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Sunday, June 2, 2019

DOCTOR NOTES: A Physician on How to Use Cannabis Effectively

A Physician on How to Use Cannabis Effectively

In partnership with our friends at Dosist
It was 2015. Dr. Sherry Yafai was working as an emergency medicine physician in Santa Monica. She noticed that her oncologist colleagues were prescribing cannabis to patients to alleviate the symptoms of cancer treatment. But they weren’t able to answer basic questions those patients had about dosage and use. “I spoke with a couple of oncologists that I worked with, and I asked, ‘When you tell patients to use cannabis, what are you telling them to do?’ They were telling patients to Google it,” Dr. Yafai says. “We tell people how to take Tylenol in explicit detail. How do we not know how to instruct people how to use cannabis, which has been considered a medication in California since 1996?”
That was the start of a new path for Dr. Yafai, who opened an office specifically to help patients navigate the world of medicinal cannabis. We recently partnered with Dosist to host a conversation between Dr. Yafai and our chief content officer, Elise Loehnen, and we spoke to Dr. Yafai afterward to learn more about her practice and work.

A Q&A with Sherry Yafai, MD

Why did you decide to move from emergency medicine to cannabis medicine?
I went into emergency medicine over fifteen years ago because I wanted to be the type of doctor who could take care of everything, a doctor you could call to help in any situation. I’ve been in the emergency department at Providence Saint John’s Health Center in Santa Monica for the last decade, and in that time, I’ve treated thousands of patients, seen a lot, and grown a lot.
In 2015, two family members of mine were diagnosed with cancer. Both of them were told that they should use cannabis products to help with chemo-related nausea and vomiting. But neither their oncologist nor their general practitioner knew how they should get or use cannabis products. It was medically legal, but it wasn’t recreationally legal yet. With some effort, before 2018, you could get a recommendation from a doctor, but to do that you’d often need to go to a clinic and talk to someone; the whole evaluation would take just minutes. In that evaluation, they’d barely look at you, they’d make you circle where it hurt on a chart, and that was the extent of it. It didn’t feel like much of a medical exam. Then you would leave that place with a paper in hand and start the process of finding a dispensary. Someone at the dispensary would make suggestions about what you should use.
My younger family member who was diagnosed with breast cancer was in her forties, and she kind of figured out how to use it in the best way for her. My other family member, though, who was almost seventy, took a piece of a cookie and had an accidental nonlethal overdose: He basically couldn’t get out of bed for two days. He was dizzy and nauseated on top of having esophageal cancer. His experience led me to this place where I thought: As medical practitioners, what are we doing for people like him?
Cannabis is not part of our education in medical school, it’s not part of our residency training, it’s not part of our internship, and it’s not part of our continuing medical education. After this experience with my family members, I started seeking information and educating myself to be the cannabis specialist that patients can rely on in their time of need.

Where did you start?
I took my first cannabis patient through referral in 2016: He was sixty-five years old and in a lot of pain after having shingles on his face. He’d been to a dermatologist, an internist, and a pain management doctor, and he had tried a variety of painkillers and medications. He had really done his homework trying to go through the right avenues of how to treat this pain. Nothing was working, including a cannabis product he had picked up from a dispensary. He was taking about three shots of tequila at night to get himself to fall asleep, just because the pain was so bad. He’d lost about ten pounds, because the pain on the side of his face covered the muscles he used to chew food. He had a variety of medical issues, had stents put in his heart from heart disease, and was on about five or six medications for heart disease and diabetes. It was a really complex situation.
He was an engineer by training, and so he was meticulous about everything, and he would give me journals of reports on how he was doing as we were adjusting his cannabis medication. After six weeks, his pain was under control, and he was back out on the golf course. He was no longer relying on tequila at night to help him sleep, and he was sleeping well. Other than the cannabis-based medication (all nonsmokable), he was able to avoid any pain medications and use only lidocaine cream as an adjunct. He wasn’t high. But he was comfortable, and he could get back to his regular life. He was the optimal first patient—and it was then that I realized that if I could do this with him, I might be able to help other people
That is when I decided to open up a practice. It gives me goosebumps when I think about all the positive changes that have come out of it; many of my patients have been able to reduce and occasionally eliminate narcotics for pain. My patients tend to be more severe medical cases. They are usually people who have tried many different things before coming to me through the referral of another physician.
If somebody wants to go smoke pot and have a good time, they don’t need me. Most people can figure out how to smoke for recreational purposes on their own.

Why is cannabis helpful in many different healing contexts?
We have a system within our bodies called the endocannabinoid system, which has cannabinoid receptors in many different organ systems. Those receptors are involved in physiological processes that include appetite, pain sensation, and mood. So we see responsiveness on multiple levels across different diagnoses.
The other part is that we’re talking about multiple medications within one plant, CBD, THC, different ratios of the two together, and the less-discussed alphabet soup of cannabinoids. And these are just a few out of more than a hundred cannabinoids in a plant. We are seeing the future of medical research now: Where and when is CBD more beneficial in a certain diagnosis than THC? And in what precise combination? We want to create a more predictive patterns that patients can rely on and physicians can prescribe.

How do you integrate what you do with cognitive therapy?
I have a fifty-five-year-old male patient who’s had twenty to thirty years of insomnia issues. He’s been popping pills for twenty to thirty years to get himself to sleep at night. About fifteen years ago, that started including alcohol. About five to ten years ago, it started including just getting whatever pills he could get over the internet.The problem that became very apparent after a few visits is that this is not just a sleeping issue, this is a how I deal with life issue. How he’s dealing with his sleep issues is how he’s dealing with his personal, physical, and social relationships that day. And it’s not working.
I’ve helped him quiet his sleep issues without abusing alcohol or drugs. But now we need to deal with the rest of the issues that have caused this, and he needs help from a therapist. Because those issues are going to keep coming up. Cannabis is not the answer to everything, but it can be a part of the solution.

In your practice, how do you use cannabis to manage pain?
I primarily see three different types of pain-management patients. The first is patients with cancer; cancer patients have a very different kind of pain than the rest of us. Cannabis can be a complement to narcotics and other treatment modalities—sometimes pain is pain and it can get really bad, and we want multiple methods of attack. Cannabis can help with pain and at the same time help with the nausea that’s associated with chemo, act as an appetite stimulant, and work as a little bit of a mood elevator.
The second type of pain is chronic pain, which can include a variety of different diagnoses, like chronic low-back pain, chronic abdominal pain, or fibromyalgia. Patients who are on narcotics and would like to get off of them while still managing their pain tend to be very successful with my cannabis protocols. And this is something we’re seeing a lot more of.
Lastly, I work with people who are newly sober from heroin and alcohol abuse, and create a plan for their sobriety maintenance with the use of cannabis products.

Do you face stigma within the medical community for doing this work?
I work with a group called High Sobriety, which is where I see patients who want treatment for opioid and substance addictions. This concept of using cannabis as an alternative sobriety pathway is definitely difficult for many people, even physicians, to understand.
The first piece that’s important to explain is that with these patients, we don’t use any products that will get them high. Another thing people always say to me is, “Well aren’t you just replacing one drug with another?” Yes. In fact, the medical community has been doing that for decades, with methadone. Methodone is also a drug that can be very easily abused and misused in the right context. Same thing with buprenorphine or Suboxone. They are all opioid-based drugs and medications. We as a medical community have no issue doing that because there is research supporting it and we’ve been trained and educated in this. But most doctors haven’t been trained and educated in cannabis, and so the medical community and medical personnel are very uncomfortable. We want people to do things that are scientifically based, and we want to show that this is a good route of an administration. But until we start practicing and performing those studies and going about this the right way, we’re never going to be able to get over this hump. One very promising step forward is the latest research from Yasmin Hurd, PhD, the director of Mount Sinai’s Addiction Institute in New York City.

Are there ways to consider using cannabis as part of an overall commitment to wellness, that you recommend?
Sex is an important part of wellness. We know way less about female arousal and orgasm than we do about male arousal and orgasm. There are currently plenty of drugs in this realm designed for men, like Viagra and Cialis, but none as researched, talked about, or useful for women. There are a lot of really helpful cannabis-based products that can help women with arousal and orgasm.
And of course cannabis can be really helpful tool for sleep. That’s something people in the cannabis world have known for a long time that the rest of the world had yet to learn. We’re starting to see research coming out about how hypnosedative medications like Ambien can be harmful to our lives and our personal health.
Using cannabis may be appropriate for you or it may not be. If you are taking more than one medication, a mood stabilizer, a sedative, or pain medication, please discuss your use with your doctor. It’s something you need to bring up, discuss, and evaluate with a health care practitioner.
There’s a medical professional society called the Society of Cannabis Clinicians, which can help you find a knowledgeable clinician near you. We get together once a quarter to provide continuing medical education around cannabis-based medicine to doctors who are interested.

Sherry Yafai, MD, is an emergency medicine physician who transitioned into cannabis-based medicine in 2017. In 2018, she joined the John Wayne Cancer Institute as an adjunct associate professor. She offers individual counseling and management of medications in a personalized, small private practice. She ishosting a conference on October 5, 2019, on the topic of integrating cannabis into medical practices.

This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.

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