off, but just for consumers, I’ve noticed this as I have shopped around. If you’re looking for something that’s cheap, you will be very challenged to find something cheap. Like if you are at a dispensary and you go to the counter and you find just regular marijuana or a regular marijuana-derived edible, that’s mostly THC. And you compare the price of that with something that’s pure CBD or high in CBD, the price difference is two to three times, I’ve observed. So there’s definitely a price impact there. You’re absolutely right.
DrCM: And there’s no question. And then the question is, “If you get something very inexpensively, are you really getting what you think you’re getting?” And I’m sure you’ve given this analogy. Driving along and you see $0.99 sandwich. Well, what am I getting for $0.99? So if someone said, “Hey, I got $0.99 gasoline per gallon. Not per liter, per gallon,” would you stop? You’re like, “I don’t know if I want to put that in my car. What’s wrong with that gasoline?”
So I would say, look for that. But also make sure that whenever a person is shopping for either the recreational side of things or medicinal side with the THC or the hemp side—because there’s all these companies now springing up is—where’s the quality? Show me a certificate of analysis. Show me what the solvents are. Show me what the pesticides are. Show me any heavy metals. Because people are always attracted to the fast dollar. But ultimately, we’re investing our health. And once we’ve ingested it or inhaled it or whatever, it’s in us.
And so, just like when we want to go for some cheap tuna, because you worry about the mercury and PCBs, well, you have to make sure that, regardless of the price, because there can be bad, expensive stuff. There was a study done in the Journal of American Medical Association—and I’ll repost that on my Facebook page—and it actually showed that the vast majority of products are either under or over labeled. This was in JAMA last fall. So the Journal of American Medical Association studied the product data and marketing. They failed. And it’s like, “Okay. Well, what does that mean? I didn’t get in that consistent dose from time after time after time.”
Once you find a brand that’s good, stay brand loyal. But do your research ahead of time. Ask for the certificate of analysis. And make sure that they’ve actually tested for the nasty, toxic stuff, and/or have they used the nasty, toxic stuff substances like, once again, toluene or benzene or butane or propane or acetone, to do the extraction process and as a residual in there. I just looked at the certificate of analysis another day. And it’s like, you’ll be getting milligram dosages over the course of a month of acetone. I’m a zero acetone guy. No fingernail polish remover for me.
DrMR: Let’s say someone doesn’t know anything about this. They just heard that and they feel very overwhelmed. Is there a certain label that they’ll look for? Are there a couple different things? For example, people are probably familiar with looking for the ‘Certified Organic’ seal. Are there a couple key things people can look to, to assure, at least for the most part, that the product they’re looking at is high quality, meets the label claims, is devoid of toxins, what have you?
DrCM: I wish it was that easy. And I’m sorry for overwhelming people. Actually, the certificate of analysis that I looked at was from an organic company. And the product was organic until they touched the chemical. So remember, organic is, by definition, how was it raised, not necessarily how was it processed after it was raised. And so we assume integrity, so nearly a certificate analysis. I would say, look for CGMP just like with our supplements. Whether it be CoQ10 or anything else, look for CGMP or a USP. Look for those labels. But any good hemp company, because there is plenty of profit in this, they should be doing a certificate of analysis, which means a third party’s tested their product. And the select ones that I use with my patients, and my rule—I’m sure it’s the same as yours—if I wouldn’t be willing to take it, my patients, for sure, aren’t taking it.
DrMR: Sure, sure. And you have a list of brands that you like?
DrCM: Yeah. I actually do. But I don’t necessarily want to promote them here. So I will go ahead and put them on my Facebook feed, just so the ones I use with my clinical patients.
DrMR: Sure. And we’ll include a link to that in our show notes for people.
All right, last one or two questions for you. Side effects, memory is probably the one that people are most stereotypically going to be cognizant of and perhaps concerned with. So memory effects from CBD compared to THC? Or is it affected by either of these, both of these? And is that effect something that’s substantial?
DrCM: So with CBD, not so much. And what’s interesting—and maybe people can relate to this that are listening. When you have a cold or a sinus problem, if you have the flu, it’s not the time to balance your checkbook or file your taxes, because you can’t think clearly. When you control your inflammation in your body, whether it be with turmeric, which is curcumin, boswellia, fish oil or CBD, if it’s appropriate for you, then you’re actually going to have greater mental clarity. Because when we’re feeling sick, we have brain fog. And a lot of people that use CBD and need to be using CBD, once you get working with a healthcare provider, they feel like, “Wow, I feel great. I feel more clear.” They always have what’s called a body high, because there’s no THC in it. They just feel good. And then it felt good for a long time. It’s like, wow, the veil of mystery has been lifted.
So now, with the THC side of things, that’s the greatest limitation. And once again, since I’m not allowed to prescribe it legally, I could just relate stories. That’s the number one reason patients discontinue using a product with THC, even at miniscule amount, is because, once again, they don’t like the altered state of being, because it’s like walking around constantly with a little buzz. Now, the chronic users, once listening, that user would be like, “Doctor, he doesn’t know what he’s talking about.” Now, if you could habituate it, if you’re using it regularly, you get used to it. And you can be functional. And I’m not saying you can’t be functional and be using a THC product. You just want to realize that if you’re going to a dispensary in a legal state and ask for a product, “Oh, yeah, this is the weak stuff.” Weak according to whom and which tolerance? And if you’re new to the mix, then there’s a challenge.
I had an 85-year-old gentleman working at Downey, California. He was a distant patient of mine, working with a medical doctor, which was—“Oh, don’t worry about it.” He had never been high his whole life. He was a military guy. And needless to say, he said, “I don’t like this.” And he already had a fracture of his spine. And his disequilibrium and dizziness and spinning of the room from getting high off of very low dose of THC was something—he said, “I’m never going to do this again. I don’t care how much pain I’m in. It’s not worth it.”
Susceptibility to Infection
What about increased susceptibility to infection? And this, to me, makes a lot of sense because—and this is something that we were discussing off air, which is both sides of this conversation, which is there’s definitely a lot of improvement that can be garnered by cannabinoids. But there, often times in Biology, is a trade-off. Especially if you go too far in one direction, you start to trade one thing for the other. Anything that is anti-inflammatory and/or immunomodulatory potentially runs a risk. Again, especially if being used in too high of a dose or too often, opening the door and making one more susceptible to infections. What are your thoughts in this area?
DrCM: Actually, I’ve not came across anything—and if you have, I would love to hear it—showing that there’s definitive evidence that there’s increased potential for infection. However, once again, my dosing for my patients is in the very low milligram dosages. If you go too high on anything, I think you can be disruptive. Just like I think you can overdose on vitamin D. Vitamin D, as in David, the sunshine vitamin. So I think you can overdo things. But have you came across anything showing immunosuppression from CBD or THC?
DrMR: No. In this review paper that I’m citing, they list increased incidence of common infection, viral infections, herpes simplex, a number of organisms. And they cite a little over 10 references. But I haven’t looked at those references to see if those references are quality references or not. I will send you a note once we finish up, so you can have a look at this. And I would be curious after you looked at this if you have any follow up notes that you want us to include in the transcript and the notes.
DrCM: Certainly. And what’s interesting about these articles that come out is, “Was it synthetic CBD? Was the CBD balanced with THC?” And so, once again, we could give people water and say, ‘water causes everybody to be sick’, because it was the purity of the water. There’s a lot of question there because, once again, our body makes natural endocannabinoids. It could be a dose thing. But, yeah, I would love you to take a look at that and dissect it, because it may be true.
And I like to think of the commercials on television—well, I don’t like to think the commercials on television. But think of these biological drugs and small effect. Okay, you have psoriatic arthritis. “By and large, why don’t take this drug and change your immune system and your psoriasis will go away. You will die possibly of lymphoma and/or…” And so, I guess, the question is nudging the body, not shoving the body, and always being respectful of the body with its trillions of cells and also trillions of visitors within the microbiome, in our GI tract. It’s always trying to do a delicate little dance.
So I’m one for even when I do a supplementation in my clinical practice to start low, go slow. And if a little of something that works, better. And I think as long as you’re respectful, you decrease the likelihood of side effects. But I have a classic example, maybe, to finish on. Many of the people on the audience, and of course, you know about Echinacea. Echinacea is a wonderful little immune supportive herb. My wife is deathly sensitive to Echinacea. She has Hashimoto’s disease. I would bring home, over the many years of us being married, going on 27 years. She said, “I got a cold.” So I bring the latest, greatest thing from my practice home. And I say, “Here, wife, take this.” And she would say, “Oh, no. Does that have Echinacea in it?” I would say, “Why?” “Well, the last two things you gave me had Echinacea and I think it makes me feel worse.”
So strangely enough, there’s cross reactivity. So she’s allergic to certain kinds of flowers. So I mostly have to buy her roses, not that I mind. But mixed flowers, daisies, no. There’s a cross reactivity. Just like for example, if you’re allergic to birch trees, you shouldn’t eat tree nuts, celery, carrots, soy, or apples during that same season. So once again, looking for the fact that this is an herb. It is a plant. And if you go “Ha-choo” outside, you can have just as much reaction to this as to anything else. So just caution, I think, is the better part of valor on this one.
DrMR: Got you. Okay. And then, two final questions, and we can make these kind of short and sweet, if that works on your end. Dosing, this might be highly individual but, again, trying to give the beginner at least some kind of guideline out there. How would you recommend someone to start with the dosing?
DrCM: Of course, my caveat will still be, talk to your healthcare provider. But my general rule with my patients, emphasis on the word “my patients”, would be 5 to 10 milligrams once a day of CBD, and see how their body responds. And realizing that if you hold it under your tongue, there might be some hypothetical increased absorption, but that not all CBD products are equal. Some have been now made to be water-soluble. Some have been made to be more fat-soluble. In fact, if it’s from an economic perspective, I just posted this on my Facebook page on CBD, once again, Hemp ICCT page on Facebook, about how if we eat fatty foods before CBD or THC, you’re going to get more bang out of it. And so, even from one day to another, like “Well, I had a pepperoni pizza, because I was hungry. Not because I had the munchies. I was just hungry for pepperoni pizza.” Bad example. And now, you did some THC or CBD, you might get more of an effect than after you’ve decided, “I’m going to have a salad dry.”
DrMR: Right, right. Okay, okay.
DrCM: So, yeah, I would say 5 or 10 milligrams is my starting dose. You’ll see in the literature high, high milligram dosages. I remember the first lecture I gave, I was quoting from the medical literature, 600 milligram doses for stage fright. And not that I recommend 600 milligrams, it’s like wow. That would probably have an effect, because it’s once again a bull in the china shop. Remember, our cells are so intricate and they’re so delicate. And as a result, just because we can shove them around, doesn’t mean that we ought to.
DrMR: And did you reevaluate the dosing after a number of days? Because I’m assuming this might be a little bit different than THC, which again, if you’re thinking about this from the perspective of a head high, that’s going to hit you within a couple of minutes, and last maybe a few hours and then be gone. Is the anti-inflammatory, immunomodulatory dosing, is that something that you are looking for a slower turn in someone’s symptoms and reevaluating after a few days or after a week? What does that look like?
DrCM: Yeah, a few days to a week. Also depends if I’m doing the Oreo effect. Let’s say, if a person has a knee issue, so we’re doing a little bit transdermally on the affected area, a little bit orally. I’m going to see, generally, a quicker effect. But once again, because we’re shifting the gears, we’re going from first gear to second gear to third, like a manual clutch, we’re going to, of course, see the body gradually going into the right direction. But we’re shifting at the cellular level, and I will give a very simple, short into the point example.
I was lecturing in New York to 400+ medical doctors that were East Coasters. I said, “Well, I’m tired.” And it was 7 a.m. their time. I’m an Oregon guy, so it’s 4 o’clock my time. I said, “How many cells in my body have to be tired before I feel tired? And which cells?” I said, “If anybody knows, let me know. I’m going to tell you things that I know.” Nobody in the whole audience raised their hand, very bright group of people. I said, “Well, how many cells in my index finger have to hurt before I perceive it hurts?” Still, nobody answered.
And so, when we looked at the impact on the human bodies, how much did it take for us to get out of whack and how much will it take us to get it within the balance? And what caused my index finger to hurt? What caused me to be tired? We still may have to be, well, we’re looking to supplement or augment or use a botanical or what not, why did I get into this ditch to start with? And how do I prevent myself from continuing in this ditch? Do I pretend I’m not in a ditch? Do I create a mirage of symptom relief naturally or through drugs? But we have to still figure out why is my body complaining and how did it start?
DrMR: And I’m assuming that you will start someone, let’s say, just for conversation purposes, at 5 milligrams of the CBD, once per day. You give it a week and then you reassess. And then, if you’re not seeing impact, I’m assuming you’ll increase by maybe another five or 10. And do this slow titration upward. And at some point, if you’re not seeing an impact, either some time interval or when you’ve reached some dose, you’ll then say, “Okay, this therapy doesn’t seem to be beneficial. We’ll move on to something else.” Are there more granular guidelines you can provide us there?
DrCM: That’s usually the general approach I take. As I do with all my botanicals or supplements is, if I’ve—and I do a lot of laboratory testing as well. So if I know which inflammatory pathways are going on or if I have documented an elevated ANA, antinuclear antibody for autoimmune, then I’m going to then measure also somewhere down the road, have I shifted those numbers, and also looking for the other variables. Okay, great, well, I’m going ahead and I’m doing all these things.
But, yeah, well, I started feeling good now—you’ve had this problem, I’m sure, with your patients. Not a problem, it’s just an honest conversation, “Yeah. Well, actually, my knees are really hurting.” “Well, have you done anything differently?” “Well, I did start feeling a little bit better on x, but it stopped working.” “And well, did you do anything differently when you started feeling better?” “Yeah. I started playing soccer again.” “No wonder your knee hurts again, because you just injured your knee, because you just started feeling good.”
And so, once again, teasing out the variables. I always tell people, one thing at the time. Clean up the diet. Nurture your bodies. Stay hydrated. And then, be very analytical. And most of patients who are doing CBD products are actually documenting on a daily basis, what are the variables?
DrMR: Sure. I think that’s fantastic. So are you increasing a certain milligram dosage per week? And then, how long until you’ll jump ship to something else or maybe you have a certain dose ceiling when you’ve achieved 50 milligrams per day or what have you? At that point, you’ll say, “Okay, if we haven’t seen any impact here. We’ll try something else.”
DrCM: I would say that, if I’m at 50 or 100 milligram dose and there’s no effect whatsoever—and once again, that’s why I have people quantify it, because, let’s say, someone comes in and I love going to my chiropractor. And he says, “Are you doing better?” “Yeah. It still hurts in my costochondral junctions.” And he says, “But is it any better?” And he gets me to think, ‘Yeah, it’s better. I’m taking a deeper breath’.
And so, I think quantifying and being really analytical is important. But I would say, 100 milligrams, if it’s not doing the trick and you’re not seeing a percentage change—and just because, once again, this might be the right angle for one of the many problems causing these symptoms, you still have to find the other reasons for the symptoms.
DrMR: Got you. Okay. That’s very helpful. Cool. Well, this has been a great conversation. Please tell people your Facebook page again. And if there’s a website or anywhere else you want to point them, please.
DrCM: Well, certainly. Well, DivineMedicine.com is my website page, so divinemedicine.com. And it has access to 200 articles, some of my 16 books. But my Facebook page with the hemp education, from the peer review literature is of course Facebook.com/hempicct
DrMR: Awesome. Well, thank you again. I really appreciate you helping provide us with some guidelines and some details in terms of what to use, when to use it, how to use it, what to expect, and what conditions may benefit. So again, thank you. This has been a very enlightening conversation.
DrCM: Hey, thank you and thanks for inviting me.
DrMR: My pleasure.
What do you think? I would like to hear your thoughts or experience with this.
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