Dr Niraj Singh, a consultant psychiatrist and member of the Medical Cannabis Clinicians Society, shares his journey prescribing cannabis over the last 18 months.
For me medicine has been a calling since adolescence, when I took pride in helping people.
Not providing them with a treatment protocol or management plan as we call them in medical language, but just to be around to help, lend a hand or just listen to them about their troubles.
As a medical student I was fortunate to have access to an education of the wonderment of the human body, its functions, how things malfunction and how they get better.
What has always struck me though was the distinct separation of specialties. We have a heart doctor, a lung doctor, a bone doctor, a brain doctor and the list goes on and on.
Clearly the fall out of entrenched Descartian thinking, whilst the mind and body had its clear separations in service provision, the fact is that the two are united and inseparable.
Think of anxiety and the physiological effects on our body, with increased heart rate and blood pressure. Or even gut health and the effect of mental health through the gut brain axis.
Undeniably a doctor has to focus on both mental and physical health to truly assist the patient in healing.
The symbiotic relationship
Having realised I had two left hands and surgical practice was a non-starter, I set my mind on general practice.
But working on a stroke ward as a house officer (the first year of work following receipt of a medical degree) and spending large amounts of time just listening to patients, many struggling with depression and anxiety, I soon realised that psychiatry was my path.
I didn’t have an easy time and was met by opposition from several quarters suggesting I reconsider my choice.
Sticking to my guns though, I took up a psychiatry rotation and eventually higher training in neurodevelopmental disabilities treating people who struggle with conditions such as depression, anxiety, OCD, bipolar disorder, schizophrenia, ADHD and treating mental health problems in autistic patients.
I count my blessings every day that I have the opportunity to help others as well as learn from them.
Medicine in my view shouldn’t just be paternalistic or maternalistic, though this approach has its place. It’s symbiotic, because it is also aided by the patient’s understanding of what is going on with them, if they are able to express this.
Healing starts from the beginning of the interaction, not from the first prescription.
We are what we do
Another important saying I’ve always related to is the importance of having two ears and one mouth, so one can listen twice as much as they speak. We all have the innate capacity to heal and also have the capacity to help others heal. Nature is the primordial force.
In my practice, lifestyle is vitally important. The old saying ‘we are what we eat’ has relevance. I’d add ‘what we do’ also.
Giving attention to exercise, sleep hygiene, hobbies, work and recreation, has clear impact on the mind and body.
The use of plants for healing has been around for thousands of years. Many of us know the benefits of turmeric, nigella sativa, Echinacea and the list goes on.
Cannabis has been used for an uncountable number of years for healing. A plant in our natural environment, which works in synergy with our bodies to relieve illness, heal and even have health-promoting benefits.
It has multi-systemic effects through the endocannabinoid system, the system that underlies the entire major systemic and organ functioning as well as that of the autonomic nervous system.
It has the capacity therefore to transform health and lives through its effect on mind and body, working in synergy and getting to the foundation.
Conventional medical treatment has its place, however room should be permitted for other therapeutic options.
But cannabis has been demonised for decades.
When one looks at recreational misuse and the negative impact on mental health from uncontrolled elevated doses of THC in people who may be predisposed to psychosis, the concern is understandable.
Moreover lives can be impacted through uncertified products, resulting in physical and mental health detriment as well as possible criminal proceedings.
However, to box everything negatively to the expense of removing potential life- saving treatment options (and I don’t use these words lightly) for children and adults, is negligent and unethical in my opinion.
It’s the data that speaks
Building the evidence base is crucial and we must be able to progress quickly from only a handful of patients being able to access prescriptions on the NHS.
Project Twenty21 and the fantastic work being done will shed further light. As practitioners, we’re only too aware of the incredible benefits medical cannabis accords. However, ultimately it is data that speaks.
Mental health problems, neurological conditions, pain, cancer, gut disorders and the list continues. We are only just scratching the surface in relation to chemovar knowledge and the myriad of benefits that medical cannabis has on mind and body.
As we gain further information on cannabinoids, our knowledge of terpenes and effects of flavonoids will also increase. And what an exciting time it is.
Having prescribed medical cannabis for around 18 months now, I have seen first hand the incredible impact it has on mental and physical health, quality of life and the impact of lives around those who are being treated.
Speaking with patients, it is a privilege to learn from their experience for they often have a greater knowledge and understanding on what works for them and the reasons for this. It is truly a symbiotic relationship.
I leave with you a quote from Paracelsus (1493-1541), one of the first scientists who pioneered the use of minerals and other chemicals in medicine.
“The art of healing comes from nature, not from the physician. Therefore the physician must start from nature, with an open mind.”
Find out more about joining the MCCS here
If you’d like to share your experience as a medical cannabis prescriber or patient, we’d love to hear from you. Please email email@example.com
Is it time for a T (tolerance)-break?
A medical cannabis prescriber explains why it’s important to take a break
How do you know if it’s time to take a tolerance break? Dr Niraj Singh, a consultant psychiatrist and member of the Medical Cannabis Clinicians Society, explains.
But we all need a break from time to time, and so it seems do our cannabinoid receptors.
Readers will be familiar with the issue of tolerance developing with continuous use of medical cannabis. The definition of tolerance is “a person’s diminished response to a drug, which occurs when the drug is used repeatedly and the body adapts to the continued presence of the drug.”
The cannabinoid receptor 1 lies mainly within the brain and spinal cord. THC binds directly to this and CBD indirectly. With continuous binding of THC, CB1 become ‘down regulated’ ; this means a decrease in the number of receptors on the surface of target cells, making the cells less sensitive to THC binding.
Medical cannabis users may experience this as their treatment becoming less effective and the requirement to take more for symptomatic relief.
Timing for development of tolerance will depend on one’s history of cannabis use, the chemovar of the product itself and other physiological factors.
At times therefore the CB1 receptors need a rest. With reduced consumption, this gives the ‘overworked’ receptors a break, giving them a chance to expand in number again, a term called ‘up regulation’.
The idea of reducing consumption can be anxiety provoking for users and not an easy one, however the benefits are unquestionable. With up regulation, a lesser amount of medical cannabis product is required for the same effect. Using less product, also means less financial expense.
There is no specific guidance on the time frame for how long a tolerance break should be. Up regulation is said to take place 48-72 hours hours after stoppage and levels out between 21 days and 4 weeks after, so this is the range after which most benefits can take place. This is because THC clears the system completely within this latter period.
A T-break has to be balanced with the patient’s circumstances, current symptoms, as well as risk of any deterioration in health. Treatment dosages can also be reduced gradually rather than sudden stoppage.
It’s important therefore that any tolerance breaks take place during periods of less stress. Alongside ensuring regular exercise and a healthy diet to boost the endocannabinoid system (ECS) is important.
One can still use CBD and terpenes during the tolerance break periods. If there are any problems with sleep, natural supplements can be used.
Once medical cannabis is re-started, it’s important that this is gradually built up rather than starting back on the dosage used prior to the tolerance break.
It’s vital that the doctor and patient discuss the tolerance break and agree on a plan. It’s important that patients discuss this with people in their household and those in close proximity as irritability and frustration can occur particularly in the early stages.
A few things to remember:
- A T-break should be planned and measures put in place to ease it as best possible. Decide on a realistic time frame. Doctors and patients need to discuss and agree this also.
- Ensure it happens at a time of fewer stressors but at the same time ensure a good level of activity is taking place to ensure the mind is focused elsewhere.
- Ensure a healthy diet and adequate exercise. Connect with the natural environment.
- Use natural supplements for sleep where required.
- If needs be use CBD oil which is broad spectrum with a good range of terpenes.
- Stay resolute but also realistic. Remember any break above 72 hours will be beneficial.
- Build up the dosage gradually after re-starting.
Find out more about joining the MCCS here
If you’d like to share your experience and insight as a medical cannabis prescriber or patient, we’d love to hear from you. Please email firstname.lastname@example.org
Cannabis offers new hope to those with chronic back pain
Medical cannabis is offering new hope to those living with chronic back and spinal pain, writes Dr Anthony Ordman
Medical cannabis is offering new hope to those living with chronic back and spinal pain, writes Dr Anthony Ordman, hon. medical director of Integro Medical Clinics.
Anthony Ordman spent over 20 years working in the Pain Management Clinic of London’s Royal Free Hospital, having set it up in 1997 and is a former president of the Pain Medicine section of the Royal Society of Medicine.
Awarded the Fellowship of the Royal College of Physicians in 2005 in recognition for his work, Anthony is now senior clinical adviser and hon. medical director of Integro Medical Clinics and is a medical advisor to charities helping musicians, and those in the performing arts.
I became a consultant in pain medicine some 24 years ago, and have always had a special interest in back and spinal pain which trouble so many of the people attending the pain clinic as patients, and indeed so much of the general population.
Perhaps back pain is so common because our spines are designed by evolution for walking on all four limbs and supported at both ends.
But we, as humans, insist on walking only on our hind limbs and sitting upright, putting much more mechanical strain on every structure in our backs than they were designed for. Many of us also mobilise our backs through exercise rather less than we perhaps should.
We only have to look at our pet cats, to see how regular bending and stretching of our spines should be done several times a day, to keep spines healthy.
We also tend to be much more sedentary than we should be, and so the postural ‘core stability’ muscles surrounding our spines, can become rather less effective as “guy ropes” than they should be. Then, as intervertebral discs become worn, and facet joints at the back of the spine become enlarged and stiff, nerve roots leaving the spine to go down the arm or leg become pinched, and spinal muscles can become painfully tight, and spines can become stiff and painful.
Often, with the right balance of rest and exercise, and simple pain medicines such as paracetamol and ibuprofen, an episode of back pain can settle down relatively quickly.
But sometimes people are not so fortunate, and pain in the spine and limbs can go on to become long-term or chronic.
There are many other people, who suffer spinal pain brought on by their long-term medical conditions, such as multiple sclerosis, inflammatory arthritis, fibromyalgia, or hypermobility and Ehlers-Danlos syndromes, who have a very difficult time, despite the best medical treatment of the underlying condition itself.
Modern physiotherapy and medicine can often be of great help in such circumstances.
But sometimes, even in the best of pain clinics, with x-ray guided spinal injections, the best pain medicines, expert physiotherapists, clinical psychologists, acupuncture and homoeopathy, are not enough, and we struggle to help people rid themselves of back pain, enough to be able to enjoy life again. Often, this is because the pain has been ‘centralised’ by changes in the nerve cells of the central nervous system.
Thinking in particular of the specialist pain medicines we have to offer, choices can be surprisingly limited, and we have to be careful not to do more harm than good.
Opioids such as codeine, tramadol and morphine don’t often help after a few weeks but continue to cause sedation, brain fog and constipation, with a high risk of dependency.
Medicines such as amitriptyline used for nerve pain, low mood and poor sleep, often take more away more from patients in terms of memory and alertness, than they give through pain reduction. The same is so often true for gabapentin and pregabalin, and many of the other medicines licensed for treating pain. And while we are hopeful that the new classes of pain medicines will come along soon, we can’t expect any miracles just yet.
The role of the endocannabinoid system
But throughout my years in pain medicine, I’ve always attended national and international scientific medical meetings and, interestingly, almost every scientific conference seemed to have at least one lecture on the mysterious endocannabinoid system (ECS).
This is a system of natural biological pathways present in all of our bodies, where nerve cells, and immune and others cells use natural ‘cannabinoid’ substances to signal to each other, regulating bodily processes such as pain transmission, inflammation, and so on.
The function of the ECS seems to have to do with normalising body activity after illness or injury. The hope had always been that, very soon, the big mainstream pharmaceutical companies would find us the medicines we needed to modulate the ECS to reduce pain and improve lives.
Exploring medical cannabis
I was keen to find out for myself what cannabis medicines might have to offer patients who I could not help in other ways
I was extremely fortunate to be approached by the chief executive of Integro Medical Clinics to see if I would take up the medical leadership role in a service that would specialise in using the new cannabis-based medicines.
With the partnership and expert support of IPS, the country’s, leading expert pharmacy in dispensing pharmaceutical cannabis medicines, and several months of study on cannabis medicine, I found myself prescribing cannabis medicines for people whose lives were on hold because of pain.
Many had already tried CBD oil and found this just wasn’t enough to help, something we’re seeing more and more now. But in the clinic, we find that by blending just the right amount of THC and terpenes in each patient’s cannabis oil or flower, we are improving patients’ nerve and inflammatory joint pain and the painful muscle spasm of spinal pain, as well as improving sleep at night, without the daytime sedation or dependency of conventional pain medicines.
People can begin to get back to their work and childcare and leisure activities, with a clear head and sharper memory.
Within two or three months we can begin to relieve people of the burden of their conventional pain medicines. The very same cannabis medicines can also restore healthy sleep to patients, and lift mood, which had been depressed by pain for so long. People also felt brighter and less anxious than before.
Integro Medical Clinics Ltd always recommends remaining under the care and treatment of your GP and specialist for your condition while using cannabis-based medicines. The Integro clinical team would always prefer to work in collaboration with them.
Visit backcare.org.uk further support with your back pain
Why we need to reframe CBD as good nutrition
The absence of CBD as daily nutrition is causing a major health crisis, says an industry veteran.
The absence of CBD as daily nutrition is causing a major health crisis, writes founder of Master Plant and Mee CBD, Oli Osgood.
The conversation around CBD, particularly in the mainstream media, has focused on factors that have been detrimental to a true understanding of its benefits.
Rather than viewing cannabis as a ‘cure’ we need to reframe the debate and focus on how the absence of CBD as daily nutrition is causing a major health crisis.
CBD can help restore balance for us as individuals and for wider society. After 18 months of lockdowns and a growing mental health crisis, changing thinking has never been more important.
A quick Google search on top questions related to CBD highlights some of the spurious notions about CBD – ‘Is it a bad drug?’ or ‘is it legal?’ or even ‘is it a cure for cancer?’
These ill-informed views highlight the scale of the challenge we have in seeing its wide embrace in this country as a key component of our daily nutrition.
It is subject to the kind of scrutiny that simply doesn’t exist in the rest of the wellbeing industry. And therein lies the problem. It is viewed as somehow separate and other due to being sourced from a beneficial plant that has been outlawed for nefarious reasons for so many years. The upshot is any sensible debate is stifled.
With cannabis as a drug first being banned in 1928 in the UK, we have no living memory about a time before prohibition.
As a result, we lost any understanding of its potential benefits for society. Instead a moral panic grew up around it. The fact that this prohibitionist culture has existed for close to a hundred years means misperceptions are sadly hard wired into many psyches.
In a way it is not dissimilar to how discussions around mental health are suppressed by some cultures and societies. Of course our mental health is a vital part of life and so is CBD.
As a society we need to move away from the prohibitionist culture and mindset. We need to throw off the shackles of the past to develop a laser-like focus on the clear scientific basis on its vital role within the regulation of our bodies.
Activating what is already inside us
Adding CBD to daily nutrition is a game changer and we need to communicate this more publicly.
It has the ability to regulate and balance so many processes in the body, including immune response, communication between cells, appetite and metabolism and memory. There is a host of new compelling evidence highlighting its benefits that seems to get little traction in the mainstream media.
A recent report from the Frontiers in Public Health showing patients with chronic pain, PTSD and sleep disorders found their conditions improved after starting medical cannabis treatment. Thankfully titles like Cannabis Health report on these important breakthroughs.
All CBD is doing is activating the body’s endocannabinoid system (ECS). The ‘absence’ of CBD has had a detrimental impact on the health of us as individuals and I would argue our society.
We’ve seen from our own evidence remarkable results in our tests with the product of people who have clearly suffered from a range of ailments from chronic pain to anxiety.
One client had struggled to walk for seven years due to pain in her feet. She takes CBD and is now dancing and smiling – this seems like a miracle – but it’s just good nutrition performing miracles in the absence of a balanced diet that includes cannabinoids.
Having a wider perspective
Part of reframing the debate around CBD is looking outside our own narrow and parochial parameters to benefit from the perspective of a wider lens.
In my long experience of working overseas and travelling I have been struck by the much more mature understanding other societies have of the power of plant science and botanicals to help regulate our systems.
Indeed the inspiration for our brand was Margaret Mee who in the 1950s was one of the foremost figures to go deep into the Amazon and highlight the rare, valuable botanicals she discovered there. Margaret Mee used her fearless creativity to show the world the beauty and power of plants, a mission we share today.
The opening up of the world particularly in the last 20 years has gone some way to also open minds to the role CBD and other botanicals can play as part of a balanced life. These are fundamental to the wellbeing of so many societies. Meanwhile Western countries dominate the list of countries suffering from a mental health epidemic as revealed by Our World In Data.
These countries are also suffering from imbalances caused by eating too much or drinking too much alcohol – the permitted and by far most dangerous drug of all.
Government’s role to play
Of course the ‘solution’ to these crises is neatly provided by the pharmaceutical industry to ensure their profits remain sky high.
Hugely well funded global corporations with armies of powerful lobbyists have Governments at their beck and call and bombard doctors with information on why prescription drugs are the answer to all our ailments. With so much money to be made it is inevitable. But these drugs merely tackle the symptoms and not the cause.
In regulating our systems and restoring balance, CBD has the ability to negate the need for powerful prescription drugs, yet our industry is nascent. David compared to the Goliath of big Pharma.
Government needs to reject the lobbying and look at the compelling evidence, promoting CBD like they promoted milk for good teeth and bones rather than having a slightly uncomfortable arm’s length relationship.
They should invest in some mass double blind studies showing the benefits of CBD in a range of areas. This would help to level the playing field and of course ultimately save the Government huge amounts by not requiring so much use of the NHS.
Project Twenty21 which will see 20,000 patients supplied with subsidised cannabis products by the end of 2021, should help provide compelling data to shift thinking.
Water-soluble CBD can change the game
As well as winning the argument with Government, we of course still need to win round the public. Key to this is a method of consumption that appeals to people.
The next generation of CBD is water-soluble and can be the catalyst for change. As it can be added to food and drink, people will see how it can seamlessly integrate into our daily lives, moving CBD from our medicine cabinets to our kitchens.
This will help to literally reposition it as part of our daily nutrition and away from the misperceptions of the past. Additionally the enhanced bioavailability and super fast acting nature of water-soluble create noticeable results, and we believe, should further propel CBD further into mainstream life.
With consumers and the media better educated about the benefits of CBD we can start to see it in a new light. No longer something on the fringes of society – an unknown and frowned upon substance, but instead a vital component in helping us achieve a balance that is vital for our wellbeing.
Oli Osgood is CEO of Mee CBD and Master Plant and was formerly a CEO in the Virgin and Strauss Groups following 14 years private equity investment and financial director experience. He is a London Business School Alumni and ACA qualified.
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