This is our 4th and final installment of our in-depth interview with Cannabis Pain and Healing Guru Dr. Michael Moskowitz. His story is so astounding and the interview is so in depth, that we had to split it into several parts. Part One of this interview is about his experience with intense pain and his journey back from a probable cancer diagnosis and how he used cannabis in its various forms to get back to health. In Part 2 he talks in depth about Cannabis, THC and CBD in its various forms for pain management and anxiety.
In Part 3 we cover the astounding positives of medical marijuana and the new frontier that isolating the myriad cannabinoids hold for medicine in areas of physical as well as mental and psychological healing properties.
In Part 4 Dr. Moskowitz gives a candid opinion on the Opioid Crisis – the positives and negatives of the drugs and how it has been misrepresented. He also covers the nascent medical marijuana treatment industry – the great discoveries that lay ahead, and the positives and negatives of what will likely happen when the major drug companies begin to be involved.
Charlotte Parker: Do you feel that using Cannabis products for pain for your patients and others helps ease them off opioids?
Dr. Moskowitz: Let’s talk about that. On the study I did, which was my patients, I was following them every month. I started them on our protocol, not at the same time, but they all were varying times of having been started on this. I followed them over 19.4 months, I followed 163 patients. 127 of them were on opioids. I did not tell them to lower their opioid medication. 77% of them lowered their opioid medication. 15% of them got off. I did not push them to do it.
Charlotte: Basically, you feel that a lot of people can handle their pain without the negative effects of opioids, even though opioids can be very helpful in many cases.
Dr. Moskowitz: They can be very helpful. The current opioid epidemic is misstated so much I can’t even tell you. There is an opioid epidemic, it’s among drug addicts, it’s not among pain patients. Pain patients are not dying in droves. The numbers that are thrown out there, 40,000 people a year, they’re lies, they’re not true, that’s not the right number. These are made-up whisper numbers that Joe Kennedy threw out, or some other talking head threw out there.
The truth of the matter is, for people on medical substances, in 2016, which is the last data I saw for this and the last data before the CDC told coroners around the country to call everybody who died with an opioid onboard an opioid overdose, even if they didn’t die of that, to assume it was an opioid overdose, that in 2016 before they did all that, there were exactly 7,500 drug overdose deaths in the United States.
3,500 weren’t opioids. Of the 3,500 that were, the vast majority were mixed with other drugs. 1,200 of those people were getting opioids that were prescription opioids without a prescription, and they were just getting them off the street. 1,200 were suicides. You’re left with about 1,100 to 1,200 people who died from using them, out of 100 million cases of people who have chronic pain.
Charlotte: What do you make of this vilification of opioids?
Dr. Moskowitz: I’ve watched it happen over the last five years. It’s been horrendous. It started off with different groups making a lot of noise about this, a lot of publications came out about the negatives of opioids, they conflated the drug abuse epidemic, which is really serious and is the opioid problem, with a medical problem. The states started suing doctors so that they could get to drug companies.
They sued a friend of mine for $1 billion, the State of Michigan and the State of Maine, and this guy is a very prominent pain physician who did the right job and has worked his whole life to make pain treatment effective for people, and been very, very careful and cautious. They just were suing him, because they knew he didn’t have $1 billion, to get to Purdue and these other drug companies, they put them on trial.
“The Sacklers are villains, they’re horrible people, blah, blah, blah, blah, blah.” They’ve made this whole narrative happen, and once they sicced lawyers on this, these weren’t state lawyers, these were outside lawyers they hire to go after these companies, they’ve bankrupted Purdue now, it’s going out of business. The other companies that are making opioids are being fined. All this is legal treatment, it’s all legal treatment.
Charlotte: People need these drugs who are not drug addicts, don’t you think, to help with pain?
Dr. Moskowitz: Yes, they do. I don’t know what would have happened to me if I hadn’t had those available when I needed them.
I don’t know what would have happened to most of my patients if they didn’t have it available to them. I think the good thing about the opioid epidemic is, it’s gotten all of us to lower opioids in patients to the lowest effective amount and it can be a lot lower than what people were built up to, because of that thing that happens with our medicines where we give people a medicine and they’re designed to work in a system by imitating it and suppressing the system and taking over.
That’s the real problem. With opioids, you keep building up tolerance to them, and you need more and more and more to get the same effect. At least the one good thing that I’ve seen come out of the opioid epidemic is it’s gotten all physicians to try
to make sure they stay on the lowest dose possible that gives effective pain relief for patients, but it’s a terrible crisis for people with pain.
My daughter had ovarian cyst torsion where the ovary twisted, and she had to have surgery to have it removed. They wouldn’t give her an opioid, That’s insane. They gave her Tylenol and Ibuprofen. I’m sorry, that was not enough to take care of a gangrenous ovary that had to be untwisted to get blood back into it.
Charlotte: Are they going to stop doctors from legitimately prescribing opioids now?
Dr. Moskowitz: They’ve already done it. It’s very hard for a patient to get an opioid prescription, very hard.
Charlotte: I’m wondering, who benefited from this vilification of a drug that helped people?
Dr. Moskowitz: The states are now benefiting quite handsomely. They’re getting a $9 billion settlement out of the drug companies, but the people that benefited from this were the people who were dealing with drug addict populations and people that had problems like that. It certainly was not the pain patients who benefited from this.
Charlotte: Basically, you’re saying there were some bad actors, but they painted everyone with the same brush.
Dr. Moskowitz: That’s exactly right.
Charlotte: That’s sad.
Dr. Moskowitz: You’re telling me.
Worse part of it is, the press. Every man, woman, and child in this country believes that if you look at an opioid, you’re going to die. It’s ridiculous. They’re effective therapeutic agents. For a very long time, we were like this, and the pendulum swung very much in the opposite direction too much and people were just being thrown on tons of them.
We as pain specialists made a horrible, I think, a horrible judgment, and decided that there weren’t enough of us to treat people who needed this kind of treatment and that we would get them started on it but primary care had to finish it off. A lot of people were sent to their primary care doctors to also manage their opioids, they don’t have time to do that, they don’t have the training to do that.
That’s part of where everything got out of control and it wasn’t primary care’s fault. We shove something down their throat that we never should have done. That’s where the real opioid problems with prescribing came up. You don’t see heart surgeons decide they’re going to send out the coronary artery bypass surgery to primary care, they do their own specialties work and our specialty failed. I’m sorry, it just failed.
Charlotte: Wow. To some degree, is cannabis is now stepping in — what do you think?
Dr. Moskowitz: The problem with it is what you’ve identified in talking to me, which is that the problem with cannabis is doctors aren’t trained in it, patients have to seek their information from people that are often dropped out of high school at age 18 to become budtenders. The information that’s out there publicly is very confusing and conflictual.
Some people claim, for instance, that CBD is the greatest thing since sliced bread, and some people claim it doesn’t do anything, and honestly, on some people, it is the greatest thing since sliced bread and on some people, it doesn’t do anything. You have to go beyond just CBD. Using medical cannabis treatment, it’s a sophisticated treatment and there isn’t a sophisticated way of either informing people about it or delivering it.
Charlotte: What do you think about the MORE Act is going to come eventually in front of Congress, what do you think about the role of the federal government in this?
Dr. Moskowitz: The greatest blessing to medical cannabis has been leaving the federal government out of it. I have nothing against the federal government. I’m a fan of the federal government. It’s not that, but had the federal government gotten into this, everything I’m telling you about –that we’ve looked at over the last 10 years –would not be available because this stuff would have had to been put into huge studies, we’d have had to do randomized double-blind placebo-controlled trials on this stuff.
To get to that you’d have to do a bunch of case theories before that. It would literally cost $600 million for any of these substances to even get to market. Cannabis as a whole plant is impossible for the FDA to study because it’s got too many components. It would have to all be broken down into isolates. Isolates are great if you know what you’re doing with them, but if you don’t…
This was what I was talking about before, if you take an isolate, you’ll get benefit from that isolate, but you won’t get the same benefit from the synergies between that isolate and other cannabinoids. The only way to do that is to add that into your body when you’re doing other treatments, or into some of those treatments to blend that in with some of those other treatments like tinctures and things like that, and gummies and stuff like that.
Charlotte: What happens when there’s legalization, which I believe is eventual?
Dr. Moskowitz: It’s going to come. I think what we’re going to see, and I have no inner track on all this, but from what I read, I think from what we’re currently seeing, what will occur is it will be decriminalized nationally, which is different than legalizing it. They’ll stop it being a criminal act, they’ll free people that are in jail, which is one of the most horrible social injustices that has ever occurred in the history of our country, is putting these people for marijuana offenses in jail. It’s ridiculous.
I’m taking it to save my life and people are going to jail with it, what kind of baloney is that? It is absolutely ridiculous. The MORE Act I think if it goes through or some semblance of it will decriminalize cannabis. Then they’ll start to do medical cannabis once it’s decriminalized, then you’re going to see the FDA get in, and then things are
going to get harder to get, but because this has been kind of the people’s medicine for the last 20 years as of California, the people have developed ways of using this, and styles of using that you’re never going to be able to put a prohibition on that. That is out of the box and it’s never going back in the box.
I think you’re going to see two systems. You’re going to see cannabis as medicine that’s developed by pharmaceutical companies and goes through the FDA and costs gazillions of dollars. For instance, right now, we have a synthetic form of THC called Marinol or Dronabinol. What you would get in a $45 bottle of tincture would cost you $3000 plus a month. That’s the problem with legalizing. Once these become pharmaceutical products, the prices are going to go through the roof.
By the way, the stuff you get in the dispensary, it’s better than the Marinol which is a pure extract of just THC. Stuff in the dispensary is a blended kind of tincture that you can get that is going to have several other cannabinoids, several terpenoids in there that enhance the effect of the main cannabinoid. In Dronabinol it’s just dronabinol.
Charlotte: You don’t think they’re going to stop the dispensaries or anything like that?
Dr. Moskowitz: No. There’s no way they’re going to stop this that’s going on. There’s going to be a legal market for people and there’s going to be a drug market, is what’s going to happen out of it.
Charlotte: As a pain specialist, do you think that the opioids will be able to be prescribed or come back, or do you think their vilification is so complete that people won’t be able to get them who need them?
Dr. Moskowitz: I think this is a dead-end treatment and I think for a good reason. While I don’t agree about the ridiculous numbers that are being set out there about pain patients and overdose deaths, they’re absurd. What I do agree with is this is a much more dangerous substance, it can result in an accidental death, it can certainly result in abuse and misuse, and when that happens, that’s where some of the deaths come up.
If you look at the people that actually died from this, almost all of them were on multiple substances, not just opioids, but it gets called an opioid overdose, but there are other drugs involved in this as well. It’s not a great treatment out there with kids getting into it. There are many,many reasons to phase out opioid treatment if you can replace it. I do believe that cannabinoids can replace opioids, but they’re not quite ready yet. They’re not at that place.
Once we get this into real medical forms, like capsules that are a mixture of isolates of opioids, I think we’ll be able to find potent analgesics out of this that’ll be incredible, much better than the opioids. Once we can do that, there are also no cannabinoid receptors in respiratory areas of the brain.
No one dies from cannabis use. There’s no risk of death in cannabis use. It’s a more pleasant experience, people don’t tend to get nausea and on too much THC they can.
In some people even CBD makes them nauseated. There are things that have popped up that you have to watch for on people as you do the treatment but as this treatment evolves, I think it’s going to be a far superior analgesic to anything that we’ve ever had before. Once we really figure out how much THC you need, how much CBD how much CBN, how much CBL, which we don’t even know about yet, these are the kinds of things that we have to figure out.
By the way, I actually think CBGa has the potential to be one of the most potent medical cannabinoids that exists. We don’t know anything about it.
Charlotte: Well, who are the people that are working on these things?
Dr. Moskowitz: Me.[laughter]
But there are other people too. There are researchers in Israel, there are researchers in the United States,there are researchers in Canada. There are people that are really looking at this stuff. It’s just that you have to look at this– the whole pharmaceutical era really started with Bayer aspirin. That was an over the counter kind of thing –and then probably in the 1940s is when we started seeing antibiotics start to come along and stuff like that. That’s what really spawned the drug industry.
It’s 80 years later, and this is where we are now. Cannabis is just at the beginning of what they are. We don’t even have it refined out to knowing what the individual substances actually do alone and together. We have a lot of work to do to figure this out. The research is essential, and my big hope about legalization is research will go through the roof when that happens. If you go on PubMed, and you type in– I’m going to go on it right now.
If you type in cannabis, okay? PubMed, type in cannabis, and do a search on it. I’m just doing it, I’m looking. You get 7,062 results. Those are all papers that have been written on cannabis, but if you type in, medical cannabis, you get 30,000 results. That’s my point, which is there’s a lot of research that’s out there. It’s not well integrated and it’s not made the crossover from basic science to clinical research very well. We’re still struggling with all that and a lot of that is because this substance is illegal all over the world. Nobody can really freely research it.
To research it now on a federal level, you have to treat this like it’s plutonium. You have to account for every milligram of it. You have to have safety procedures that are triple safe. You have to lock the thing up. You have to have– And you know, meanwhile, the people that are setting these rules, their kids are up in their bedrooms, smoking a joint. This is crazy. This is one of the safest substances around.
Charlotte: They made it a Schedule I drug, which is insane.
Dr. Moskowitz: Right, that’s true, and that really inhibits research. To do research on this, you have to go through years of applications, you have to build up a safety profile where you can store it and lock it up and make sure nobody gets it, you have to account for every little bit of it. Nobody wants to get into that. Nobody wants to do that. That’s not how we research things normally.
Charlotte: Then that would be one of the real positive outcomes of decriminalization?
Dr. Moskowitz: It would. It would be a big deal. In California, they initially tried to set up the current law, that UCSF (University of California, San Francisco) would be the Research Clearing house for anyone that wanted to do research. It didn’t have to be hospitals, it didn’t have to be doctors. It could be businesses, it could be anybody, and UCSF would be the center, but by the time the bill got done, that was pulled out of it and UCSF doesn’t know anything about this, but they were set up to be that that clearinghouse for all the research.
Unfortunately, it never happened. This is the problem that you can’t pay for this with credit cards because banks run under federal law, and it’s illegal. You can’t get medical insurance to cover any of this because medical insurance companies have to follow federal law. Anything that has to follow federal law, and where the feds haven’t said, “Okay, we’re going to make an exception,” you can’t do anything with this.
By the way, in the states where this is legal medically, there are 25% less prescriptions on Medicare of everything. And opioids are not the only drug that can be reduced with this. I’ve reduced opioids, I’ve reduced the anti-epilepsy drugs, I’ve reduced anti-anxiety agents and psychotropics. I’ve reduced muscle relaxants. It’s amazing what you can do with this.
Charlotte: If only people knew what they were doing.
Dr. Moskowitz: Correct, and they know. There are doctors around who are doing this like me. I’m the only guy I know in the Bay Area that’s actually doing this, this way. There’s a woman in Southern California, Bonnie Goldman, who I think is a pediatrician, who is doing work with this. There’s a guy in New Hampshire, I’m blocking his name, but he’s doing some of this work.
There are other people in other places in these small numbers that are doing this. There are hundreds of pain specialists in the Bay Area. They should all be using this. There are thousands of them across the country. They should all be using this but they’re not. When they use it, they just say, “I’ll give you permission to use it. Go talk to the person at the dispensary.” That’s like telling a person to go to the pharmacy and ask for pills. I don’t blame the doctors. They don’t know anything about it. They’re not educated in it.
Charlotte: This is really fascinating. I want to thank you so much.
Dr. Moskowitz: You’re welcome.
Charlotte: I don’t know if you know anything about me or the magazine but I started Head Magazine in the late ‘70’s. I was a big proponent of decriminalization early on.
Dr. Moskowitz: I wish you had prevailed but you didn’t. Now you have. You did great work, because honestly, all those voices that were screaming in the wilderness for a while, they all came together and made this happen 20 years ago, in California.
Charlotte: I was in New York at the time.
Dr. Moskowitz: Well, New York’s got terrible laws. They’re pathetic.
Charlotte: I moved here now, and I have moved here quite a while ago.
Dr. Moskowitz: This is part of the problem. The problem with states legalizing this is every state has a different law. What happens when you are using this as real medical treatment and you have to travel from one place to another? What happens when you move from one state to another and you can’t get what you used to be able to get in the other state? If you get Valium in New York, it’s the same as Valium in San Francisco.
If you get propranolol in New Mexico, it’s going to be the same as the stuff you get in Canada, but here, every state is going to have different supply, different availability, different rules, different regulations, how much THC you can use, how much you can’t use. It’s a tower of Babel and nobody’s speaking the same language. That’s what’s inhibiting this. On the other hand, it’s also allowing people to develop the people’s medicines and there are a lot of non-medical people who become quite expert in this and they’re really quite good at.
I would say, cannabis and how it’s out there is the most innovative thing I’ve ever seen in my career. It’s incredible what people are doing, how they’re making it, what they’re doing with it, how they’re making sure it’s safe, how they’re making sure it’s effective, it’s really quite remarkable what happens when you turn this over to everybody.
Charlotte: It’s wonderful –the natural ingenuity and brilliance of people.
Dr. Moskowitz: Yes, I would say definitely that.
Charlotte: Herbal healers have always been– gifted herbal healers have always been really wonderful. Even aspirin which was a miracle drug was willow bark, wasn’t it or something like that?
Dr. Moskowitz: It was. It was and digitalis was foxglove and all this other stuff. Taxol, which is a chemotherapy agent for breast cancer, it was developed from a plant, from a bark of a tree. You’re basically talking about a process that’s been there from time immemorial. I would say, the pharmaceutical takeover of this thing has been remarkably helpful for treating people and for keeping people alive.
I won’t say it’s been remarkably helpful for making people feel well. It makes people feel less sick and that tends to be what they shoot for. It’s a reasonable thing to shoot for. Cannabis really makes people feel well, and that is a big difference. It’s one of the reasons I really like working with my patients with it. I’ve got a lot of people with really serious pain problems that feel well.
Charlotte: Well, this has been incredible. I cannot thank you enough. It’s been totally fascinating on so many levels. I really appreciate your time.
Dr. Moskowitz: Well, I’m very happy to talk to you.
Note: Please do not use any of the above information without consulting with your physician. The above is exclusively the experience of the person being interviewed.
Michael H. Moskowitz, MD, is the President of Bay Area Pain Medical Associates. He is Board Certified in both Psychiatry and Pain Medicine and has served as a member of the Examination Council for the American Board of Pain Medicine and as the Chairman of the Educational Committee of the American Academy of Pain Medicine.
Dr. Moskowitz’ clinical practice in pain medicine uses the Biopsychosocial approach and he is a pioneer in the development of treatment approaches to brain neuroplasticity and pain. He co-founded Neuroplastic Partners and built the top rated website in the world on neuroplastic treatment (http:// www.neuroplastix.com). He coauthored, with Marla Golden, the Neuroplastic Transformation Workbook, used by practitioners and people with persistent pain to guide them through non-medication, brain based approaches to treating persistent pain.
Dr Moskowitz was a guest at the fifth annual international pain conference at for Army, Navy, Air Force, and VA at Walter Reed Medical Center where he lectured on the benefits of medical cannabis.
Since 2015 Moskowitz has specialized in the use of medical cannabis for the treatment of pain and anxiety and he wrote a book on the subject, Medical Cannabis: A Guide for Patients, Practitioners and Caregivers.
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