Recreation use of marijuana but should marijuana and it derivatives be used for health purposes. A very controversial issue, one in which frequently there is far more heat than light and where we frequently see people who seem to be immune to data. We have experts tonight to talk about this, it will be moderated by doctor david who is chief of Palliative Care at pennsylvania. Im a psychiatrist and i often think that most people including physicians dont understand what psychiatry is. Nobody understands what Palliative Care if its a wonderful branch of medicine and needs to be better understood. We launch the book a year ago, this is his second book he is launching here, no we do not have royalties ongy n it, but in two copies of it. Dr. David kasser at will come up in a minute, we, we believe all of you are literate, we print biographies in the program, this is not an imac went to sit up for ten minutes and read every paper that people wrote. Dr. Katz it will come up and will introduce our three panelist and will moderate a discussion amongst them. If you have questions there are notecards you can write on, you can pass them and will be collected and well put a microphone up later for questions. Please dont interrupt the speakers in the middle. Thanks everyone, its its delightful to be here again, a year later. A different topic and devices as problematic. Im rearranging the script a little bit, i was supposed to ask this question in another half an hour but i would i would like to ask it now. I would like to know, what people in the audience would think about legalizing america medical marijuana in pennsylvania. You you can either before, against her undecided. So all of those of you who are for, all of those who are against, those of you were undecided which often means you have an opinion but you dont want to state it for the record. So my goal for the next half an hour is not to change your mind, im not going to try to take all of those or even one of you who are prolegalization and shift you, im surely not going to take those of you who are negative and shift the other direction, and im not going to take someone in the middle and try to nudge you one where the other. Honestly i shouldnt be able to do that, if you can be nudged that easily in the space of half an hour for an issue thats this important you havent thought through carefully enough. Thats not my goal, that should be your goal either. What id like to do in the next half an hour, and what i asked our panelist to work on in the sessions they have following this is not to try to change your mind but to give you enough data, enough evidence so you can have a thoughtful discussion to support whatever your opinion is. To do that knowing what the other person on the other side of the debate thinks too. What were after is not a consensus that medical marijuana should or shouldnt be legal, but a thoughtful discussion and wherever that discussion is up for you. Okay. Sponsors thank you for all of you folks in a round of applause for jill stall who is standing in the back in the bright dress [applause]. She is responsible for doing all of the lastminute things including giving me a glass of wine for free about 15 minutes ago which really, really helps. Thanks for that. For my conflict of interest ive asked the panel to describe their conflict of interest as well. Is she for or against . [laughter] ill take that as an undecided. We will work on that. I dont have any conflicts of interest im about to describe those of myself not to those of the university of pennsylvania. I couldnt resist putting this picture appear with a book review for stone, show this to some of our social workers on the Palliative Care service at the hospital of the university of pennsylvania asked them if this guy look like me, they said no, which was good until they said that guys much more cute than you are. So thanks for all of you. This ultimately is the question we need to wrestle with, whether youre thinking if medical marijuana could help you or loved one, or on a policy level whether it should be legal. Is it. Is it a medication, is it a weed, is it something that could be helpful, is it an illegal drug that should be banned. Or, maybe is there some middle ground we could find a consensus about. I wrote the book stone for a patient i took care of about a year and half ago. Was a hospice patient she had a band patient created cancer and she described weight loss, nausea, pain that sounded like it had a pain due to nerve damage. In that conversation she asked whether i thought medical marijuana might be helpful for her. I told her what i learned the medical school which is that medical marijuana doesnt exist, marijuana is an illegal drug, theres no randomized control data to support its used. But what i can tell you about judith issues a retired glacial professor, she spent the last 50 years of her life giving to students a tough time and crossexamining them. So. So when i said no there is no can troll to support random use she said really because i went on the internet and i found a couple of studies in here they are. She pulled them out of her bag and at that moment i had to admit to her that maybe this retired english professor knew more about medical marijuana and symptom management than i did. I promised i would look at those papers, i i look for other studies published and i would estimate my colleagues and experts in the field and get back to her with an answer whether how merit medical marijuana might help her. My advice was based on the evidence out there it could certainly be helpful to her. That realization that one of my patients, with no medical training actually knew more about the evidence for medical marijuana than i did made me realize that there are probably others out there, policymakers, legislators, patients, families, other physicians who had the same perception as i did that theres no evidence to support its use. That is what led me to Research Medical marijuana and also embark on this process of writing a book. As i did i came up with three big surprises and in the next half hour or so i will walk you through these three big surprises. Parenthetically, people in the press interviews for stone have asked me which Science Writers i find the most influential for me who ive looked to to be role models, on on how to be a medical science writer. Mary roach is someone im can paired with a lot, oliver sacks, honestly the most influential writing example for me have been travel writing. Travel narratives, the really good travel narratives like paul drew, jan morris, these are people who write travel narratives very well. What makes makes a good travel narrative . Is mistakes. Surprises, misconceptions that get rearranged along the way, good travel narratives arent about getting to point a to point b its about trying to get from point a to point b and winding up someplace else entirely. Or getting to the end and realizing its not what you thought it was going to be. When i think of what a good science, nonfiction looks like, ill share with you the ways in researching this book and reviewing studies and visiting clinics and try medical marijuana for myself, what that has taught me in terms of science and also in terms of surprises. Ways in which ive been surprised, and ways ways in which ive been wrong. The first is that there seems to be a science in the way medical marijuana will works, the second is as my english professor told me, medical marijuana does have benefits, and three that it has risks. Although not necessarily the risks that i expected. So this is the science of medical marijuana, i i really thought that medical marijuana or the appeal of it was just about getting stone, the feeling of getting high, the chance to forget whatever else is going on with you, whether that, whether that was a terminal diagnosis, pain or nausea. It was something that was dissociated and kept us from focusing on whats going on but it wasnt really therapeutically valuable, thats what i thought. A background is useful, two main species of marijuana, some people argue that a third specie is a true species, some people would mix it in with these two but generally when were talking about medical marijuana or Recreational Marijuana we are talk about two species. Were talking about the active ingredient in marijuana, the big ones, the main once we know most about is those are present in these little tri cones that look like nail holes on the leaves and stems. When you talk about the cannabinoids in medical marijuana at your not talking about the entire plant you talking about whats highly concentrated in those little male had things. Youre talking about these two molecules, there dozens of cannabinoids out there, this is present in the largest amount and has gotten the most attention in terms of what has been study. Keep in mind that what i will talk about in terms of benefits and what youll hear from the panelists, will be benefits but there are other cannabinoids in marijuana and many which we dont know what they do. There certainly reason to believe they could be there you dick or they could cause risk that we dont yet understand. Another surprise for me in this category is marijuana acts through receptors, not not just a global feeling of being high, but theyre very specific receptors in the brain and also the reproductive system, cbd binds to other receptors in the immune system and elsewhere in the body as well. Interestingly it at it works in the brain to be into think that cbd may be useful in treating neuropathic pain. Other cannabinoids that i told you and other receptors, this is just one angle, one snapshot of what we know. What convinced me that there was a science to medical marijuana, that i really hadnt appreciated is that the man pictured here is arguably the grandfather of medical marijuana, i made a pilgrimage to meet doctor in his laboratory at Hebrew University in jerusalem to hear about some of his work. He was, the one who discovered a molecule. What is interesting for us is it gives us an idea of how it marijuana does what it does. We do not have a or were not born with receptors that are designed to bind with phd preceptors. We are when you take this into your body in the form of marijuana that is inhaled or vaporize, or even in the form of an edible, what youre doing really is tricking the body into thinking that it is suddenly experiencing and inrush of the substance. Youre basically hacking into the natural and okay system and you can visit the the body that its receiving a lot. Three so its important is in the system its very complicated, its in the immune system, the brain, and most organs, at least some degree and its also present in every species out there except for insects for reasons i really dont understand. So so when you are using medical marijuana or wreck relational marijuana into your system you are hacking into a very complicated system that we dont quite understand. Not only is the science of medical marijuana much more complicated than just getting stone, its more complicated than just one molecule binding to one or two receptors in the brain. Youre really tapping into a complex and in ways thats hard to understand a very complicated system in the body. That was one surprise, theres microbiology, theres receptors, there also natural variations in receptor and cannabinoid receptors are not the same as mine, so how you respond is different potentially than how i would respond to a joint, gummy bear, or brownie. One surprise is medical marijuana really does have benefits, i really thought medical marijuana was a joke starting out, but i had to admit based on some of those studies that judas showed me that there really is some good data out there. Increasingly some of the best data on marijuana for a variety of ailments including pain come from these vaporizers. You heat a marijuana but, usually to usually to a temperature thats hot enough to make the cannabinoids change and evaporate but not hot enough to get the stuff in marijuana to burn. So you are in haley viewer but youre not inhaling all of the the gross things that you inhale when you wouldnt use a joint or cigarette. Other people are starting to use it to so its beginning to be an easier way for people to figure out if theyre getting the doses of cannabinoids that they think they are which is useful for research purposes. This is what one owner told me, i said their benefits to medical marijuana i wouldnt go this far , but one thing i discovered in looking through the world of medical marijuana, particularly dispensary owners and those who have a vested interest in pushing medical marijuana is that there are a lot of overstated claims. There are medical benefits to medical marijuana i would not not say its the new best thing, i would not say its a wonder drug, it doesnt cure all ills, doesnt cure doesnt cure cancer so well just say that for the record. If you look at state laws including some indications that are in the legislation moving to pennsylvania you see very long list of things that are listed as qualifying conditions, that is one interesting fact. Another fact is there is a huge amount of agreement from state to state so what is a qualifying in one state may not be qualifying and another which is fascinating because either there is enough evidence to support the use of medical marijuana for human their pe or other ailments or there isnt. Its not like that evidence would be greater in california than it would be in colorado yet there doesnt seem to be huge amount of agreement from state to state. There are many ideas out there of how medical marijuana can help. So how much is there, really benefit from medical marijuana, i could spend, probably, probably a few hours walking you through the evidence it would be a very efficient way putting you all to sleep, which i will not do. There is a very carefully done, review of the evidence of both smoke marijuana and cannabinoids, both natural and synthetic. I may summarize the evidence more than i could reasonably do it a short period of time so i will tell you what they found. There is some evidence, but probably not as much evidence as a lot of people would like, certainly not as much evidence as many patients who are looking to medical marijuana relief would hope would be there. These are there reservations that mine, theres week evidence for some other indications. I remember looking at that list thinking thats a little bit odd, because thats not entirely opposed to what i said and stoned or the impression i got but it seemed like it was a little bit tougher, little more more harsh than what i had thought. I remember they said there is moderate evidence for medical marijuana for neuropathic pain so i took one study at random, a reasonably well done study published in a decent journal, it was a study that i cite as evidence and there seems to be a reasonable amount of evidence that medical marijuana is useful in the treatment of neuropathic pain. If you unpacked that a bit based on that journal article criteria there is notable strength, there is a controlled trial, placebocontrolled. They can remove the drug in marijuana just the way the like you can remove coffee from a coffee bean. Many of these studies use a placebo marijuana. It also used low and high dose groups, in that article they also part pointed out weaknesses, a small amount of subjects, some of the people in the active group and Placebo Group knew how they were assigned, they knew what they are getting. And that makes sense if you think about it, if you cant tell if youre getting real, honest to god marijuana or the pharmacologic equivalent of oregano, youre probably not paying attention. So some so some people manage to figure out what group theyre in. Those two weaknesses were enough to downgrade that study i was going to show you. So it degraded into a poor quality study. I dont mean to argue with those criteria, they can use whatever they feel are important but keep in mind those criteria are really tough, theyre also tough because right now theres no federal funding for medical Marijuana Research. Those of you who are researchers know its really hard to do large randomized controlled trials, this grading criteria that this article used call that a small study if there are fewer than 200 people. Thats pretty much every single study of medical marijuana thats out there. Its hard to do studies that will hold up to that level of evidence that jam article a call strong. If youre looking at the wrong criteria, when we hear discussions of evidence being weak, moderate, or strong its important to know as educated consumers, followed policymakers, followed policymakers, physicians its important to note that means. Rather than summarizing the evidence and talk about nuances i thought it be most useful to post this question for you, i think it gets to the heart of the debate of medical marijuana and how we should think about it. How much evidence do we really need . I think the answer depends on who you are. If your policymaker, if youre a hardcore researcher, the amount of evidence youd want to make sure that a new treatment, whether its a new cardiac device or a new form of medical marijuana, be sure that it actually works you would want multiple large, meaning several hundred people randomized controlled trials. If youre patient, as were many of the patients i spoke spoke with, one young guy in his 20s had a bad treatable form of lymphoma, he was having horrible nausea after every round of chemo there. That he couldnt couldnt even leave the house for a week. This is a 24yearold who is thinking about stopping his schema therapy and going into hospitalist because he couldnt stand the nausea, he he has been through several types of antinausea medication and his dr. Finally recommended he tried medical marijuana he said sure he would give it a try. I tell you that story because his level and threshold for evidence is going to be different and lower than that of an administrator at the fda, or a hardcore researcher. Im not saying one of those to his right, the administrator at the fda, his or her job is to protect the public, so their their job is to ask for the highest possible amount of evidence. If youre that kid trying to struggle through chemotherapy, or if youre a parent who is trying to get cbd oil for your kid with seizures or a guy that is suffering through ptsd, who has been through a dozen different medication, suicide attempts and need some form of relief, your threshold for what constitutes enough evidence is going to be different. Again im not trying to say one of those positions is better, i think whats going on is people know exactly how much evidence there is but they have a different tug point as to what constitutes enough evidence. So well think about that as we go forward through the debate. The other thing i learned thinking about the potential benefits of medical marijuana, and this is an oped i wrote to the New York Times for a brief period of time and its one of the most emailed articles in the New York Times. The head of it is an article about sending puppies to prison. The point of the article which has got a lot of traction ha