Should lupus patients use medical marijuana?
Medical Marijuana (Cannabis, Cannabinoids, THC, CBD)
Marijuana (cannabis) and its active components (THC and CBD) has become more popular for medical treatments. As of this writing (April 2021), 42 states in the US allow the use of medical marijuana, and 11 states (and the District of Columbia) have fully legalized its use recreationally. Many of my patients ask about using it, so I think it is important to go over some important information about it.
My goal is to present the facts based on scientific evidence without bias.
Cannabinoids are the active compounds of the cannabis plant. There are over 140 different cannabis-derived cannabinoids known, and each acts differently in the body. The 2 most studied and well-known are cannabidiol (CBD) and tetrahydrocannabinol (THC). THC is the cannabinoid responsible for the “high,” intoxicating effects with recreational users. CBD does not make people “high.”
Since CBD does not cause people to be high, U.S. federal law allows CBD-containing hemp (“industrial hemp”) to be grown as long as it contains no more than 0.3% THC when dried. Industrial hemp is used to produce CBD products that can be purchased in all 50 states.
You can buy CBD; but it is illegal, how can that be?
CBD has an interesting legality and availability issue. CBD products (with our without CBDA) are available for purchase in all 50 states since industrial hemp is legal to grow. However, the FDA does not permit them to be sold. CBD is considered an investigational drug. The FDA gives out warning letters to companies selling CBD products. However, to our knowledge, individual citizens are not arrested or prosecuted for purchasing them.
Many CBD products are poor quality; ensure you get the best brands
One problem with these products, similar to all herbal products, is that they are not FDA regulated. A 2017 study bought 84 CBD products online. 70% of the CBD products were mislabeled. They either had significantly more CBD than stated on the label, or significantly less. A 2020 study showed that only 1 out of 5 CBD products purchased in Mississippi contained the amount of CBD stated on the label. Problems with dangerous amounts of lead, mercury, and other contaminants have also been seen in unregulated products. Consider checking lab reports that measure CBD purity, such as ConsumerLab.com.
Today, responsible producers have improved their quality by having batches of products regularly tested for quality. If you decide to use CBD, try to stick to products from sellers who can produce a “Certificate of Analysis” for its products. Online examples of high-quality companies include “NuLeaf,” “Joy Organics,” “Bluebird Botanicals,” and “Charlotte’s Web.” These products typically have a QR code on the package that you can scan with a smartphone to check the 3rd party testing analysis results for the batch used to make your product. The United States Department of Agriculture (USDA) also tests and certifies high quality products. Using a brand that is USDA-certified ensures the highest quality.
Use products that list the amount of CBD per serving. If the label states only “cannabinoids,” it may not contain much CBD.
Cannabidiolic acid (CBDA)
Some CBD products contain another less-studied cannabinoid called cannabidiolic acid (CBDA). CBDA occurs in industrial hemp and cannabis. Therefore, it is available in all 50 states when it comes from industrial hemp. Though human studies are lacking, animal studies suggest it may help reduce pain and nausea. One study also showed that it reduced COX-2 (cyclooxygenase-2) activity in mice and may have anti-inflammatory properties. COX-2 is one of the enzymes that nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, and celecoxib, inhibit. Could this be more helpful in inflammatory diseases such as lupus? We do not know, and more studies are needed.
What the research shows: using medical cannabis for pain
In 2018, a Canadian Evidence Review Group evaluated all the randomized, controlled trials (RCTs) studying the medical uses of cannabis. Their final conclusion was that the evidence for use in chronic pain, including nerve pain, was low. Their final recommendation was to avoid medical marijuana products for acute pain, headaches, and rheumatologic conditions (such as lupus). If all other standard, proven therapies had failed, it could be considered for nerve pain and to help decrease pain and suffering in people who were dying.
A 2017 National Academies of Sciences, Engineering, and Medicine review of 35 RCTs concluded there was enough evidence to use cannabinoids for chronic pain. Another 2017 study from Portland, Oregon, U.S., found a small amount of evidence that cannabinoids may help nerve pain, but not enough evidence for other pain types.
All agree that more high-quality research is needed.
The problem with research so far is that cannabis is a Schedule I drug (illegal). Therefore, high-quality studies are lacking. We are not going to thoroughly understand the proper use of medical cannabis unless the government allows researchers to do so. Though studies so far do not greatly support cannabinoids for treating pain, it does not mean they are not effective.
Could cannabinoids help autoimmune disorders like lupus?
Many cells have receptors (attachments) on their surfaces to which cannabinoids can attach. They are called cannabinoid receptors. There are 2 types: cannabinoid 1 (CB1) and 2 (CB2) receptors. CBD, CBDA, THC, and other cannabinoids bind to these receptors, causing chemical changes within the cells to react in particular ways. When cannabinoids bind to receptors in the brain cells and pain nerves, they can potentially result in desired medical effects such as less nausea, reduced pain, less seizure activity, and fewer muscle spasms. THC (but not CBD) binding to brain cells can produce the “intoxication” and euphoria that some people seek when using it recreationally. However, binding to receptors on some cells can result in many potential side effects as discussed below.
CB2 receptors are on most cells of the immune system, especially the B-cells. When cannabinoids bind to CB2, they can lead to less inflammation. For example, when CB2 is activated on young (premature) B-cells of the bone marrow, they stay there instead of going into the blood to cause inflammation. CB2 activation on T-cells also reduces inflammation.
Lenabasum (ajulemic acid, JBT-10; formerly called anabasum and Resunab) is an experimental cannabinoid drug that binds to CB2. In 2017, it was shown to reduce the inflammatory cytokines TNF-alpha and interferons. These are chemical messages sent from one immune system cell to another telling it to become more active and cause inflammation. Then, in a phase 2 clinical trial, it significantly reduced dermatomyositis (a systemic autoimmune disease that attacks skin and muscles) skin inflammation (redness and itching) within 2 months. Potential side effects included dry mouth, dizziness, and fatigue. Lenabasum is in clinical trials for cystic fibrosis and for the systemic autoimmune diseases SLE, scleroderma, and dermatomyositis.
If cannabinoids (such as lenabasum) are shown to significantly reduce inflammation and damage, they could potentially play a role in treating autoimmune diseases, such as lupus. However, they would also need to be proven to be safe as well. There are no research results yet regarding their use in treating the inflammatory problems of lupus. Therefore, I do not recommend their use in this manner (such as for lupus arthritis, pleurisy, kidney inflammation, and skin lupus).
How to get properly evaluated and treated for medical cannabis treatment
If you decide to use medical cannabis, do not rely on the salesperson's advice in a marijuana dispensary (called a “budtender”). Instead, seek the advice of a physician trained in medical cannabis. The signs of a proper evaluation should include the doctor doing a thorough history and physical examination with a review of your past medical history, followed by a discussion of the potential risks and benefits of cannabis. The physician should discuss the different types available, the THC and CBD amounts, what dose to begin with, and how to adjust the dose. A responsible physician would require “informed consent,” often in the form of a “Pain Contract” that lists the potential side effects. Close follow-up, usually every few weeks at first, associated with a drug toxicology screen (for cocaine, heroin, etc.) should be performed. If you see someone with a waiting room full of “patients” and your visit is a hurried affair and a quickly written prescription, this is the sort of doctor you want to avoid.
Generics and Brands available:
There are 3 FDA-approved cannabinoids (as of April 2021)—dronabinol, nabilone, and cannabidiol. Nabiximols is available in many other countries
Dronabinol (Marinol, Syndros) is approved to stimulate appetite in wasting conditions, such as HIV and cancer, and to prevent nausea and vomiting from chemotherapy.
Nabilone (Cesamet) is approved to treat nausea and vomiting from chemotherapy. However, it is labeled as being “discontinued” (1 mg capsules) per UpToDate.com as of April 2021. The 1 mg capsule was also discontinued in Canada on August 2020 as of this writing, April 2021.
Cannabidiol (CBD, Epidiolex) is approved to treat seizures from Dravet syndrome, Lennox-Gastaut syndrome, and tuberous sclerosis. Note that this is a pure prescription-strength form of CBD. It does not have euphoria, “getting high,” and intoxicating effects (like marijuana) due to not containing THC.
Nabiximols is approved to treat muscle spasms from multiple sclerosis (MS) in many countries (including Canada and the United Kingdom) but not in the U.S. It is an aerosol sprayed on the insides of the cheeks. It contains equal parts THC and CBD.
Recreational and Medical Cannabis from regulated Dispensaries:
These are found in the states that legalized their use. Products come in many forms, as discussed below, with varying amounts of THC and CBD. If you decide to use medical cannabis, make sure you get it from a reputable dispensary, not homemade, so that you know what you are actually getting. Potential dangers of homemade products include unknown THC and CBD quantities, mold, pesticides, and contamination with other drugs. Also, do not smoke or vape, as discussed below.
OTC CBD: Many over-the-counter preparations of CBD are available. See the discussion above.
Synthetic marijuana: These are laboratory-produced cannabinoids sold under names such as “K2,” “spice,” and “crazy monkey.” These have similar effects on the body as naturally produced cannabinoids but are unregulated and not studied. Around 7,000 cases of intoxication side effects from these are reported to the U.S. regional poison control centers yearly. They can cause psychosis, dangerously high body temperatures, muscle and kidney damage (rhabdomyolysis), seizures, stroke, and life-threatening blood clots. Avoid synthetic marijuana.
How cannabinoids work:
What benefits to expect from cannabinoids:
When used for pain, they may help to “take the edge off.” They will rarely get rid of pain. Many of the studies assessing cannabinoids looked at their ability to decrease pain by 30%. Studies showing the best pain relief used THC-containing products. CBD-only products do not appear to have as much benefit. A real-life experience from Dr. Peter Grinspoon, a Harvard (Boston, Massachusetts) physician who specializes in medical cannabis, stated in a 2019 interview:
Among my patients to whom I have suggested CBD for chronic pain, a few have noticed great benefit, a few have noticed some benefit, and a lot have noticed no benefit. For those who have said they noticed benefit it is unclear whether that benefit was just the placebo effect."
He also stated that for severe arthritis pain, pure CBD probably has little effect. However, medical cannabis containing THC could possibly help.
A good habit to get into is to rate the severity of your pain on a scale of 1 to 10 before use (1 is minimal pain, 10 is the worst pain you have ever had in your life, such as slamming your thumb in a car door). Then write down your level every 30-60 minutes after taking the cannabinoid to assess its effectiveness.
How quickly they work depends a lot on the form used. For example, tinctures/oils/concentrates placed under the tongue can work within 30 minutes, while edibles (discussed below) can take several hours. Topical CBD oil, if it helps, can take 6 to 8 hours. A Cleveland Clinic review article found that preparations containing THC probably work better than pure CBD products.
Cannabinoids may also help with insomnia, lessen anxiety, and reduce nausea. A 2019 Brazilian study demonstrated that taking CBD two hours before public speaking reduced anxiety during the speech.
For insomnia, CBD tincture under the tongue can take half an hour to work, while an edible can take an hour or longer. It is essential to also follow “sleep hygiene” recommendations (chapter 6). CBD does not appear to adversely affect the quality of sleep (but THC does).
Dronabinol is a synthetic prescription THC. It is used to treat nausea from chemotherapy and appetite loss from AIDS.
It causes euphoria and “high” responses after 2 hours, similar to what is felt 30 minutes after smoking marijuana. Reduced pain and nausea and increased appetite begin within 30 to 60 minutes after ingestion and peaks at 2 to 4 hours.
An important point to note is that if you use a THC product, pain relief does not correlate with feeling “high” or not. In other words, if you notice a decrease in your pain but do not feel “high,” don’t go up on the dose thinking that your pain will be even less when you do feel “high.”
How cannabinoids are taken:
Cannabinoids can be used in many different forms—smoked, vaped, ingested (such as “edibles,” capsules, concentrates, and tincture drops), topicals (ointments, creams), and as an aerosol sprayed on the insides of the cheek.
Marijuana edibles (“medibles”) come in many forms to include popcorn, baked goods, candies, butter and oils, mints, and beverages. Be extra careful to keep these secure and hidden from children. Caution is needed if you consume cannabis edibles. Their absorption and effects are slow and gradual in onset. It may be several hours before feeling anything. This can lead inexperienced users to eat an additional serving (called “stacking”), thinking that it must not be working. This can easily cause an overdose with nausea, nonstop vomiting, psychotic thoughts, and heart palpitations.
Tincture (liquid) drops, and concentrates are placed under the tongue (sublingual). These are absorbed and have rapid effects. These are some of the easiest forms to adjust the dose for reliable effects.
Topicals (ointments, oils, salves) are advertised to rub over painful areas.
Smoking (and vaping) cannabis. Lupus patients should never smoke any form of cannabis. There are many proven dangers of smoking tobacco for lupus patients. It can lead to the onset of lupus, trigger lupus flares, decrease the effectiveness of its most important treatment (antimalarials like hydroxychloroquine), make skin lupus much harder to treat, cause heart attacks and strokes, and lead to lung cancer.
Cannabis smoke contains many of the same dangerous chemicals and carcinogens (cancer-causing substances) as tobacco smoke. Cannabis smoking has been shown to increase the risk of heart attacks and strokes. Since these are the most common causes of premature death in people with SLE, this is another reason for avoidance. Medical studies show that smoking cannabis can lead to chronic bronchitis, a disease due to permanent lung damage. This condition increases the risk for infection, and infections are among the leading causes of death in people who have SLE. Smoking cannabis worsens dry mouth, can cause thrush, and increases periodontal disease. All of these are already problems in SLE that could be worsened by smoking cannabis.
Since smoking cannabis has not been studied in SLE patients, and its potential risks are so high, please do not smoke.
All forms of medical cannabinoids should be started at a low dose and go up very slowly over time until the desired effect is achieved. If any side effects occur, go back down on the amount.
-Prescription-strength CBD (Epidiolex) is dosed at 2.5 mg to 10 mg per kg of body weight twice daily to prevent seizures. For a 150 pound person, this comes out to 170 mg twice daily up to a maximum of 680 mg twice daily.
-OTC CBD dosing by disorder treated.
Proper dosing has not been adequately studied. One recommended dosing is to start with 1 mg per 10 mg of body weight. For a 200 pound person, this would be 20 to 110 mg. Others recommend that new users begin with 5 mg at a time and slowly increase the dose.
The following CBD doses were used in research studies that suggested benefits at these doses. However, it is safest to start at a low dose, such as 5 mg to 25 mg at a time, and go up slowly on the amount.
Anxiety and public speaking: 150 mg to 600 mg capsules or edibles once or twice daily. For public speaking, 150 mg to 600 mg 2 hours before speaking
Insomnia: 160 mg to 500 mg tincture oil under the tongue 30 minutes before bed or 160 mg to 500 mg capsules or edibles 1 to 2 hours before bed
Chronic noncancer pain and nerve pain: CBD-only products may not be very effective. THC products containing CBD may be more helpful. Ask a physician experienced in medical cannabis for proper dosing.
Acute pain: There is no evidence of effectiveness
-Prescription-strength THC (dronabinol) is dosed at 2.1 mg once daily up to 10 mg twice daily for nausea and to increase appetite.
-OTC THC dosing: 10 mg, or less, at a time is a commonly recommended dose. Use products that are low in THC and higher in CBD for safer use.
Alcohol/food/herbal interactions with cannabis:
Cannabinoids can increase the intoxication effects of alcohol. Avoid alcohol.
Take oral cannabinoids after a fatty meal for best absorption. If you use a THC product and develop side effects, try taking it before eating a meal instead.
Potential side effects of cannabinoids:
THC causes intoxication and a “high” sensation, but CBD does not. THC products are potentially addictive and have abuse potential. Pure CBD products do not. If you decide to use cannabinoids, choose a product that is low in THC and higher in CBD.
One potential side effect of cannabinoids (primarily higher THC products) is called “hyperemesis syndrome.” Emesis is the medical term for “vomit,” and “hyper-“ comes from the Greek for “a lot of.” Fortunately, this is rare, but when it occurs, it is life-altering with uncontrollable nausea, vomiting, and abdominal pain that can last hours to months. Hot baths and showers often help decrease the symptoms' severity. The usual drugs to treat nausea are often of little benefit. Interestingly, topical capsaicin use may also help.
THC-containing products (including dronabinol) can cause unpleasant withdrawal symptoms if taken regularly then stopped abruptly. If taken regularly, it is best to slowly wean off to prevent withdrawal. People who take CBD products (including Epidiolex) for seizures should also taper off gradually to prevent withdrawal seizures.
The use of THC products and marijuana at an early age can increase the risk for schizophrenia.
Weekly cannabis use at least doubles the risk for testicular cancer.
THC-containing products can cause “cannabis use disorder” in 10% of users. With daily users, it occurs in around 1 out of 3 users. Those affected become used to the effects of cannabis (tolerance), go through withdrawal symptoms if they try stopping it abruptly, and continue to use it even if it is causing them harm. It is associated with poor school functioning, a higher likelihood of requiring socioeconomic assistance (social welfare programs), low income, unemployment, criminal behavior, and lower life satisfaction.
Long-term cannabis users can develop permanent brain abnormalities, including decreased hippocampus size, lower IQ, and reduced nerve activity in parts of the brain.
A 2014 study of 158 cannabis users showed significantly worse memory, attention, and performance scores than nonusers. It is not surprising that these were worse in daily users compared to sporadic users. However, even those who had previously stopped using cannabis had significantly lower brain function than nonusers, suggesting permanent negative brain effects.
Research suggests that CBD may possibly decrease some of the unwanted side effects of THC by preventing THC from attaching to CBD1 and CBD2 receptors on specific cells of the body. However, the research is preliminary and more studies are needed.
If you used to smoke cannabis many years ago, keep in mind that THC strength has increased from only 3% in the 1990s to around 20% today.
Potential Side Effects of pure CBD (Epidiolex) from the FDA-approved package insert
Stomach upset, nausea, diarrhea, weight change, loss of appetite
Elevated liver enzymes
Drowsiness, fatigue, insomnia, difficulty thinking, moodiness, aggression/anger, suicidal thoughts
Infection and fevers
Rash, hives, angioedema
Potential Side Effects of pure THC (dronabinol) from the FDA-approved package insert
Euphoria, “high” Very common No intervention required
Abdominal pain, nausea, vomiting, weight changes, diarrhea
Facial flushing, heart palpitations, fast heart rate
Muscle weakness or pain
Elevated liver enzymes
Thinking abnormalities, altered judgement, sexual indiscretion activity, drowsiness, memory loss, anxiety/depression, incoordination, confusion, “flu-like symptoms,” headaches, nightmares, speaking problems, ringing in the ears, psychiatric symptoms (hallucinations, paranoia)
Low blood pressure, lightheadedness, passing out (syncope)
Rash, hives, angioedema, mouth sores
Hyperemesis syndrome (uncontrollable vomiting)
Weighing the side effects vs potential benefits:
What if we, your doctors, prescribed a pain medicine that causes side effects in 1 of 6 people who take it? However, only 1 out of every 19 people get adequate pain relief. All of our patients would look at us like we were crazy and absolutely refuse to take it. Guess what? These are the actual numbers when you look at the averages from the best research studies assessing the use of cannabinoids to treat chronic noncancer pain (such as arthritis and fibromyalgia pain).
Look at the side effects listed above. If you take an over-the-counter CBD product in small doses, you are unlikely to develop serious side effects. However, at higher doses, you can potentially have the problems listed. These are the effects that occur with prescription-strength CBD using 2.5 mg to 10 mg twice daily. While over the counter CBD is popular (because it is easy to obtain and is in the news a lot), the studies do not show very good pain-relieving effects from these products. The research studies that suggest pain relief from cannabinoids are primarily with THC-containing products.
Other medical marijuana products available in states where it is legal have a combination of CBD and THC. Medical marijuana and edibles purchased from both medical and recreational dispensaries contain an average of around 20% THC and 2% CBD. However, amounts vary widely, ranging from 0 to 45% THC and 0 to 40% CBD. You can estimate the potential for side effects by combining both charts' side effects in proportionate amounts. The THC amount in most products was 2 to 3 times higher than what is needed for pain relief. These more elevated amounts of THC place the person at higher risk for the dangerous psychotic side effects of cannabinoids but without additional pain-relieving effects.
Since the potential for side effects of using medical marijuana is much greater than its proven benefits, we cannot recommend its use for pain until more rigorous studies are done. However, we realize that many of our patients will use medical cannabis, often due to dissatisfaction with the results of prescription therapies. Therefore, we want them to know the facts to make well-informed decisions, hopefully in conjunction with a physician experienced in medical cannabis.
What needs to be monitored on cannabinoids:
A responsible prescriber will ask you to read and sign a pain contract that discusses how pain medicines work, the potential side effects, the need for close follow-ups, and the need for regular drug screens (such as for cocaine and heroin). Close follow-up with your physician should occur to monitor its effectiveness and tolerability. If you have thoughts of suicide, depression, anxiety, moodiness, drowsiness, or other side effects, report these to your physician ASAP.
Liver function tests, weight, blood counts, and kidney function should be monitored regularly.
Reasons not to take cannabinoids (contraindications or precautions):
Do not use if you have had bad allergic reactions to cannabinoids. Do not use if you have had a history of “cannabis use disorder.” Consider not using if you have had any history of alcohol or drug abuse.
While OTC CBD products contain less than 0.3% THC, they can potentially cause a positive THC drug screen. If you are in a job that requires urine toxicity screenings, or need a professional security clearance that does not allow THC use, you should avoid even OTC CBD products. The U.S. military does not allow the use of any hemp or cannabis product. Insurance physicals requiring drug toxicology screens may also be negatively affected.
Do not take if you have cirrhosis of the liver, or use smaller doses than usual.
There are many potential drug interactions. Have your doctor check before you begin taking a cannabinoid. For example, antifungal drugs used to treat thrush and other yeast infections in lupus patients can significantly increase the blood levels of cannabinoids. Cannabinoids may increase the drug levels of cyclosporin, tacrolimus, and voclosporin (Lupkynis), which are used to treat lupus nephritis. Other drugs commonly taken by SLE patients that can have significant interactions include cholesterol lowering medicines (statins), sildenafil (used for Raynaud’s and pulmonary hypertension), blood pressure medicines (nifedipine, metoprolol, propranolol, valsartan, diltiazem, and verapamil), proton pump inhibitors for acid reflux, NSAIDs (naproxen and celecoxib), and many antidepressants. Cannabinoids can dangerously increase warfarin (Coumadin) blood levels. Warfarin is commonly used in our patients who have antiphospholipid syndrome.
Liquid dronabinol (Syndros) contains alcohol and should not be taken with disulfiram (Antabuse) or metronidazole. Otherwise, stomach cramps, nausea, headache, and flushing can occur.
Products containing THC (including dronabinol) have the potential for substance abuse. If you have a history of alcohol or drug abuse, avoid these products.
While taking cannabinoids:
Do not drive, climb, operate machinery 24 hours after using THC. Do not take other medicines that affect the brain and nerves without consulting your doctor. This includes antidepressants, anti-anxiety drugs, sleeping medication, and other pain relievers.
If you use a cannabis product regularly, be cautious of stopping use abruptly. Taper off slowly to prevent withdrawal problems such as seizures.
Store in a secure place (especially tempting edibles) away from children and pets to prevent accidental use and overdose.
Pregnancy and breastfeeding while taking cannabinoids:
Do not use while breastfeeding or while pregnant. Fetal and infant exposure to THC increases the risk of permanent brain damage leading to autism, hyperactivity, lower IQ, memory problems, and psychiatric illness.
Cannabis smoking decreases sperm counts by around 30% and should be avoided in men trying to have a baby.
Geriatric use of cannabinoids:
Older individuals have a higher chance of side effects, and lower doses are usually needed. The side effects can increase the risk for falls that can be very dangerous. Do not use it without discussing it with your physician. If you have osteoporosis, you should consider not taking a cannabinoid.
What to do with cannabinoids at the time of surgery:
It is always best to double-check with your rheumatologist and surgeon regarding specific instructions. Cannabinoids should probably be avoided before surgery to prevent dangerous interactions with anesthetic medications.
Cost of cannabinoids:
Prescription cannabinoids are not covered by insurance, other than for the FDA-approved indications of chemotherapy-induced nausea, appetite stimulant, rare forms of seizures, and muscle spasms from MS. The costs, out of pocket, as per UpToDate.com for a typical one day supply are as follows:
Epidiolex: $6,000 for a 150-pound adult
Generic dronabinol: $5 to $20 a day
OTC CBD products: per ConsumerLab.com, prices range from US 24 cents for 10 mg up to US $2.67 for 10 mg.
ConsumerLab.com also tests product quality. The least expensive product was also one of the highest quality brands. This is a case where more expensive does not mean higher quality.
Website to learn more about cannabis: www.projectcbd.org and https://www.cdc.gov/marijuana/index.htm
What are your thoughts, comments, or experience with medical marijuana?
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Note that Dr. Thomas' posts are for informational purposes only, and are not meant to be specific medical advice for individuals. Always seek the advice of your healthcare provider with any questions regarding your own medical situation.
DONALD THOMAS, MD