Dr. Regina Koepp 0:02
Cannabis use is a hot topic. And cannabis use in older adults is a super hot topic right now. Older Adults are using cannabis for sleep, for mental health, for appetite, for managing agitation with dementia disorders, for managing pain. Admittedly, I am naive when it comes to cannabis use in general, and then especially cannabis use for older adults. So, today on the podcast, I invited Dr. Peter Grinspoon, a medical marijuana expert and physician to help us understand the pros and cons of medical marijuana use and the risks and benefits.

Dr. Regina Koepp 0:47
I'm Dr. Regina Koepp. I'm a board certified clinical psychologist and I specialize with older adults and families. I created the psychology of aging podcast to answer some of the most common questions I get about aging questions about mental health and wellness changes in the brain like with dementia, relationships, and sex, caregiving, and even end of life. Like I say in my therapy groups, no topic is off topic. We just have to have a healthy way of talking about it. So if you're an older adult, or caring for one, you're in the right place. Let's get started.

About our guest, Dr. Peter Grinspoon

Dr. Regina Koepp 1:27
Welcome to the 26th episode of the psychology of aging podcast. The topic of cannabis use in older adults is particularly timely. Even on Dr. Grinspoons website, he talks about medical marijuana or cannabis soaring in popularity, especially among baby boomers and the elderly. Millions of people are finding it useful for chronic pain, insomnia, anxiety, PTSD, fibromyalgia, colitis, and many other conditions. And today, on the psychology of aging podcast, Dr. Grinspoon will share with us the pros and cons of cannabis use in older adults and even talks about cannabis use with adults with dementia. Let me tell you about today's guest. Dr. Peter Grinspoon is a primary care physician at Massachusetts General Hospital, and is an instructor in medicine at Harvard Medical School. He's a certified health and wellness coach and is currently serving as a board member of the advocacy group, doctors for cannabis regulation, which works toward legalizing cannabis with an eye towards social justice issues. Dr. Grinspoon is also contributing editor to the Harvard health publications in recovery from opiate addiction himself, he has been a national leader on the issue of physician health, and has served as an Associate Director of the Massachusetts physician health service, where he helps physicians with addiction and mental health issues. He's the author of the memoir, free refills, a doctor confronts his addiction. Let's jump right into the conversation. I'm so excited to bring this interview to you today. If you would be willing to talk a little bit about who you are and what you do and what led you to be interested in cannabis use in your profession as a physician.

Would you be willing to share about who you are, what you do, and what led you to be interested in cannabis use as a physician... in your profession?

Learn about Dr. Grinspoon and what led him to become interested in medical marijuana

Dr. Peter Grinspoon 3:21
Sure, well, I'm Peter Grinspoon, I'm a primary care doctor in Boston. And I've actually been at Mass General Hospital and instructor medicine at Harvard Medical School, and I've been interested in medical cannabis my whole life. That's probably in part because my father, who unfortunately passed away a couple months ago, was Lester Grinspoon, who was one of the leaders of the legalization movement for cannabis, medical and otherwise. So I was brought up with either proponents or opponents of medical cannabis in my living room, my entire childhood. So I was, you know, either like smoking joints together or throwing things at each other. So I was like, exposed to the issue my entire life. Part of it is that my brother, Danny, unfortunately passed away when I was eight years old, and he used medical cannabis for his cancer induced nausea and vomiting. My parents got it for him illegally at that point. This was sort of unrelated to my dad's research, but I sort of saw firsthand how effective medical cannabis can be. And my whole family was very pro medical cannabis. Just because of my brother's experience. So I went through medical school residency, sort of immune to all the propaganda and nonsense that they typically teach, or taught, I guess they'll teach doctors about cannabis. You know, we really need to start from scratch and you know, wipe the slate clean and you know, really teach doctors, nurses, physician's assistants, sort of modern updated knowledge that hasn't been tainted by eight decades of the war on drugs about what cannabis really is, what the harms and dangers actually are, which have been wildly exaggerated though there are harms and dangers of any medication and what the actual benefits are. So, I've been interested in it my whole life, I've always recommended it for patients for things like Fibromyalgia or migraines, you know, things that are very poorly treated by Western medicine and things that are, you know, very well treated by medical cannabis. So, in a nutshell, I'm a primary care doctor who's always been interested in medical cannabis. More recently, I've become involved in the movements to legalize medical and recreational cannabis. I'm a board member for the group doctors for cannabis regulation which is a great nonprofit group which helps both get doctors up to speed on cannabis and also helps work on legalization because you know, living in in Massachusetts or California you could forget that there are still a lot of places that don't have legal medical cannabis, let alone recreational cannabis and there are still hundreds of thousands of arrests every year for cannabis possession, which is absolutely crazy. So that is in a nutshell where I come from in terms of my my involvement with cannabis.

Dr. Regina Koepp 6:19
Wow, thank you for sharing about your brother and your your dad's experience. It's so rich and animated. Your brother, did he die as a child or as an adult then?

Dr. Peter Grinspoon 6:31
He died when he was 16 and he was having such a hard time with the chemotherapy they didn't have some of the medications they have now like ondansetron and um, you know, he just couldn't eat couldn't hold down food. And they tried... my mom actually, not even known to my dad, kind of surreptitiously went to my brother's High School of all places Wellesley high school this kind of upper class, upper middle class, suburb where we lived and asked my brother Danny's friend to get some cannabis. He was like, "What?" Like, couldn't believe it. But then they smoked it without telling my dad and my dad knew something was up because my mom and my brother Danny were acting suspicious. But on the way home from the chemotherapy, Danny was like, "can we go get a sandwich? I'm starving." And, you know, usually he's just like lying in the back of the car throwing up. So, it actually worked really well. And it helped him eat for the last year or two of his life. And it just made such a difference. And, you know, this is why oncologists aren't against medical cannabis at all. They're all completely in favor of it because they see how helpful it is to their patients. Now, this is one of the most obvious uses for it is cancer induced nausea and vomiting, one of the most clear cut, but when the patients benefit, the doctors are in favor. It's pretty straightforward.

Dr. Regina Koepp 6:42
Yeah. And what what do you suppose inspired your dad? Was it your brother's journey with cancer? Did something else inspire your dad to become interested?

Dr. Peter Grinspoon 8:04
Well, that's a long story. But you know, in short, what he says is that he was best friends with an astronomer, a famous astronomer, Carl Sagan. And Carl Sagan used to smoke a lot of marijuana. And my dad was like, "that's dangerous. You can't be doing that." And Carl's like, "No, it's not. It's completely harmless. It's just propaganda." So my dad sort of wanted to prove that it was dangerous. So he went and did a lot of research on it. And actually, Carl was right, in that it wasn't dangerous. He was, um, I mean, yes, it is not dangerous, you know, people who are pregnant or breastfeeding have to be very cautious people on other medications or who were prone to confusion, dementia, cognitive impairment, have to be careful, um, you know, teenagers shouldn't be using it. But aside from that, it's a lot less toxic than a lot of the alternatives that we use. It's less toxic than opiates, which people get addicted to and can be very dependent on. It's less toxic than benzodiazepines that a lot of people use for, you know, for anxiety, which can be very habit forming and can harm your memory, and can maybe even precipitate dementia. So, you know, when I say non toxic, I mean, it's less toxic than a lot of the alternatives. So he tended to get interested in it because, well, one origin story is that his friend, Carl Sagan, and he had a very big disagreement about it. Another is that he was concerned about what the youth were doing all this hippies in the 60s and 70s were doing and he's like, they shouldn't be doing this. This is really dangerous. I want to investigate it. And then he did investigate it. And when he did the research himself, he saw that a lot of it was really kind of slanted towards harms and very little slant toward the benefit. And then when you look towards the research towards harms, a lot of it was very contrived and that it actually had been used for thousands of years very, very productively, and not just for medical uses, but for, you know, sexuality, for creativity, for religion, for music, for a lot of ways, I mean, um, you know, his book "marijuana reconsidered" is a masterpiece. It still is a masterpiece, even though it was written in 1971. It was reviewed in the front page of the New York Times Book Review. And, you know, it's just amazing the history that this plant has, and the extent that the extremes that our government and other governments have gone to kind of eradicate it, and they didn't do anything to eradicate it. All they did is put a lot of people in prison and ruin a lot of lives, but people are still using it. And I'm glad that it's finally becoming legal so that people will continue using it like they have all along without having the revives needlessly ruined.

Dr. Regina Koepp 10:57
Right. You're so proud of your dad, it just comes out it is so cool. That's really...

Dr. Peter Grinspoon 11:05
Yeah, no, I had a great dad. I mean, I got really lucky.

Dr. Regina Koepp 11:09
Yeah, what a beautiful thing. So, I'm so curious, what are you noticing are some trends with cannabis use in older adults?

What are the trends with cannabis use in older adults?

Dr. Peter Grinspoon 11:17
Well, first of all the uses are going up. It's because of decreasing stigma, increasing availability, but the the percentage of elderly people... who knows what elderly is? I guess, in this study the defined it is greater than 65. But you'll look at your average 65 year old, they don't look very elderly to me, but, um...

Dr. Regina Koepp 11:38
...don't identify as elderly...

Dr. Peter Grinspoon 11:41
Yeah...went up from something like 2.6 to 4.2% and is growing. You know, the study is always underrepresented because people are still afraid they think the DA is listening or something. But, um, the trends are that it's the use going up because people are first of all hearing about it. Second of all, they're curious. And third of all, they're sick of their current medications. I mean, for pain, what are people going to do you know, Americans are getting like older and creakier, you know, they have knee pain, they have back pain, Tylenol doesn't do anything. Nonsteroidals like your Advil, your ibuprofen, your Aleve your naprosyn, if they don't give you a heart attack, they'll destroy your kidneys. That's if they don't give you an ulcer. I mean, you can't be in those for long term. And nobody wants to be on opiates for so many reasons. We could spend the whole discussion talking about why you don't want to be on an opiate. They're addictive, they hurt your quality of life. So medical cannabis these days, you can be on it for a low dose, there are different strains. It doesn't have to be all THC, which is the part that gets you high, there are other cannabinoids other active ingredients of cannabis like CBD, which is very popular and other ones that are being bred up. So you don't even have to be high or very high. And, um, if you can get off the nonsteroidals and protect your kidneys, or if you can get off the opiates, or if you get off your sleeping medications which make you confused and affect your memory or get off your muscle relaxants, which can make you confused and cause falls, people are finding great success with you know, polypharmacy is something which I'm sure you talk to your geriatric patients about all the time, the fact that they're all on 20 different medications, none of them want to be on 20 different medications. And they all want to get off 20 different medications. Cannabis does about five things at once. It helps people with anxiety, sleep, depression, pain, and mood. And it also helps people you know, connect with other people sometimes, you know, isolation is such a huge issue in the elderly. And, you know, I've had elderly people come back to me and say, Yeah, my hip pain's great. And this is really fun. I'm painting again, or, you know, I'm going to the daycare center. So, people are finding it to be really helpful. And not just in one particular facet of their life, but in a multifactorial way, and they're getting off these other medications. So, as long as they start low, and go slow, I have them start at very low doses. I say, if you're going to make a mistake with the dose, make a mistake where you didn't take enough and you're disappointed. Do not make the mistake where you take too much you get anxious and you have a bad reaction. I have them work their way up over a month. Just to be sure that they don't take too much as long as they don't go into a dispensary get overzealous say this brownie looks delicious and take a huge dose, they're going to be fine. So as long as they start really slow, and work their way up really slowly with a low dose, they're going to be fine and then they can gradually try getting off some of their other medications. Once they get accustomed to how it feels, and get adjusted to the effects, because it does have a psychoactive effect, and you do have to be careful.

Dementia and cannabis use

Dr. Regina Koepp 15:11
Yeah, just a minute ago you were talking about populations, particularly older adults who might not... or this would be contra-indicated, and you mentioned dementia. Can you talk a little bit about that? What I'm noticing is caregivers will dose cannabis, or marijuana really, like gummies, edibles to folks with dementia who are agitated or having trouble sleeping, which is a common, you know, issue with mid stage to later stage dementia disorders. And so they're dosing this but I don't think there's guidance around that. And so I'm curious what your thoughts are, what the contra indications are around that?

Dr. Peter Grinspoon 15:54
Right. Well, there's several different things. There's CBD which is just one component of cannabis. Cannabis has like 600 different molecules. Now CBD doesn't increase your confusion and doesn't make you higher or anything like that. But CBD does help you with anxiety and insomnia. So certainly CBD is low hanging fruit if someone's agitated, um, you know, the one thing about CBD is you have to be careful in that it can affect the levels of other medications that you're taking. Exactly like grapefruit juice, it can kind of compete for the enzymes in your liver that metabolize the other medication so it can raise blood thinners or anti epileptic so you just have to be careful. I've never heard of anybody like bleeding to death because they're on a blood thinner and they take CBD but you just have to be aware of it. So um, CBD is very low hanging fruit to someone who's agitated, because what else do they give someone who's agitated, they give them these heavy duty tranquilizers. Now would you rather your loved one be on a heavy duty tranquilizer which is going to make them 10 times out of it or try a little gentle CBD so I think that's very again the low hanging fruit to try. Now, in terms of cannabis, if CBD doesn't work, you want to try some THC, something a little bit stronger. That absolutely might have an effect. But you, again, you're comparing it with these heavy duty tranquilizers they tend to give out, you know, haldol or Thorazine, whatever they give to elderly agitated disruptive patients, they give it out like candy and I'd rather see them on a gentle cannabinoid that would help them relax, feel a little bit euphoric, and calm down then have them completely drugged out on a major psychiatric sedative. So it's just a question of your perspective. I think there's a lot of potential in the cannabinoids and I think that especially as they become legal and we start exploring the other minor cannabinoids besides CBD, CBN is something that makes you really sleepy. And that's going to be a really important one. I think as we start raising up the different levels and raising down the THC. I mean, remember, like when it was illegal, everybody wanted THC so that's what got bred up. Now that it's becoming legal, we're bringing down the THC and bringing up all the other stuff, it's going to get much more interesting over the next five to 10 years, and we're gonna have a lot more medicinal cannabis to work with and I think it's going to be a lot easier. We're gonna have a lot more sort of tools in our toolbox to take care of situations like this.

Tips to help doctors and patients talk about cannabis use

Dr. Regina Koepp 18:46
But so fascinating because I'll ask psychiatrists I know who work with older adults and they'll prescribe quetiapine for example or Seroquel and then folks will come in and say, "well, I'm also using cannabis or I'm also using CBD or THC." They don't really break down THC or CBD. Typically, people will say I'm smoking weed or I'm vaping or using an edible if they're even honest about it. Sometimes the person will be honest with me as a psychologist but not honest with their psychiatrist about it. Because they're worried that they're not going to get other meds if they're honest about, you know, cannabis use. So what would you say then to psychiatrists or medical providers who are prescribing like Seroquel or quetiapine, what can they do to sort of get an accurate read on if their patients are using... a lot of providers listen to this podcast, senior care, mental health care providers... So, how... I guess I have two questions for you. What can providers do to be sure that they're extracting the information that they need in a non judgmental way so that they that they get the information that they need and where can providers learn more about CBD or cannabis use and then what can patients do to reassure them if at all, that it's okay to talk with their providers about their cannabis use? And maybe it's not okay. I don't know where the field is at with that.

Dr. Peter Grinspoon 20:15
I get exactly what you're asking. I mean, first of all, like psychiatrists have been so snooty and dismissive about cannabis for decades, and they've just sort of gone along with the US government propaganda and furthered it. And they've sort of, in the sense, painted themselves in the corner because now patients don't open up to them... exactly what you're saying. And that's the worst case scenario where you have two different tracks. You have the psychiatrists prescribing quetiapine, which I think is that like, insanely dangerous drug and it's like way worse than any possible side effect you could have with cannabis. But that's another discussion. Um, so I mean, quetiapine can cause arrhythmias and weight gain and it turns people into vegetables. Why on earth would you try that before you try some CBD? I'm not quite sure. But um, so first of all, we need to get rid of the snooty dismissive attitude or patients are never going to open up. I'm a primary care doctor people open up to me because I am easy to talk to. And I'm not judgmental. But the minute I'm judgmental, they clam up. And if psychiatrists are like you don't smoke cannabis, do you? They'll never say anything. So I think that part of it is to get rid of the snooty judgmental attitude. But to do that, you can't just fake it or pretend or act. So, the psychiatry shouldn't go to like their local acting school and learn how to act not snooty or dismissive. I think some real humility is in order. And humility is the cornerstone of being a good caregiver and a good provider. And that is sorely lacking in the medical profession, and in most of the caregiving professions. I think I have humility, because I am in recovery from an opioid addiction. So, being in recovering from an addiction is a great way to get a dose of humility, when you manage to screw up and then put together your life. But a lot of people don't have that opportunity, nor do I necessarily recommend it to them. But I think that they need to just be humble about the fact, this psychiatric profession, that they completely got cannabis wrong, and they need to relearn it from scratch. I mean, they were just wrong about it, and they just feasted on the night of funding for harms. And, you know, a study just came out that we've funded harms over benefits 20 to one, and we should have been looking at benefits all along. I mean, as my late father used to say we spent so much money, $10 billion or so, looking at harms is actually proven that cannabis is a relatively non toxic medication, because we spend so much money looking for harms, and they didn't really find that much. But the psychiatrists need to sort of, you know, re educate themselves and be humble and try to understand and be empathic about why so many patients are in favor of medical marijuana, like 93% of Americans are in favor of legal medical marijuana that patients are leading and the doctors are following. And I have to say the psychiatrists are following the rest of the doctors, the oncologists are in the lead, the primary care doctor is just somewhere behind there, and the psychiatrists and the addiction people were falling behind and part of it's the gravy train, and part of it is just years of government propaganda, or their own propaganda internalized. I'm not sure what it is, but I think humility would go a long way towards improving all of this.

What are the recommendations for older adults wishing to try cannabis?

Dr. Regina Koepp 23:55
Thank you for saying that. There are many paths to humility, you had a more colorful path. And I thank you for sharing about your own recovery journey. The thing I love the most about mental health and being a mental health provider myself are stories of redemption, and the journeys to redemption. And so your experience of being in recovery and then also being a proponent of cannabis use in healthy ways.

Earlier on, you were talking about cannabis use and contraindications, starting slow and going low and slow as you're raising the dose. I mean, these are all very thoughtful, careful methods for using cannabis and medical care. And so I appreciate that as well. I think humility gives you a broader landscape for looking at how to implement cannabis use and then also a better relationship with your patients so that they'll be honest with you when they have a positive or a negative reaction. And I mean, I can imagine if folks have a negative reaction and their provider is judgmental, that they won't want to describe the medical reaction because then they won't ever get it again, if it's helping them in other ways. I really appreciate that. I appreciate your charge for humility. It's something that I really value in care. What recommendations do you have for older adults who are interested in trying cannabis for the first time, you know, there are edibles, there is smoking, there is vaping. There are concerns if you smoke, that it's gonna hurt your lungs. Some folks have lung conditions, so they might not like COPD. And so what are your thoughts about that? So, if there's an older adult who wants to try cannabis to see if it helps with whatever, what would you recommend?

Dr. Peter Grinspoon 25:45
Well, first of all, it depends a little bit what state they're in, because in some states it is illegal. And you don't want them to get in trouble with the law. Like the AARP came out in favor of medical cannabis, if you're in a state where it's legal. So if you're in a state where it's not legal, I would get involved and agitate until it's legal, because it should be legal, it's absolutely ridiculous. And ideally, you should work with your doctor. Some doctors know a lot more about it than others. And unfortunately, some doctors just play the tape that they've been playing for the last eight years. This is no medical use. It's harmful, blah, blah, blah. So if your doctor is not helpful, your doctor is not helpful, but some doctors are helpful. So see if your doctor is helpful. And if your doctor is helpful, he or she, that would be wonderful. Or there are medical cannabis specialists in most states. Some of them charge a ton of money and don't do much. Some of them are really helpful, genuinely helpful. So see if you could find a helpful medical cannabis specialist, or see if your doctor is helpful because it would be much better to work with a medical cannabis specialist or a helpful doctor. Now, then it depends if you've had a lot of experience using it recreationally. In the past, say like in the 60s, you smoked it a lot. And it's not that much of a leap. To start to go to a dispensary, get some and start using it on your own, you can figure out whether to smoke it, we don't recommend smoking it because it's not great for your lungs. If you need to inhale it, the best way is to grind up flour, put it in a device that heats it and then take a puff or two from there. Because you know if you smoke it you incinerate everything at like 1100 degrees Celsius, and you get the carbon monoxide and everything, all the chemicals of benzene, whatever. And you really only needed to go up to three or 400 degrees Celsius to extract the cannabinoids. And then you don't actually smoke all the crap. So we recommend the safest way inhalational least is to get one of those machines, not those vape cartridges that have all those chemicals in them. But just a machine that heats it up. So you grind up the flour, which you get this at the dispensary, no pesticides, no fungus, no heavy metals, no lead and you put it in a little machine that heats it up and then you take a puffer off that. Very safe. And you don't get any of the bad stuff because you're just heating it up to three or 400 degrees, you're not burning it or smoking it. Or you could just take a tincture under your tongue or put it in a drink. If you put it under your tongue, it takes 20 to 45 minutes to work. Again, you want to start low and go slow, but that's a very gentle way to do it. Just put a little tincture under your tongue. You can get a tincture at any dispensary. You know, for medical use, we usually recommend you have a lot of CBD, and just a little bit of THC to start just so you don't get like super high and the CBD works really well for the sleep, the pain and the insomnia, which is what most people use it for anyways, medically. So usually people get like, you know, one to four THC, the CBD, and just take a drop or two under their tongue or in the drink. Or people can get a very low dose edible. But again, the smallest possible dose and then take half of that. And then if that doesn't work, try a little bit more the next night but be super conservative about that because you just don't want to take too much - the big mistake that everybody makes. And I mean everybody, well not anybody that will listen to this. And none of my patients have made this mistake yet because I browbeat them. But when you take an edible it takes like up to an hour and a half to kick in. So people eat some and then they're very excited for something to happen and nothing happens after like 45 minutes. So they take another dose and then in like two or three hours they're like way too high, because the first dose kicks in and the second dose kicks in. So if you take an edible and nothing happens wait to the next day to take a bigger dose. Don't take the next dose, the same day, because sometimes it takes a long time for it to absorb. So you just don't take more than one dose on the same day no matter what. Um, so again, if you start low and go slow, and then finally, there's topicals you could rub on. Those are very good for like muscular type things. I mean, topicals are excellent because they don't have any psychoactive effects. You can make your own topicals actually, and it's less expensive than the stuff in the store. There's nothing magical about it, the recipes you can get online, you can make your own tinctures too, it's actually pretty easy to make, I was making one for a friend. And they're actually really easy to make as well. So a lot of the stuff you can make much more cheaply yourself than buying it in the store. And they're kind of fun to make.

My mom's medical and medical marijuana journey

Dr. Regina Koepp 30:48
I am really naive around cannabis use. And I'll share a story about my mom who is not naive. And she started using, and I'll check in with her and see if she's okay with this, my sharing this, but she was using high doses of opioids and had a horrible quality of life for so many years and really was like in it and she struggled throughout her life with many mental health and medical challenges. And then later in life, she just struggled so much medically and was in so much pain and couldn't tolerate food, had a PEG tube at one point because she could not inject, like take anything orally, she would vomit everything up. And then, and she had never used cannabis or marijuana much when I was growing up, and then she now lives in Mendocino County in California, which is cannabis favorable, or maybe it's even legal there in California. So I'm guessing, but this is before it was legal. And she started using marijuana. She's living a better... this is anecdotal. I don't know if... but she's living... she's no longer using opioids. She's able to eat, she doesn't have a PEG tube. She's enjoying her life more, she's really stable. Also, opioids just affected her mood. And just it was awful for her. Um, her quality of life is 100 times better, she's more enjoyable to be around, she's enjoying life more. I'm just... if it was cannabis, and I have to check with her because it was correlated. It was around the same time that she stopped using opioids and started using marijuana. But her life is so different. And...

Dr. Peter Grinspoon 32:36
...of course it was the cannabis. I mean, this happened. It happened in hundreds of patients. The opiates in the cannabis are about equally effective for the pain, but the opiates destroy, eat up your quality of life. And the cannabis is either neutral, or it enhances it. And I'm so glad to hear that. It's like your mom back. And that's what cannabis does to people. That's why people are so enthusiastic about it because it actually gives them the real life back.

Dr. Regina Koepp 33:05
And she got herself back. Yeah, like she was... the best parts of her came back, which is wonderful. And I had my own judgments about it. I was not, you know, I had this self righteous sort of framework and thinking about it. And now like learning more about it and hearing from you today, and also, I asked her a couple of weeks ago, what was the shift for her in her own quality of life. And she was saying it was getting off all of those heavy duty medications. And she didn't say it was necessarily cannabis, but around the same time as when she also started using marijuana regularly and still does and still is enjoying her life. But...

Dr. Peter Grinspoon 33:42
...Awfully big coincidence.

Dr. Regina Koepp 33:45
Yeah, so it's helping me honestly, my own journey and humility to give her some more grace in her own journey, and figuring out what works for her and her body and using substances that are less harmful, and helping her in her quality of life. So I appreciate what you're sharing today, because it's helping me and giving my mom some more grace. Thank you for that.

Dr. Peter Grinspoon 34:08
Well, I can't tell you how many people have found that. Um, I mean, it's exactly what we're talking about, like 15 minutes ago. Um, and believe me, Your mom is not alone. I used to joke about how I could navigate to my dad's apartment by closing my eyes and just sniffing out the window of my car, because you could smell the cannabis smoke miles away. So...

Dr. Regina Koepp 34:31
That's funny. One time I was, this is when I was more self righteous and I was younger too, this was probably 15 years ago, but I brought a boyfriend home to meet my mom and my mom was... it was like 10am and we were going to go have brunch... She was living in Mendocino County at the time. And I was like, okay, mom it's time to go, we're gonna go to brunch and she's like, Okay, let me just finish getting ready and she sits down on the couch and she pulls out a bong and she starts hitting the bong. And I'm like, mortified standing at the front door and I'm like, "Mom, what are you doing?" And then she looks at me and she's just innocent and says, "Oh, I'm sorry, where are my manners? Would you like some?" And so anyway, that is my mom too...

Dr. Peter Grinspoon 35:17
She would have got along with my dad really well.

Dr. Regina Koepp 35:20
She would have and Carl Sagan I'm sure yeah. Okay, so now, just to be clear, which older adults should stay away from cannabis or marijuana?

Who should steer clear of cannabis?

Dr. Peter Grinspoon 35:31
Well, I would say that, obviously, if you have like severe respiratory problems, you shouldn't smoke it, that sort of no brainer. And you should just be very careful. If you have delirium, confusion, or cognitive impairment you just have to be super careful. I wouldn't say you necessarily have to stay away from it completely but you should work with someone you shouldn't just like go to the dispensary and go crazy. And, you know, with psychosis, you know, that's a contra indication. Again, the CBD is fine. People use CBD to treat psychosis, but the THC can aggravate it. So I would say with psychosis, you want to be careful.

Dr. Regina Koepp 36:18
What about seizures?

Dr. Peter Grinspoon 36:21
Well, they use CBD to treat seizures. And now they're looking more and more at cannabis to treat seizures. But again, the CBD can also raise your anti epileptic levels. So um, I would just say work with your doctor. Seizures aren't really a contra indication. But you do want to work with your doctor on that one. But seizures, they can help the seizures. Cannabis doesn't cause seizures, but it could hypothetically affect the levels of the anti epileptic medication. So just work with your doctor on that one. But I don't think seizures are really a reason not to use it. You just have to be cognizant of the medications you're on.

How to find a cannabis friendly physician

Dr. Regina Koepp 37:00
How would somebody go about, in a cannabis legal state, go about finding a cannabis friendly, cannabis helpful doctor?

Dr. Peter Grinspoon 37:11
Well, um, it depends on the state. I mean, you know, some states have very well developed medical cannabis programs, to the extent where it's virtually legal. And other states have like the most rudimentary ones, where it's like in name only, just so they can like say they've done something to quell public pressure. So it's hard to generalize, it really depends on like, what state you're in, you know, whether it's like a, I guess a Texas versus a New York, but um, you know, I would start by googling, or, there's always like your local normal chapter, national organization reform of marijuana laws or Marijuana Policy Project, you know, there are these advocacy organizations that could probably set you up with friendly local physicians. Or, you can just google medical marijuana doctor in Texas. The doctors that are there are probably advertising and trying to make a living doing extra, probably doing that instead of regular medical practice. So, I think they're probably pretty findable. What is the biggest objection that you see from medical and mental health providers with cannabis use?

Dr. Regina Koepp 38:12
Now, what is the biggest objection that you see from medical and mental health providers with cannabis use?

Dr. Peter Grinspoon 38:19
Well, the biggest objection is that there aren't like standardized doses, products and instructions, which I think is a legitimate complaint. Yeah, but it also at the same time does require the humility that we were talking about earlier. If you're my patient, if I were to give you a cholesterol medication, I would prescribe 10 milligrams of Lipitor. But if I were to give you medical cannabis, I'd make some suggestions. And then write your certificate. And then you go to the dispensary, and then you talk to the budtender. And you basically have my suggestions in mind, but you do whatever you want. So that involves like more patient autonomy and seeding of control. So on the one hand, I think that's a good thing. And doctors have to get used to that. On the other hand, I can understand how that does feel sort of uncomfortable for physicians who are used to saying, you know, take five milligrams of this, take 10 milligrams of that. And it would be easier if there were standardized products, you know, it would be easier if I could say, "take two milligrams of this type with five milligrams of CBD for six days and see if"... you know, so there is really a sciency type way of doing things that we don't have control over when we're prescribing medical cannabis. So, again, on the one hand, I think that's part of the humility that caregivers need when they're approaching medical cannabis and why it's so appealing to patients because it does involve a lot of trial and error, on the part of the patients, which is part of selling to patients. But on the other hand, I think it does highlight sort of a legitimate concern and break on the part of the physicians, which is there is like a lack of standardization and protocol. And so it is sort of like, oh, you're the headache, go for it, go to the dispensary and try some marijuana. And it could be a lot more standardized and regimented than that. So I think a compromise could be worked out between the two extremes of like, talk to the bud-tender, do whatever you want, with my vague suggestions. And, you know, here's like, exactly what to do. You know, from above, by the doctor, there certainly could be a middle path between the two.

What about cannabis and interaction effects with other medications?

Dr. Regina Koepp 40:40
Yes, and that there's no regulation in pharmacy, you know, you go to the pharmacy, the pharmacy has also a license and regulations.

Dr. Peter Grinspoon 40:48
Right. And they're really educated, the pharmacist. So the pharmacist can say, "Oh, no, that interacts with this," and they'd call the doctor's office. Whereas, you know, a lot of us are recommending that the people at the dispensary should have some minimum training where they don't at all, it's more like, I always get in trouble when I say this with the cannabis community, but it's always like, "Oh, you know, my friend's sister took this for some type of headache at a Grateful Dead concert, and they got better. So why don't you try this?" And, you know, that's not really how like medicine is supposed to be practiced. There should be some basic training for the bud tenders. And I really believe in that, and they don't think there should be but I think there should be if they're going to be in a position of giving medical advice, or they shouldn't be giving medical advice. It's as simple as that. You know, they're not paid as highly as pharmacists, they're not going to, you know, and the cannabis industry is making a lot of money, certainly they can pay for the training. Or if the state requires that, the state could pay for it. I don't think that bud tenders should have to pay. They don't get paid that much. But you know, there should be some training. They shouldn't be allowed to just say, "Oh, dude, try this strain for fibromyalgia. I heard it's good." That's a little bit dangerous. I mean, it's not that dangerous because cannabis, like no one's ever overdosed on it, but at the same time I could see why it makes doctors nervous.

Dr. Regina Koepp 42:08
Sure, yeah. Especially with interaction effects of medications, especially in older adults, because that's one of the the most common challenges in older adult medicine or geriatric medicine are medication interactions without cannabis. And so I can imagine with cannabis also there might be some similarities overlap.

Dr. Peter Grinspoon 42:30
Imagine if each dispensary had like a pharmacist who was also trained in like cannabis medicine. So cool, that would be ideal because they would understand the medicine interactions, they would understand the different strains of cannabis and that would work out really well so that's the, you know, if it were legal federally, then we could start doing things like this and it would work out. It would be safer for everybody. Couple states they need to have a pharmacist but I think it's really expensive and most places don't but I think that'll be a really good idea.

Dr. Regina Koepp 43:01
So where can people find you?

Dr. Peter Grinspoon 43:03
So um, I can be found at PeterGrinspoon.com and people can buy my book about opioid addiction and physicians, or they could sign up for, in Massachusetts, for marijuana certification, or for coaching or health and wellness coaching, or they can follow me on twitter at Peter underscore Grinspoon.

Dr. Regina Koepp 43:24
Wonderful, well I'll link to all of these things in the show notes on the podcast. And I just can't thank you enough for your time and the education that you're sharing with me and my listeners and just broadly to other mental health medical providers who, you know, a lot of older adults are using cannabis. Not a lot of older adults are sharing it readily in their medical and mental health appointments. So, if we make it a little more easy to talk about, it'll be healthier for everybody. I really thank you very much.

Dr. Peter Grinspoon 43:58
Absolutely. Thanks for the great conversation.

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Dr. Regina Koepp 44:02
If you like this episode, be sure to subscribe, so you'll be the first to know when new episodes are released, and then leave a review. Subscriptions and reviews help people to find this show. In wrapping up, it's important to share that the ideas expressed in this episode are mine alone. And that information shared does not take the place of licensed medical or mental health care. We'll see you next week. Same time, same place. Lots of love to you and your family. Bye for now.