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Alabama can learn from other states’ medical marijuana programs, expert says

The Alabama Political Reporter spoke at length with Dr. Jan Roberts on Alabama’s pending medical marijuana legalization program. Roberts is an Alabama native and an internationally recognized psychotherapist, educator, and speaker, as well as a founder of Holistic Integrative Psychotherapy, and The Cannabinoid Institute.

APR: Alabama has an epidemic for opioid abuse. Have Alabama doctors been over-prescribing opioids and would medical marijuana make more sense for many of those patients rather than being prescribed opioids or any hard narcotics?

Roberts: “Well you bring us an important point, I know historically just from my own experience with family members down in Alabama. Unfortunately, a relative that passed away from opioid abuse, this has always been something on my radar. I know some of the efforts that the state has made in regulating opioid prescriptions.”

“When you look at medical cannabis, we know a few things around medical cannabis,” Dr. Roberts explained. “We know that cannabis is absolutely effective in treating certain types of pain. We also know that if someone uses cannabinoids appropriately, they can actually reduce the amount of opioids that they consume because there is a synergistic effect that happens with cannabinoids, especially THC, along with opioids. There is this modality, this effort to try to use THC is a way to wean people off opioids.”

 
“Having said that, my experience in Delaware where I was on the governor’s regulatory board proved that if physicians do not understand the science behind cannabinoids that oftentimes they are very reticent to prescribe or to recommend cannabinoids,” Dr. Roberts explained. “So what that means essentially is that if the positions don’t have the correct information around what cannabinoids do [and] how it impacts certain receptors, they will tend to hold on to the stigma that medical cannabis is similar as a schedule 1 drug: such as, heroin or as opioids as well. So what we found–and we see this across the country–is that people who live in the adult-use states actually have an easier time receiving cannabis rather than states where there are very stringent medical cannabis laws in the access to those products are more challenging.”
 

“We had this come up in Delaware and actually our research showed that you really have to look at what the regulations are,” Dr. Roberts continued. “So physicians oftentimes right now are holding on to this kind of antiquated notion that cannabis is the same thing and will create a dependency issue the way opioids do. And the data doesn’t really support that. And the data shows that depending on what the laws are of that State as well as the physician buy-in to the products, those are the two key elements that will actually be successful in getting people off of opioids and using a medical cannabis product.”

“One of the things as well is benzodiazepine use,” Dr. Roberts continued. “So many people don’t talk about benzodiazepines like Xanax, Klonopin, and Ativan; and those are equally abused as opioids. Obviously, they have a dependency profile that is on par with opioids and actually can create dependency and within three weeks of using a benzo product. So we’ve also seen that benzo use can also be reduced as well from people supplementing with a specific type of cannabinoid medicine. People like to talk about opioids, but there are all these other drugs as well that are addictive and create dependency issues and create overdose situations that can lead to death—and benzodiazepines are part of those as well.”

APR: Opponents of medical marijuana argue that everything that medical marijuana can already be treated with something that has already received approval from the FDA. Is that argument wrong?

Roberts: “Yes, that argument is absolutely wrong. So let me explain something, medical cannabis and you have to understand that medical cannabis is just one global term that we use for a medication that has many different variations, many different chemical compounds in it.”

“There are over 180 cannabinoids that can be found in the cannabis plant,” Dr. Roberts added. “And so what we find and the data actually supports this, is that cannabis actually not only works with your physiological system but it also works with your mental health issues as well. So it is because of the endocannabinoid system it targets both physical as well as mental issues. The reason I bring this up is that when we’re looking at cannabis we find that patients actually use less medications. It can target many different issues. So for example, you know we see a lot of this with the elderly where they’re taking multiple medications for single issues. Well cannabis has this way of actually treating multiple issues at the same time.”

APR: You’ve already touched on this in your earlier answer, but many Alabamians are already addicted to hardcore street-level narcotics: stuff like hydrocodone or heroin. Is marijuana treatment able to help those people get off of their real narcotic addiction?

Roberts: “Well it’s fascinating. We know that CBD has been shown in research studies with humans as well as animal studies, to reduce cravings for certain opioids medications. There was a great study, I believe it was at Mount Sinai, looking at high levels of CBD for people who are actually going through early-stage heroin withdrawal. The data suggested that CBD taken at a higher dosage level actually was more effective than any other treatment in reducing cravings. And so this is a trend that we’re seeing in the research is looking at cannabinoids as a harm-reduction tool for many dependency, drug-dependency type conditions.”

APR: The state of Alabama has a suicide epidemic issue particularly among our veterans that are suffering from PTSD, is there anything that medical marijuana can do to alleviate the suffering of those people?

Roberts: “Absolutely. I actually specialize in treating trauma and I have many patients who struggle with trauma who have used medical cannabis for their symptoms. So for me as a clinician, this is a huge issue. You know the lab research, animal models research shows this. We are seeing this happen by looking at patient populations and in seeing the [attenuation] with symptoms. What we know–and I have seen this in my own clinical practice–is I’ve had patients who couldn’t tolerate SSRIs or other medications their physician had prescribed; however when we were able to include certain cannabinoids in their treatment regimen they found a reduction of flashbacks, a reduction of the hypervigilance and night terrors that exist. Cannabis actually works with your memory extinction–and this is why it’s so important for trauma victims to be able to have access to this product if they know how to use it correctly.”

“And I use that term, I want to be very clear here, cannabis like every other pharmaceutical has a specific dosage range and it’s very personal depending on how the patient metabolizes the cannabinoids, what their symptomatology is as well,” Dr. Robert continued. “So it’s important to find the correct dosage as well as the correct cannabinoid profiles. So for example, someone who has PTSD might want to be using a product that would have high levels CBD during their daytime so they are not really intoxicated per se but it also brings, what we call the hyper-vigilance, down; however, if you have PTSD many people struggle with night terrors, flashbacks– just really difficulty sleeping–racing thoughts and that’s why a higher level THC for the evening time.”

“So really understanding that again cannabis is a compound and so we have to be very careful what kinds of ratios of cannabinoids are in the medicine,” Dr. Roberts added, “And that’s why we need certain products that might have higher THC and certain products that might have higher CBD because they all interact with the body very differently. In my experience–and I’ll say this because you know I treat people with significant trauma including PTSD, eating disorders, personality disorders, other trauma-related conditions as well–it’s so important to understand that you know PTSD is not just a mental health condition. It activates your central nervous system as well. And that’s why cannabinoids are great at bridging that mind and body and working with people with these kinds of conditions.”

APR: Currently the state of Alabama allows citizens to buy Delta-8 and Delta-10 over the counter from a CBD store. This came up during the medical cannabis debate, should these products be regulated by the Alabama Medical Cannabis Commission and treated the same way as Delta-9 medical marijuana and require a doctor’s recommendation?

Roberts: “Well for me, it is very important to start with the fact that this is about patient safety. I get concerned with any patient or any consumer using products that they don’t know where they come from. There are many CBD over-the-counter type products that you can buy at the convenience store, or on Amazon, or at your local 7-Eleven. And the concern that I have with that is that we don’t know where those products come from, we don’t know if they are safe to use; because there has been research looking at over-the-counter CBD products and looking at patient safety and finding that oftentimes these products you know might have adulterants in it, might have harmful chemicals in it, et cetera.”

“One of the benefits of a medical program is that testing is often a requirement in these programs,” Roberts continued. “And product testing to me as a clinician, is the most important way to go forward–making sure that people have access to safe products.”

“The question really I have is whether or not the state program is going to be so restrictive that it creates hurdles for patients to access these medicines or are they going to allow patients to have an easier access to become certified?” Roberts added. “That is a huge issue. And so in the perfect world, I would say that Delta-8 and Delta 10 are cannabinoids that really are fairly harmless and that hopefully, they would be found in a product that’s safe to use. I can’t guarantee that, so that’s why I always prefer my patients to go to a medical program because at least I know the products that they’re using are safer to use and less harmful; because they might not have, you know like I said earlier, the adulterants and other kinds of compounds that might be creating more problems.”

“For example, one of my colleagues was part of a team that published a study in the journal of American Medical Association, and they found approximately 80 percent of those over-the-counter CBD products actually weren’t as they were labeled,” Roberts said. “That they had other additives and other kinds of chemicals and the ratios of cannabinoids weren’t exactly what was on the label. So those are some of the issues. This is why [Kim Macleod and Joe Flattery] are working with me is because we are wanting to make sure that patients understand anything you take, if you don’t know where it came from and if you don’t know what the safety data sheets are around that, you don’t know what you’re taking; and any kind of chemical related to cannabinoids can absolutely create change in people and because of my work with vulnerable populations, I’m always concerned about making sure that my patients have access to the safest product possible.”

“This is a very nuanced topic,” Roberts said, “That’s one of the reasons we’re really trying to make sure that people understand the nuances of this topic; and to be clear I’ll give you a great example. I actually knew someone who had come up to me at a conference once talking about the over-the-counter CBD product that she was using. And she had actually started having some sensations in her fingertips, and she had started encountering problems. Long story short, they found that the products she had ordered online had–and I can’t remember the chemical because it was tested; but it was basically neurotoxic to her. So that’s why regulated products, you know preferably we would have that, but I also understand what that means to the consumer. That means they have to go pay for a certification, they have to pay for a medical license, they have to do all of that. So if someone uses products over-the-counter it’s vital for them to understand the safety of that product and to do their own research.”

APR: The medical marijuana law in Alabama requires a doctor’s recommendation. Should the ability to recommend medical marijuana be strictly limited to traditional medical doctors or be expanded to include doctors of osteopathy, chiropractors, podiatrists, and even nurse practitioners?

Roberts: “Well you know D.O.s–Osteopathic doctors are basically the same thing as allopathic positions. They’re all physicians, they all go to medical school and have residencies. So D.O.s and M.D.s are pretty much on the same level as far as licensure goes. So they should automatically be included. If the question is around who can recommend, we have seen success with states where nurse practitioners and PAs have also been allowed to make recommendations. So that’s a fairly standard model that we see around the country. One of the things if you’re asking about chiropractors, if you’re asking about you know other clinicians that aren’t really prescribers, I think that’s a murkier area and it goes back to what the licenses in that State.”

“As far as my understanding goes, in the state of Alabama only PAs, Nurse practitioners, and physicians (whether they are M.D. or D.O.) can prescribe medications,” Roberts said. “So that’s where it makes more sense for the recommendation to get in.”

“The concern I have however–and this goes back to how I started this–is that most physicians, when states become legal or states start having a medical cannabis program, most physicians are not required to learn about cannabis-based medications,” Roberts said. “So they tend to have their own bias and stigma without really understanding the science. This has been one of the reasons we started The Cannabinoid Institute (TCI) was actually like through some research I have done through NYU. I had looked at physicians’ knowledge and attitudes around cannabis and cannabis-based medications; and what we found is that those people who have never personally experienced it–experienced it in any form– tended to have higher stigmatization for that plant rather than people who had had a personal experience. So what that tells us is that stigma is a huge issue. I know this is a huge issue and Alabama. I actually listened to the debates. I’ve been watching this for several years in the state to see what would happen. I teach all over the world for physicians, so I have some understanding of the different nuances here in the US; but also abroad like how different programs work, if they’re successful or not successful.”

“To me the biggest concern I see, and this is something that I would really hope that the state can learn from other states, is that when you have a pharmacist on staff those tend to be the states with the best patient safety records,” Roberts said. “And what I mean by that is that cannabinoids absolutely can create drug-drug interactions. There are certain cannabinoids that if you’re having underlying anxiety conditions you really don’t want to be using that heavy THC variety. You want to be able to use lesser cannabinoids in the medication. Most consumers don’t know that. They don’t understand the nuances of this pharmaceutical. Most physicians, if they do not have the higher level of education around cannabis-based medications they don’t understand it either.”

Roberts added, “In fact, I’ll give you a great example. I had a physician who was I treating, a former veteran with PTSD, and he was using cannabis-based medication. Well he injured his back and his physician had prescribed him Lyrica and an opioid and he wasn’t even taking any opioids prescribed because he didn’t need it. Well once he popped positive on a drug screen, this was a spine specialist, she basically gave him a choice of either staying with her practice or not using cannabis. And it was a legal medical card sanctioned through the state. He was using it appropriately and not abusing it. This was a 70-year old man with a significant PTSD issue and unfortunately, he had to make a choice. And this is where it gets really murky.”

“Physicians, if they don’t really understand the science, they are making judgement calls and it’s almost medical negligence if they don’t really understand the nuances of this medication,” Roberts said. “So this patient wound up backtracking with his trauma, just to be able to get the treatment for his back. So these are really important issues for the state to understand that if they don’t have physician buy-in and they don’t promote physician education around this; this is going to impact patient care. That’s where when I see successful programs and not successful programs. It’s really more about how the patients get impacted.”

APR: Under the Alabama Law, only a physician who has been certified, and received special training, can actually recommend marijuana. How much training should a clinician receive in order to get that authorization?

Roberts: “Absolutely, well so our product we offer physician certification and through The Cannabinoid Institute (TCI); but we offer kind of a continual certification in that we offer 8 hours of CME credit because what we found is that it’s more than about knowing the endocannabinoid system, it’s understanding the pharmacokinetics and pharmacogenetics around cannabis. It’s also important to understand the historical context because most people still–I run into it all the time–they still cite the Gateway Theory as a legitimate science piece and they don’t understand the role that the National Institute on Drug Abuse (NIDA) had in teaching us what cannabis is and what it isn’t. And unfortunately, when you start to get into the history, and really unpack the history around cannabis-based medications, you understand how propaganda really influenced that.”

APR: “One of the issues that came up during the debate is people being impaired by their medical marijuana. Is there a real danger of medical marijuana legalization leading to more impaired drivers on roads of Alabama?

Roberts: “The data really doesn’t support that. It’s interesting because most people–this is something that I know AAA had really lobbied around in Colorado; that drivers are going to be impaired through cannabis usage. And what we know is that these people, if they are given the actual facts, and are taught how to use this medication correctly, they tend to do that. I think we do a disservice when we assume that this is a drug that if you use it once you become completely irrational and intoxicated and want to continue to crave it. Most people use it as they do other medications. When they have the appropriate education and understand how it can impact them.”

“Now I would argue that a lot of those arguments–because like I said I listened to the debates. I was listening what was happening and paying attention to this pretty acutely– is that most of the arguments that I heard put forth, really were based on that propaganda and hysteria and really didn’t have a lot of scientific validity,” Roberts continued. “Are there going to be people who can misuse this medication? Absolutely. We see that with people who misuse alcohol, we see this with people who misuse substances like opioids and benzos, we see that with people who misuse food for example as well. Intoxication is a real issue, but that’s why–again–it’s so important to have logical science driven data to teach people how to use these things correctly and to get away from the stigmatization and getting down to what the true facts are.”

“My family is in Alabama, very very conservative people and they have learned through their own experience the power of cannabis-based medications,” Roberts added. “In treating my eighty-year-old mother who used a 1-to-1 medication after her hip surgery. And she didn’t need the sixty opioids her doctor prescribed to her after her surgery. Sixty. Never had to take it. My sister had surgery yesterday and was released and is using a similar product to try to mitigate that. So what I do know about Alabama citizens is that they are already getting their cannabis, I know of a nurse, when I was visiting my mother after her surgery, who her mother was getting it sent in from California. So it’s happening whether or not the state recognizes this. So it’s important to have a place where people can access this legally, safely, and can also get the education about how to use cannabinoids in the best way possible; while reducing harm, because we don’t want people to use medications without understanding the side effects of these medications. Cannabis, like every pharmaceutical including antidepressants, including you know ibuprofen has side effects, so we have to be able to teach people how to use things safely.”

APR: That’s about all I have, if there’s anything you’d really like to add?

Roberts: “I think that my experience, being from Alabama and having lived there a significant part of my life, is that Alabama has the unique opportunity to learn from what states have done poorly and what states have done right. And I hope that they can invest and focus on educating physicians, the public and getting away from this stigma and really starting to have an honest genuine conversation about how this medication can be used appropriately in a way to help people. I have seen outcomes that have been phenomenal. When I look at trauma and PTSD, the outcomes I’ve seen with my patients who use cannabis-based medications frankly have trumped some of the psychoactive medications and they have been prescribed prior. So it is a medicine that is very helpful for people. We see a lot of elderly using it now because they can use cannabis instead of multiple medications to handle their pain, or their anxiety, or their inability to sleep. We know that it also can play a role in inflammation too. So it’s a really fascinating medication that if it’s used correctly can positively help people.”

Roberts is an advocate for medical marijuana with experience in Holistic Integrative Therapy, EMDR, CBT and life coaching. Roberts is an internationally recognized psychotherapist, educator, and speaker whose approach merges neurobiology, cognitive processing, EMDR, and mindful strategies.  She is the founder of Holistic Integrative Psychotherapy (HIP) a new therapeutic methodology gaining rapid acceptance in the field.

The Alabama Medical Cannabis Commission hopes to have Alabama-grown and -processed medical marijuana available for persons with a demonstrated medical need as early as the fall of 2022. 

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