You’ve got questions about cannabis and how it’s used to treat issues such as anxiety, depression and insomnia? Well, we’ve got answers as John interviews to Dr. Jordan Tishler, MD, in this fascinating interview.
Dr. Jordan Tishler – Anxiety, Depression and Insomnia in Uncertain Times–Harvard Doc Treats with Cannabis.
John Malanca (00:00):
Welcome back, everybody, to the John Malanca with United Patients Group. Be informed and be well. Today’s special guest is Dr. Jordan Tishler. And if you want to say hi, doctor.
Dr. Jordan Tishler (00:11):
Hey everybody. Thanks for having me on.
John Malanca (00:14):
Thanks for being here. Well, Dr. Tishler is a cannabis specialist. Through his training in internal medicine and years of practice as an emergency physician, Dr. Tishler brings his knowledge, reason and caring to the patients at his clinic called Inhale MD and through his advocacy work at local and national levels. Dr. Tishler graduated from both Harvard College as well as Harvard Medical School, trained at the Brigham and Women’s Hospital and is a faculty at both Brigham and Women’s Hospital as well as the Harvard Medical School.
John Malanca (00:52):
He spent many years working with the underserved, particularly providing care for veterans. Having treated countless patients harmed by alcohol and drugs, his observation that he had never seen a cannabis overdose led Dr. Tishler to delve deeply into the science of cannabis safety as well as in treatment. So great introduction. Good to have you out here, Dr. Tishler.
Dr. Jordan Tishler (01:15):
John Malanca (01:16):
So you’ve covered a lot over the years and we have mutual friends that have said… This is the first time we’ve met, so thanks for being on the show, first off. But you’ve made a name for yourself out there, not only here in the U.S., but really big out there in the East Coast. And you do a lot of work with a lot of nurses and doctors and patients out there in the East Coast. Your name has been popping up, popping up, popping up quite a bit.
John Malanca (01:44):
You’ve been quoted in quite a few articles. I’m a big cyclist. I know you had one in the Cycling Magazine about pain and using cannabis in that, so I enjoyed that article. But let’s talk about, this is something that comes up quite a bit. You being an MD, let’s talk about anxiety and depression with cannabis, because that’s something that comes up quite a bit that I share… People call in all the time and say, “I have anxiety and depression,” and sometimes they go hand in hand. And sometimes when you help with sleep, these go away. I’d love to get your thoughts on that.
Dr. Jordan Tishler (02:22):
Well, it’s fascinating. And you hit the nail right on the head, that these things are sort of dramatically connected to each other. And so talking about them sort of in isolation can sort of lead us astray. But reality here is that one of the nice things about cannabis as a medicine is it really helps us address kind of all three of these issues. And really we could generalize to even wider and throw sort of PTSD in with anxiety, depression and insomnia.
Dr. Jordan Tishler (02:55):
Because again, all of these things can feed on each other and often present in the same person. The key really is, and we have a lot of literature now that kind of explains this, that cannabis can be extraordinarily helpful. But particularly when we’re talking about some of these sort of mental health issues, it’s complicated in that a little bit can be helpful and too much can, well, frankly, just be too much. And the word I tend to use is backfire. And so if we’re using this in sort of a measured and thoughtful fashion, we can get remarkable mileage out of it. But if we kind of do this willy-nilly, then we can actually make things worse.
John Malanca (03:46):
Yeah, I like how you say backfire, because people think, in anything in life, more is better. And in cannabis… I mean, I was sharing a story before we jumped online, what we do with my father-in-law. We were less is more for us and we had success. And so when we share that story first, people are thinking, “That’s impossible. You need to have this much.” And I say, “Everyone’s different.”
Dr. Jordan Tishler (04:10):
It makes me nervous when I encounter people who advocate sort of the more is more view. There are certainly reasons related to sort of the business endeavors of the industry we are in. They may want to message that more is more. But there are folks out there who are telling people, well, if you have cancer, you need to be taking in a gram of THC every day And my eyebrows go up and the steam comes out of my ears. That’s just a huge amount of cannabis.
Dr. Jordan Tishler (04:52):
And thinking about, again, the sort of mental health issues that we were talking about, my patients are getting their best benefits sort of on average around 10 milligrams. And sure, there are some variation on that, of course. But on average, 10 milligrams, that’s pretty far off a thousand milligrams, which is a gram, right? And we’ve certainly seen these higher doses just cause a wide array of problems from…
Dr. Jordan Tishler (05:23):
In my bio, I said I’ve never witnessed an overdose and the truth is that’s not really accurate. That is to say, I’ve certainly never seen anybody have a lethal overdose. But I think we all have seen people overdose in the sense of get too much and you can have a very paranoid, uncomfortable ride for however many hours that takes to wear off. And so that’s one sort of set of harm.
Dr. Jordan Tishler (05:48):
And then there’s other sorts of harms that can come up from exacerbating the PTSD or exacerbating the anxiety and depression. And then there are some other harms that are sort of more insidious in terms of the biology of dependence formation and tolerance formation, and possibly even some long-term negative brain changes, all of which are totally avoidable if we’re just doing this, as you said, sort of with that kind of less is more, very medical thought process.
Dr. Jordan Tishler (06:22):
It doesn’t matter whether it’s cannabis or any other medicine. The way we think in medicine is, how little do I need to use in order to get to the benefit Because anything above the benefit is just exposing us to side effects and risks. So it turns out when we’re talking about the mental health stuff, that you really don’t need very much. And so why use more?
John Malanca (06:46):
And one, it’s healthier for you sometimes, less is more, but also cost effective. Insurance isn’t covering this.
Dr. Jordan Tishler (06:57):
That turns out to be, to me, slightly odd, but perhaps to other people it makes more sense, is that that’s actually a very primary selling point I find with some people, is that they say, “Well, why should I come see you, doctor, when I can just go get this stuff?” And aside from all of the health benefits that we just kind of talked about in terms of getting to a better solution and a safer solution, there’s also that cost effectiveness bit.
Dr. Jordan Tishler (07:28):
And then like, look, if you come talk to me, I can actually save you money in the long run by helping you find the right product right up front and help you get the dosing right. As well as a consequence of that correct dosing, you’re going to spend less per dose than you would if you were kind of using the more is more approach.
John Malanca (07:49):
Before we go into the anxiety and depression, it’s not a one-size-fits-all as, like you said, in any type of medicine or herbs or supplements. Age, weight, current health condition, any other medications they may be on, what their mindset is like are things to look at. And so people go, “Hey, my cousin has the same ailment, how come it’s not working the same way as it worked with them?”
John Malanca (08:19):
We get there’s a lot of seniors as well. But one thing I share is I don’t want people to think cannabis is the golden pill, the golden ticket that take this and your healed. When my wife turned 50, she had just healthy, happy, everything was perfect. She started having anxiety. She’s like, “I don’t know what’s going on with me. I’ve never had anxiety. I’ve never had this feeling.”
John Malanca (08:48):
So she went to our doctors, our ND’s, naturopaths. And so they did a blood workup on her and they saw that she was off. And it was one day doing these plant-based hormones to her, some people are great and some people are not. She balanced. And so a lot of times when women call our office, the first thing, “I need this. I have an issue with sleep. I have an issue with depression. I have an issue with stress and anxiety. Help me.”
John Malanca (09:15):
And I say, “Not to get personal, how old are you?” I’d go talk to a doctor first to see if you’re imbalanced somewhere, because it might help your sleep, anxiety, depression, and stress. And they say, “I’ll be darned.” And then they come back. And I like that you are a low 10 milligrams starting point. I think two milligrams sometimes, depending on how sensitive the person.
John Malanca (09:40):
I mean, you’d never think that I’m sensitive to stuff like that. I’m sensitive to knock on wood I don’t get sick because I’m highly allergic to whatever’s in cold medicine: butter, salt, alcohol. I mean, if I had a glass of wine, I could sip by my glass of wine on my lawn. But again, the same thing with cannabis, 2.5 milligrams works with me and stuff like that.
John Malanca (10:04):
So let’s talk about anxiety and depression. I’d love to get back on the show, because everyone says, “Oh, are you going to be speaking about Dr. Tishler’s sex talk as well?” And I said, “We’re going to go…” I think that’s a great topic. We could go down the road as well, or you can go to Dr. Tishler’s site and talk to him directly about that, if you’d like, if you want something more personal.
John Malanca (10:27):
But let’s talk about anxiety and depression, what you’re seeing in your office, what you’re doing, formulations, and then we’ll get into a different cannabinoids. Or you can talk about it now, what you do with a normal patient. And again, for our listeners, this isn’t to replace a one-on-one with your medical professional. This is for informational and educational expert advice as well. But again, not to replace a one-on-one with your own personal physician. I’d throw a disclaimer in there.
Dr. Jordan Tishler (10:59):
Well, I think that’s a good disclaimer, because I think we’re seeing this… In the internet age, everybody just kind of wants to Google the answer. I’m not trying to put that down. When I have an issue, I often turn to Google. But for better or for worse, I have a little bit more of a framework when it comes at least to medical issues and to which to fit that information.
Dr. Jordan Tishler (11:28):
And quite a healthy skepticism that I think we certainly need to see more of when it comes to interpretation of the information that’s out there. Where do we start with depression? Well, the first thing I would say is that we really have to look at the diagnosis. It’s awfully easy to say I have depression or I have anxiety. But are a number of conditions that can mimic those conditions that are less psychological and more physiological, like hyperthyroidism, hypothyroidism, and there are a whole bunch of them.
Dr. Jordan Tishler (12:08):
Again, sort of to your point about maybe it’s not the very best idea to sort of DIY your healthcare, this is something that you should check in with your regular doctor about and kind of go through the checklist of what could be causing these problems before we sort of leap to that diagnosis. If, on the other hand, we’ve kind of ruled out some of these other kind of sneaky guys and we’re left with something that’s more garden variety, then we can sort of start to talk about where cannabis fits in.
Dr. Jordan Tishler (12:48):
I think cannabis as an antidepressant and as an antianxiety medication is useful and good and not super potent. I have patients who come to me and they’re like, “I have these symptoms of anxiety or depression and they’re bothering me now, but it hasn’t been such a big deal. I am not on any medications for it.” And so one might start them on a beginning dose of a medication like an SSRI or you could start them on a beginning dose of cannabis.
Dr. Jordan Tishler (13:32):
As far as I look at it, I think that either of those approaches is reasonable for the treatment of these illnesses. And so it really comes down to sort of, what is the patient comfortable with and which approach feels best to them? On the other hand, I have patients who come in and they say, “Look, I’m already on an SSRI and an SNRI.” They are on a constellation of medications that maybe haven’t gotten us to where they want to be.
Dr. Jordan Tishler (14:06):
And sometimes I hear people saying things like, “I really want to get off that medicine.” And I have to kind of question the wisdom of viewing these things as the goal is to get off something that is otherwise kind of helping you. And I can also say that because cannabis isn’t super potent for this indication, if you’re on a series of antidepressants now and it hasn’t gotten you to where you want to be, then it’s unlikely that cannabis is going to be a replacement for those medications.
Dr. Jordan Tishler (14:47):
However, one of the things that we often see is that people who are on those medications may be getting some or most of the way there, but then they’ve got a bunch of side effects. And so the side effects of common medications includes sort of feeling like a zombie, which is what people talk about. Lots of sexual side effects. Sometimes there’s weight gain, which is harder to deal with. But the point is that, thankfully, cannabis actually plays really well in that sandbox.
Dr. Jordan Tishler (15:16):
So it’s not an either or proposition. If somebody comes in and they are on nothing, then maybe a little cannabis has all they need. But if somebody comes in on kind of a good cocktail of medications, it may be that adding cannabis is all you need to sort of get over the hump and into that sort of sweet spot, that happy place, whether that’s by adding an additional amount of anti-anxiety or anti-depression, or maybe it’s simply that the conventional medications are doing fine, except that they come with this baggage. Then we can kind of undo some of that baggage by adding cannabis.
John Malanca (15:55):
Is your end goal to have them completely titrate off their medications? Hopefully if you’re doing a one-on-one with your patient and for the long run while incorporating cannabis, are you looking to lower the dose of their pharmaceutical and get that balanced? Finding that sweet spot, like you said.
Dr. Jordan Tishler (16:12):
Well, let me put it up front that I have no qualms with pharmaceuticals as a general rule. I would say that my goal for any individual is to get them to where they are happiest. I generally find that adding cannabis is a great approach. I don’t usually find that we can or should titrate the conventional medications down, although I’ve certainly had some people do so quite successfully.
Dr. Jordan Tishler (16:48):
I don’t know that I’ve had anybody come in on a significant dose, meaning something above a starter dose of a conventional medication and be able to come off it entirely. If somebody comes in and they’re on 40 or 80 in Zoloft, for example, they may be able to go back down to 40 or to 20. Ultimately, I want the patient to feel well. And if that means they need some conventional medicine and some cannabis, I think that’s perfectly fine. And in terms of the sort of biology and the biochemistry here, these things get along just fine. So there’s really no need for it to be sort of an either/or, or an up versus down kind of discussion.
John Malanca (17:34):
In your practice, do you recommend… Because a lot of families and patients call us and say, “I want the medical portion of the cannabis plant, not the recreational.” And I think all the cannabinoids in the plant have a purpose in bringing the body back to balance as well as healing. And so in your practice, you’re in a legal state. And so do you find yourself recommending more CBD-dominant ratios versus a THC, or are you doing combinations in there with different patients?
Dr. Jordan Tishler (18:08):
Well, one of the things is that just by our being a legal state, much like California, we have not gotten into some of this product types that you guys have. So we don’t have quite the range of minor cannabinoids in products yet and we don’t have as much focus on ratios. That all being said, I think that when we’re certainly talking about THC to CBD ratios, I have been very underwhelmed that adding the CBD does a whole lot.
Dr. Jordan Tishler (18:48):
And so to your question, I don’t typically suggest CBD to people. I don’t find it to be very effective at the doses that are available and the scientific literature tend to bear that out. That all being said, small amounts of the THC component, which is really unfairly labeled the recreational part, can be extraordinarily helpful. So all the data that we have in human beings at this point, with the exception of kids and seizures, is really focused on THC.
Dr. Jordan Tishler (19:30):
And we’ve got over 60 year’s worth of great data, looking at THC as a pain reliever and as an anti-anxiety medication and that sort of thing. As you say, when people show up and they sort of have that mentality, that THC is for the stoners and then the CBD is the real medicine, I think that’s bad judging on the part of this industry, in large part due to the sort of hemp bill.
Dr. Jordan Tishler (20:00):
And I really spend time explaining to patients why that’s sort of not the right way of looking at it and that yes, THC comes with intoxication, but it’s a side effect and all medications have side effects. And that, again, that less is more approach allows us to find that sweet spot, the place where they get the maximum benefit with a minimum of those side effects that they’re concerned about.
John Malanca (20:27):
A lot of the older patients, because they come from the generation of the RIFA Madness and it’s bad. Now I can talk about this with my parents. I think when I was in high school, it was the last talk I was going to have with my parents. But now the stigma has dropped. I mean, even when Corinne and I started our organization, United Patients Group back in 2011, the stigma was there and I didn’t share a lot with family and ex colleagues that I had. And then all sudden time has gone on and now everyone’s talking about it.
John Malanca (21:00):
My mom’s at church. She’s at bridge. She’s at her red hat thing. They’re talking about it at lunch. And so she’s handing out our business cards to everybody. I get calls from guys that I grew up with my whole life and he’s like, ‘I want to thank you, because my mom listened to you. She wouldn’t have listened to me, but she listened to you and she’s doing extremely well and I just want to thank you for that.” And I say sometimes it takes that. They’re not going to listen to me, but they’ll of course listen to Dr. Tishler. I mean, Dr. Tishler says, it’s like, “Mom, I’ve been telling you this for 20 years.”
Dr. Jordan Tishler (21:36):
Listen, my parents don’t listen to me either. So sometimes it just takes somebody who’s not the kid, even if the point has been said over and over again and it is completely correct.
John Malanca (21:51):
It’s funny. We’re in California, near the Wine Country. But I always use the example, you can go out and have a sip of wine and not be drunk. You drink three bottles, you’re going to feel something. The same thing with THC. Minute amounts are very helpful for some. You don’t have to have the high dose. You don’t have to be stoned to have results in inhaling.
John Malanca (22:18):
Well, CBD has gotten gangbuster not only here in the U.S., but overseas. Everywhere you turn, gas stations to your dentist office to CVS and all these, they have walls and walls of so many different options of all these products. What do you share with your patients when it comes to that? “Hi doc, I have access. I just purchased this.” Are there any warnings you share with any of your patients?
Dr. Jordan Tishler (22:51):
Well, there’s a whole lot of discussion around the THC and the levels, particularly if we’re going to use something like botanical, and that’s to do with anything. When it comes to CBD in particular, I think that we’re in this really weird place right now where sort of the sales and the marketing have way outstripped the science behind it and, frankly, also outstripped the regulation.
Dr. Jordan Tishler (23:22):
If you get your CBD through the dispensary system in California or in Massachusetts, then there are some safety standards that are applied. But if you’re going to the whole foods or the gas station or on any of these or online, as you mentioned, then there really those safety standards. And we have a number of studies now that show us that there can be a whole range of problems with those sort of more readily available products, ranging from simply it says it there’s CBD, but there isn’t any.
Dr. Jordan Tishler (23:58):
And that’s a bummer, but at least it isn’t dangerous if you buy just a jar that’s basically olive oil. But then from there, what we found is that some of these preparations have contaminants like heavy metals or pesticides, which obviously are not very good for you over the long term. And then worse than that, which just kind of floored me, is that we’ve actually found that there are products out there that have adulterants, meaning things deliberately added, like benzodiazepines or even opioids, to make them sort of do something and so that the purchaser feels like they’re getting something from the medication.
Dr. Jordan Tishler (24:39):
But obviously, this is something that we would like to avoid and certainly like to avoid getting when we don’t know where we’re getting these things. I think that there are a number of issues around that sort of over-the-counter CBD. And then there’s this other issue, which sort of gets mentioned once in a while, but it really hasn’t kind of caught on in the national conversation, which is that CBD is significantly more likely to interact with conventional medications.
Dr. Jordan Tishler (25:15):
So if you are a 20-something year old and you’re basically healthy and you have some anxiety and you want to take some CPD, it might not help your anxiety, but it’s unlikely to do too much harm, assuming that it isn’t full of any of these contaminants we talked about. But the real issue is that most people who are looking for these sorts of things, as you mentioned, are seniors, where they have a whole range of other medical illnesses and maybe on a range of medications that if it interacts with that CBD can become dangerous.
Dr. Jordan Tishler (25:48):
That kind of drug-drug interaction is something that we physicians spend a fair amount of time being concerned with. And it’s not really kind of getting out into the real world and where people are using this not necessarily with the guidance of somebody like myself, then we can start to see some prop. I’ve had this come up in my clinic a few times, because it takes a lot of CBD to be useful, but it doesn’t turn out that it takes a lot of CBD to start to get into that danger territory. So it really depends upon what you’re taking whether this can be a problem or not.
John Malanca (26:30):
That’s a good point. I’ve never looked at it that way, the way you just described it. And so especially with anxiety and depression patients, you have to be very careful on what you’re working with. Is that true? I mean, I have friends that are going through this and they’re just, not only before the COVID, but really in the COVID, they’re at home. They’ve been in quarantine. They haven’t seen their parents. They can’t bring the kids over to see the parents.
John Malanca (26:55):
And so this stress and anxiety now that these parents are working from home, but also becoming homeschool teachers as well. And they’re thinking, wait a minute, I was enjoying sending the kids off to school. Dosing is important and timing is important. People say, “I work all day, I can’t be intoxicated,” Or, “I need to drive,” Or, “I’m doing heavy machinery.” Can you talk about, in your practice, what you recommend for best timing as well as the dosing? Again, we talked about less is more in many cases. Can you talk about that?
Dr. Jordan Tishler (27:36):
Sure. So timing, as you pointed out, is a huge issue for exactly the reasons that you mentioned. I mean, most folks are busy doing what they need to do during the day and can’t afford to be intoxicated or even just kind of mildly fuzzy headed. The thing that I find most interesting about cannabis when it comes to anxiety and depression is that I think most of us think that the benefit comes from the intoxication.
Dr. Jordan Tishler (28:14):
And in some instances, that may be true, but not specifically about depression and anxiety. And so if we can give that little dose that we’ve been talking about sort of around bedtime, then not only can we improve sleep, which is sort of, as we said at the beginning, that it’s kind of part of that ball of wax. But what happens is whatever the chemistry is doing to sort of reset our brain, it’s not directly tied to that intoxication.
Dr. Jordan Tishler (28:46):
So the intoxication wears off overnight and you wake up feeling rested and clearheaded, but the anti-depression and anti-anxiety benefit persists throughout the next day. And that is an ideal situation, because then we don’t have to use a dose in the morning and then start to intrude upon all of those activities of life that we need to be sharp for. So using this stuff around bedtime turns out to be really ideal.
John Malanca (29:16):
Again, helping with that sleep.
Dr. Jordan Tishler (29:19):
I don’t think it’s strictly that. I mean, I have patients who come in with depression and anxiety and no insomnia and they still get maximum benefit with that low dose before bedtime. Certainly, as we talked about, there are people who have kind of all of the above and then they’re getting… They’re related, but not directly tied.
John Malanca (29:45):
Have you seen cannabis that induces anxiety?
Dr. Jordan Tishler (29:51):
John Malanca (29:54):
I’ve had that, where it was, okay, great. I’d be relaxed at night. My wife would say, “When at 10 o’clock at night you took your dropper or something, I knew the day was over.” And I’d go to sleep, have a great evening, wake up and be like… I’ll comes back a hundred folds at you. And so I’m like, okay, let me just see where my body works with this. And so I’ve talked a lot of patients over the years that, “It brings on my anxiety. It brings on my depression.” And so do you see that in your practice? And if so, what would you recommend?
Dr. Jordan Tishler (30:31):
I have not seen it as you describe, where it’s bringing on these symptoms after the intoxication has worn off. I’ve certainly seen lots of people have their anxiety…
John Malanca (30:49):
Dr. Jordan Tishler (30:51):
Yeah, triggered during the use of it. And I think that really it comes down to dose in particular. What I’ve seen is, again, that it’s the higher doses, the sort of more recreationally informed doses that seem to trigger the anxiety and also sort of worsen depression. When we start to use the really, really small doses, we seem to be getting more benefit than sort of backfire.
John Malanca (31:25):
And with that earlier, you were talking about you kind of like step back on CBD on that. I know we spoke earlier and you were talking about… How does CBD factor into your dosing practice? Because it’s not a one-size-fits-all. And I know you’re limited sometimes with your products out there. What are you recommending and in what form? Are you going for the tincture so you’re doing the vaporization? A lot of seniors like the gummy or something to put in their mouth, like they’re used to taking a pill every night.
Dr. Jordan Tishler (32:02):
Right. So I have not found CBD to be terribly useful. So if somebody comes to me and they say, “Doc, I’m using this. What do you think of it?” If they’re telling me that it’s benefiting them, I’m certainly not going to contradict that. But if people are coming to me and they saying, “Doc, I’ve got this problem. What do you recommend?” I typically am not saying, “Oh, I think you should go get some CBD.”
Dr. Jordan Tishler (32:26):
There are certainly a few exceptions to that, but that’s kind of the general rule. As for the approach, from what I can see from this far away, California is very into their tinctures. I have to say that we know that there’s very limited absorption orally, meaning through the skin of the mouth. And that really the primary absorption is, again, through the gut, as one might expect.
Dr. Jordan Tishler (32:58):
And in those circumstances, the absorption of tincture tends to be pretty lousy compared to that of an edible. So generally speaking, I would opt for an edible. I think the other thing with tinctures is that people get a little bit inexact about their use. If you’re counting drops and such like that, I think it’s very easy to mess that up.
Dr. Jordan Tishler (33:25):
So if you have a little gummy that’s five milligrams of the THC component and you take that, you know you got five milligrams, right? I really dislike it when people are like, “One, two, three.” That’s just a recipe for disaster. In the few instances where I really need to use a tincture, I always tell people, “Don’t drop it into your mouth. Drop it onto a spoon, and then take it like cough syrup.” So into the mouth and down the hatch and chase it with something, because they usually taste terrible.
John Malanca (33:59):
It sounds like you’re not coming from the school, and I heard this about you, because now I’ve changed the way I do take mine. I used to keep it at 30 seconds to a minute. One of our friends said, “Nope. Additionally, just take it, throw all of it and chase it.” And so I’ve changed that. I’m like, okay, I’m not going to hold this in my mouth for two minutes while I’m making my morning oatmeal or something like that or before bed.
John Malanca (34:24):
So I’ve changed that process of how I consume the medicine. And I call it medicine. First, when we got into this, I remember people would say, “We have to take medicine.” And we’re like, “Come on, really?” And as time had gone on and seeing the results we had with my father and my friend’s dad, it is medicine and seeing all the patients that we worked with over the years as well.
Dr. Jordan Tishler (34:54):
Cannabis is interesting in that way. I mean, we clearly have a legitimate recreational use for it. But as people get older, and I’m generalizing, and things start to bother them, they’re old recreational habits may not be the best approach any longer. And thinking of it in terms of medicine, as you describe, and also thinking about it in sort of that more controlled and more precise approach to the dosing and the timing, it works better that way.
Dr. Jordan Tishler (35:28):
Another example is a lot of my seniors come in and they’ll say things like, “I haven’t touched this since the ’60s. Back then, I used to smoke a joint once in a while, but then I stopped because I smoked a joint one day and I had this horrible, paranoid reaction and I just decided it wasn’t for me and I had this bad experience.” And there ensues a conversation about, first of all, that was a long time ago.
Dr. Jordan Tishler (35:53):
And second of all, that whole approach to dosing is recreational, meaning it’s not exact. You don’t sit there and think, how many milligrams of the THC am I getting when you’re 20 years old in a college frat party or whatever? So people end up imbibing much more than they think plus the setting comes into it, which means in the subway or at the frat party may not be the best place to have sort of a pleasant experience.
Dr. Jordan Tishler (36:24):
When we’re looking at this now when you’re 80, we’re talking about a very different process. We’re talking about doing this in a very calm environment. We’re talking about using very specific types of products with a very specific dose at a very, very low level, starting low and titrating up as needed and not beyond what’s needed. And it just leads to a completely different set of outcomes both for the problem, as well as for sort of the psychological experience of that patient.
John Malanca (36:56):
The seniors, that’s the thing. They’ll try something as they had used it in the past and they go, “This wasn’t grandma’s old weed that we had back in the ’60s type of thing.” Do you ever get warnings with the gummy bears like, “Oh, these taste great. They’re so small. Oh, I’m sitting there. I don’t feel anything. I better have two or three more,” and now they’re panicking?
Dr. Jordan Tishler (37:21):
Well, one of the things that’s a little bit different from the way I approach things, from the way things have been approached in the past, is that I tend to be pretty straightforward and specific with my patients. If they need a gummy, I will tell them I want you to go buy a five milligram gummy, and I want you to start taking five milligrams gummy in the evening and you’re going to do it for this many days.
Dr. Jordan Tishler (37:49):
And then if that’s working great, but if it’s not, you go up to 10 milligrams. But if 10 milligrams isn’t working, then I want you to not take more, but get in touch with me. So I’m very hands on in that way and very available to my patients, because I think that’s the only way for us to really get honed in on what it is that they need. You asked me a question a little while ago that I didn’t get to, which was about sort of gummies versus other routes. And we talked about gummies versus tincture.
Dr. Jordan Tishler (38:22):
But I think one of the other things that people don’t focus on enough is that cannabis behaves differently depending on how we take it. And so that actually means how we take it really is based on what we’re treating. Everybody knows about smoking. I don’t recommend that anybody smoke this stuff because smoke isn’t very good for us. But smoking is not the only form of inhalation available to us.
Dr. Jordan Tishler (38:49):
So we can put the cannabis… Oh, I happen to have it right in front of me… In a little cannabis vaporizer, and this machine is smart enough to extract the medicine without burning the plant material. And that allows us to get the medicine without all of those risky chemicals. And that’s kind of an ideal way to approach inhalation. Why do we want inhalation? Because inhalation is inherently rapid onset, 10 to 15 minutes.
Dr. Jordan Tishler (39:18):
And then it’s also sort of a modest duration, like three or four hours and then it starts to wear off. So for certain indications, certain illnesses or conditions, that’s a better approach. If we have somebody who has trouble getting to sleep at night, then you want something that’s going to work when they need to get sleep. If somebody has migraine type headaches, you want something that’s going to work before the headache gets out of hand.
Dr. Jordan Tishler (39:44):
The oral stuff, the edibles and such like that are really the opposite. They’re slow to work and even can be a little unpredictable in terms of when they’re going to kick in. So yes, we absolutely talk about warnings and being aware of that and expecting it. What’s the advantage to edibles? Well, they’re like the extended release. Once they do kick in, you got more like 8 to 12 hours of coverage.
Dr. Jordan Tishler (40:09):
So for somebody who has chronic 24/7 debilitating pain, if you use inhaled, you’re going to get this kind of yo-yo effect up, down, up, down. Feel better, not feel better. You don’t want that. We know from other areas of pain medicine that something that’s more level actually does better at controlling pain. So something like an edible, which is kind of, again, that extended release version, is a better way to get pain control. And actually you end up using much less in terms of total dose. So thinking a little bit about the problem that needs to be treated kind of dictates not only dose and timing, but also the route of administration.
John Malanca (40:48):
You made a point, I know we were talking about anxiety and depression, but pain can also be that. You’re in pain, you can’t do anything. You can’t get outside and run or do what you’re normally used to, or you’re in 24/7 pain. I work with a lot of fibromyalgia patients that are in pain nonstop, and it’s a hidden pain. And so it brings on that heavy cloud over them of what’s going on. They have to still be a mom or dad or a parent of young kids or children, parents, I should say. What do you normally do with… Like I said, at the beginning, we talked about it’s all connected.
Dr. Jordan Tishler (41:28):
John Malanca (41:28):
And so with anxiety and depression, are you seeing more cases? Are you back to work? Are you doing stuff like this with your patients via Zoom calls now?
Dr. Jordan Tishler (41:42):
So I never stopped working. I transitioned even before the state permitted it, frankly, to doing this via telemedicine. And as you might guess from my generally skeptical nature, I was not super excited about seeing people through the computer as opposed to being in the same room together. But I have to say that I changed my tune quite a bit. I really do like being in the same room, but the telemedicine has allowed me to take care of a wider range of people, people who were having trouble getting to my office either because of their illness or because of just physical distance.
Dr. Jordan Tishler (42:30):
There’s actually some silver lining here, which is the office is a great environment, but it’s an office environment and I’ve been able to sort of meet with people in their homes this way. I was talking to a woman a couple of weeks ago and she was sitting in her kitchen and I’ve gotten to see how people live and it’s part of a relationship building. And then her five-year-old son crawled up in her lap and said, “Mommy, I want to snuggle.” That’s priceless. And it’s what we in clinical medicine live for, is that kind of interaction. I wouldn’t have had that if I were in the office. So I’ve actually kind of changed my tune a bit.
John Malanca (43:16):
Are we all going to this route, to stay at home? Do you have pants on, I got to say, or you’re in shorts?
Dr. Jordan Tishler (43:24):
I have pants on. But I think that right now we are in an interesting short window, where due to all of the efforts we’ve made over the last three to five months, things are starting to look a little bit better with regard to COVID-19. But I’m afraid that what’s going to happen is everyone’s going to decide or seems to have decided that it’s kind of done. And so we’re going to go back to work and we’re going to have these safeguards in place, but it seems that people aren’t actually taking them very seriously.
Dr. Jordan Tishler (44:05):
And if you look at the numbers that are coming out of places like Florida, you can see that their cases have spiked up tremendously. In fact, they had last week the single largest spike in the entire process for that state. I have the feeling that we’re in for a rocky few months over the summer and that by midway through the summer we’re going to be backpedaling a lot. So I’m in no rush to reopen my office when I can take care of people equally well, if not better, by using telemedicine.
John Malanca (44:42):
Modern technology. I know we said an hour and we’re right about that point here. So what would you say to any of our listeners right now that may be experiencing anxiety, depression, PTSD? Can you give them any words of wisdom, some hope? I mean, hope is a great thing. I never want to give anybody false hope, but I think hope is a great thing. And again, with that, how they can get a hold of you and anything that you’re working on as well.
Dr. Jordan Tishler (45:09):
Sure. So as for hope, I totally think that this is a great medicine that provides absolutely wonderful results for a wide range of people. Nothing works for everybody. Not all things work equally well for all people. But if anxiety and depression and PTSD are an issue for you, I would absolutely look into this. And it’s really about doing it carefully and methodically so that we get the best benefit.
Dr. Jordan Tishler (45:43):
And to that end, I do telemedicine. I do telemedicine worldwide at this point. So if you want to reach me, you can come to my website, which is inhalemd.com. I’ll repeat that. It’s inhalemd.com. And there we have over a hundred articles on various subjects, including PTSD and anxiety and depression and all that sort of thing. So you can start to read up a little bit and kind of fill in some blanks there, and then you can reach out to me and we can get you in to be seen, online to seen.
Dr. Jordan Tishler (46:19):
And one last one I’ve got to mention, I think that it’s a little factuable at the moment to say that there aren’t many doctors who know this sort of material and a certain amount of that is kind of a political statement, some of it is actually true. And so what I’ve spent a lot of my time doing is trying to fix that. And to that end, I started a now international group called The Association of Cannabis Specialists. And you guys could check that out, if you’re interested. It’s cannabis-specialists.org. Again, cannabis-specialists.org.
Dr. Jordan Tishler (46:53):
And we have a whole range of educational material there, again, mostly aimed at clinicians, but certainly not something that is above our listeners today. And then they can get involved and support and all of that sort of thing so that we get more people out there knowing what they need to know, so that more patients have people that they can rely upon.
John Malanca (47:17):
That was going to be my last question, what can you say to any of our listeners who their doctors aren’t on board and what’s the best way? But you just mentioned what to do. And I think the ripple effect that Dr. Tishler was talking about, I talk about it as like throwing a pebble in a pond and the ripple effect gets out there. Listening to our conversation today, you’ll take that back and say, hey…
John Malanca (47:42):
Talk amongst your family and friends, maybe even your doctors. And if any doctors are watching, the same type of thing. Getting involved with a doctor that knows about the cannabis plant, the endocannabinoid system, dosing. It’s not a one-size-fits-all. More is not better. These are all questions to ask and be on top of. And the testing. Earlier, Dr. Tishler spoke about testing what’s in your medicine.
John Malanca (48:06):
Always make sure you’re using a product, if it’s cannabis versus hemp or anything else like that, that has been tested. As the consumer, you don’t have to do it. Where are you buying it from? It should have the labels. The products, I don’t have any products near me, should have a QR code or a website that shows that accurate and up-to-date testing report for mold, pesticides, fecal matter is in there, metals.
John Malanca (48:33):
There’s a lot of products that have metals in it, arsenic and hemp. So make sure if you are going the hemp CBD route and that’s your only option, make sure it’s… I’m a fan of whole plant medicine, but also that has grown here in the United States and has testing results. Even the gummy bears that you are probably seeing at your local dispensary should have test results.
John Malanca (48:53):
And I guess current test results, not something from two years old. I say six months is good. If you can get something sooner. But these are just things to be careful. You’re putting this into your body and this is what you’re trying to do to bring your body back to balance. And so Dr. Tishler, I thank you so much for taking your time away from your practice. The closest I got to Harvard was my grandfather graduated from Harvard.
John Malanca (49:21):
But it’s a beautiful campus. I’ve been there. But thanks again, and I appreciate your help, Dr. Tishler, with Inhale MD. This is John Malanca with the United Patients Group. Be informed and be well, and we’ll see you soon. Bye bye. Thank you.
John Malanca (49:39):
Hi, John Malanca here with the United Patients Group. I hope you’ve enjoyed our videos. Please click like as well as subscribe to our channel here on YouTube. Also, follow us on Twitter at upatientsgroup and on Facebook at United Patients Group, as well as for our podcast, please click the link in the description below. We’ll see you there. Bye bye.