you so much for taking the time to visit my website. My name is Aury Lor
Holtzman, M.D. I am a physician that has been practicing primary care
medicine in California for almost 25 years. During that time I have also
practiced pain management/addiction medicine, and have discovered the almost
miraculous therapeutic benefits of medical marijuana. Marijuana has so many
alleviating benefits that I have added medical marijuana evaluations to my
general practice. Please take a minute to look over my blogs on medical
marijuana. I have started posting basic information about marijuana as a
remedy and how to medicate with it. I will be posting more blogs on issues
related to treatment with marijuana and specifics on medicating with marijuana
for each disease, illness and medical conditions that it can be used for.
These blogs are my opinions alone, based on my individual observations, while
personally doing almost 10,000 medical marijuana evaluations. If after
reviewing my blogs you would like to schedule an appointment for a medical
marijuana evaluation, please feel free to download our "New Patient
Forms” to fill-out before you come in.
hope I have provided some information that may help or interest you or someone
you know. If I may be of further service in any way, please feel free to call
our office. Thank you, again.
One story is that the term marijuana or marihuana comes from
Spanish slang for, "low quality smoking material or tobacco
substitute.” Over time, marijuana has come to be synonymous with cannabis. A
genus of plants that include several species; the most notable of these are
cannabis sativa and cannabis indica. Cannabis plants contain a family of
chemicals known as cannabinoids, which are responsible for most of the effects
produced by medicating with cannabis. So far, approximately 86 cannabinoids
have been identified in nature and others have been chemically synthesized.
The two main cannabinoids are THC (delta-9-tetrahydrocannabinol) and CBD (cannabidiol).
There are lesser amounts of other active cannabinoids including: CBN (cannabinol),
THCV, CBG CBC, CBL, CBT, and cannabielsoin.
human body contains a class of neurotransmitters referred to as
endocannabinoids, which exert their effects by interacting with the body's
endocannabinoid/cannabinoid receptors. The naturally occurring cannabinoids in
live cannabis plants have very minimal effects on these receptors. These
cannabinoids can be converted to their active forms by heating and drying the
plant. That is why medicating with cannabis involves some form of heating
dried cannabis plant material. Once plant cannabinoids are activated, they are
able to exert efforts on the human body's endocannabinoid/cannabinoid
receptors. The cannabinoid (CB) receptors are not completely understood, but
it is known that there are two main types. CB1 receptors are found in the
brain and are responsible for the psychoactive effects produced by cannabis.
The CB2 receptors are found in the extremities and immune tissues and are
involved with some of the other more purely "medical” effects of
medication is right for me?
medicating with cannabis, you will have to choose which type of cannabis would
be best for your specific needs. The more you know about cannabis, the better
you will be able to medicate effectively. Cannabis is a genus of plants and
the two main medical species, cannabis indica (Indica) and cannabis sativa
(Sativa) were originally two very different naturalized breeds from different
parts of the world. People who know me know that I'm a dog lover and I like
the analogy of dogs and wolves. Dogs and wolves are both canines but they're
different animals. Indica and Sativa are both cannabis, but they're different
plants which have completely different effects. There are a lot of criteria
people use to differentiate between Indicas and Sativas.
think the best way to divide cannabis is based on cannabinoid content. Sativas
have high THC content and the effects of medicating with Sativas are mostly
due to THC. Indicas have relatively higher cannabidiol levels and the medical
effects of Indicas are mostly related to the cannabidiol. Sativas act like
stimulants. The high THC (tetrahydrocannabinol) tends to stimulate the
thoughts, activate the mind, and mildly alter perception. Patients choose to
medicate with Sativas for pure lethargic depression, where they want a mental
stimulant to help uplift their thoughts. I always caution patients with
depression to be on guard for suicidal thoughts. I feel that everyone with
depression, whether they medicate with cannabis or other antidepressant, needs
a good support system, family, friends, or therapist or psychiatrist that they
can call day or night for suicidal ideations. In my professional opinion,
not increase suicide risk.
other patients that tend to choose medicating with Sativa are those who suffer
from ADD or ADHD. Most report that Sativas tend to give them a reverse effect;
instead of being stimulated, they feel calm. Just like with other stimulants
such as Ritalin or Adderall, which calm them down, Sativas have a similar
effect, without the loss of appetite. I always caution patients who medicate
with cannabis for ADD or ADHD that they should never drive or do dangerous
tasks while they are medicating.
who I advise not to medicate with Sativas are anyone who suffers from anxiety
disorder or bipolar disorder. Sativas make anxiety worse and can destabilize
bipolar disorder. In addition, Sativas might also make insomnia worse. Anyone
who does not tolerate stimulants should not medicate with Sativas.
patients I see choose to medicate with Indicas. The higher cannabidiol (CBD)
levels are a strong sedative. Indicas relieve anxiety, pain, and cause
sedation, which helps you to sleep. Indicas are used at night for pain where
morphine or oxycodone might be used, or where high doses of Xanax or Valium
might be used for anxiety. Overall, Indicas help you sleep.
with pain or anxiety who wants to relax and sleep should choose an Indica. For
nighttime medicating, you should always choose Indicas. Indicas have two
separate effects: 1. The sleep effect. 2. The body numbness effect. These two
effects are separate and vary depending upon the strain of Indica. The sleep
effect can knock you out, help you sleep, make you drowsy or just relaxed. The
body numbness is for pain control. It can go from completely numb, where you
can't feel your body at all, to just a little pain relief and no numbness. I
recommend that patients keep notes on which Indica strains they use to
medicate and what the effects were so they can learn which strains work for
them (i.e. how much sleep effect and how much body numbness). If I can use my
dog analogy, there are as many strains of Indica as there are breeds of dogs.
Indicas vary as much as dog breeds from Chihuahua to St. Bernard.
make anxiety worse and don't take away pain but Indicas help you sleep, so how
can you medicate for pain or anxiety during the day? Let me first state that
it is very difficult to medicate with cannabis during the day. If you are
medicated you are impaired and cannot drive. If you have to medicate during
the day for pain or anxiety, a hybrid is recommended. Hybrids are made by
breeding an Indica and a Sativa. What you try to do is get pain control and
anxiety control from the Indica with less sedation and use the Sativa
stimulation to counter the residual Indica sedation. If a 50/50 Indica/Sativa
hybrid does not give enough pain or anxiety control, you can move to an Indica
dominant hybrid. The more Indica leads to more symptom control, but also more
sedation. If a 50/50 hybrid is too sedating, you can move to a Sativa dominant
hybrid. The more Sativa, the less sedation and more stimulation (except for
people with ADD who get reverse effects) and the less symptom control. Hybrids
are used where a Tylenol with Codeine, Vicodin, or low dose Xanax or Valium
might be used. You're impaired but not asleep.
To sum this all up, you have a lot of choices with cannabis. Usually
Indicas are used for nighttime medication. If having difficulty medicating
during the day, you should try a Sativa or hybrid. If you choose a hybrid,
you can go from 50/50 Indica/Sativa to almost pure Indica, or the opposite
of the spectrum that's almost pure Sativa. One last thing: cannabis is like
any other medication - it is not for everyone. A lot of people benefit from
it, but for some people, it is not the right medicine for them.
2011 Aury Lor Holtzman MD
matter what form of consumption you choose, while treating with cannabis, you
are impaired, "under the influence” and can't drive, operate machinery
or participate in hazardous activities. With all forms of medicating, the same
general rules apply regarding indicas and sativas. Indicas are for anxiety,
pain, and insomnia at night because they help you sleep. Sativas are
stimulants; they wake you up, and should only be used during the day. Hybrids
are used if you have to medicate for anxiety or pain during the day. You will
be impaired, but not asleep. Smoking is only one of many ways to medicate with
cannabis and I advise patients against smoking as a form of medicating. Any
form of smoking (i.e. joint, blunt, pipe, bong, water pipe), still exposes the
body to smoke and we all know that smoke is harmful. I always advise patients
to consider vaporizing, instead of smoking. A vaporizer is a machine that
heats the cannabis to a temperature that causes the resin, which contains the
medically active cannabinoids (THC, CBD, etc.), to evaporate out and turn to
vapor. The vapor is then inhaled without any smoke. The vaporizers heat the
cannabis to below the point of combustion, around 356-392°F (180-200°C).
This vapor is cleaner, healthier, and has much less smell. In addition, once
you have vaporized consistently, you will find that each strain has a unique
& distinctive flavor. Because smoking burns the marijuana, much of the
taste is lost. You may even find yourself selecting strains simply due to your
specific flavor preferences.
always advise patients to do as much research buying a vaporizer as they would
on buying a car. A good vaporizer usually will cost at least $150-$400. It is
always best to get a vaporizer that has no knobs, dials or displays. These
features may look cool, but no one wants to mess with these at the end of the
day. Most patients just want to grind their cannabis to increase its surface
area, place the ground cannabis into the filling chamber, then plug-in their
vaporizer, turn it on, let it heat to the factory setting, and then medicate
with no hassles. With a good vaporizer, you should feel much greater effects
from your usual cannabis dose. A good vaporizer will provide 80% of the
contained cannabinoids as vapor to be inhaled, while smoking only provides
50%. The reason for this difference is that with smoking, some of the
cannabinoids (resin) are destroyed by the fire and some are lost to
side-stream smoke. The bottom line is this: If you don't get more effects from
the vaporizer then from smoking, with the same dose of marijuana/cannabis,
then the vaporizer is no good and/or not set right.
you switch from smoking to vaporizing, don't be surprised if you notice a lot
of coughing. Cannabinoids are good bronchodilators. As your lungs open-up, all
the carbon and other products of combustion that have collected in your lungs
over time from smoking, will rattle around and your body's natural response is
to cough-up this toxic, foreign material to clear it out. Just drink more
water, and if you want, breathe some steam and your lungs will clear with
time, and you will feel overall much better. With smoking or vaporizing,
naturally occurring inactive cannabinoids are absorbed through the lungs, into
the blood, and the blood goes directly to the brain. New cannabis patients may
not feel the effects the first few times they medicate. Sometimes for Veteran
patients, the effects from smoking or vaporizing are immediate. The dose can
be adjusted by the patient and the effects peak in around 15 minutes, and the
effects last about 3-4 hours. This is usually perfect for patients who are
medicating for insomnia due to anxiety or difficulty sleeping due to pain.
Most patients who medicate with an Indica at night for sleep related problems
can get a good night's sleep and wake up feeling refreshed, with no hang-over
or residual effects.
most patients, vaporizing with cannabis is sufficient to get them through the
night. Some patients have conditions, like pain, that are so severe that when
the cannabis wears off, the patients are woken up and unable to sleep due to
the pain. There is no way to make the effects of smoked or vaporized cannabis
last longer, so these patients are advised to try other forms of medicating,
like sublingual or edibles.
for sublingual medicating is often prepared in alcohol or glycerin based
tinctures or dissolvable strips. The medication is placed and held under the
tongue so it can be absorbed into the blood vessel under the tongue. From
under the tongue, it is transported to the brain. It takes about 15-30 minutes
for the medication to take effect; it peaks in around 1 hour, and lasts
approximately 6 hours. Patients can medicate with a Cannabis Indica 30-60
minutes before bed, and if the dose is accurate, the patient should get about
6 hours of pain control and sleep. If 6 hours of pain control is not enough, I
advise patients to consider edibles. Edible cannabis comes in every form
imaginable, from butter to brownies, cakes and candies. Special tea bags
dipped in cannabis solution are also sold to make tea from. Tea made out of
just cannabis in hot water does not work the same because most of the
cannabinoids are not water soluble.
is very important to understand that when medicating with cannabis by an
edible route, the onset of effects are delayed from 30 minutes up to 3 hours,
depending on how much food is in the stomach. The cannabis has to be digested,
and then it is transferred to the liver where it is metabolized. The cannabis
that leaves the liver into the blood stream has processed forms that are
different than the cannabinoids that are absorbed through the lungs and under
the tongue. Cannabinoids processed by the liver are active much longer and
also produce effects that are felt a little differently for patients that need
longer acting pain control at night. I recommend that they medicate with
edible Cannabis Indica during or after dinner (at or around 6:00pm). If dosed
correctly, patients should feel effects by around 9:00pm and fall asleep by
10:00pm. They should be able to sleep 7 – 9 hours and wake up with minimal
to no hang-over.
reason why I keep harping on correct dosing is that with edibles and
sublinguals, once the dose goes in, you're stuck with it. You just have to
ride it out. Every day I hear horror stories of patients who ate a brownie
that their friend made and it was "nothing”. Then the patients buy a
brownie at a collective/dispensary and without checking the dose, the patient
eats the whole brownie at bedtime. They wake up with nausea, diarrhea,
dizziness, hung-over and sometimes hallucinations. Since a lot of brownies are
8 (eight) doses, this bad experience can last up to 3 days. If they are
unlucky enough to have eaten a Cannabis Sativa, you can add agitation,
paranoia and possibly psychosis to the experience. It is extremely important
to know the dosing on edibles and sublinguals. After you are sure you know the
proper dose, take only ˝ of the calculated dose. Make sure you don't have to
drive the next day. If it's for nighttime, make sure it is a Cannabis Indica.
For sublinguals, medicate 30–60 minutes before bedtime, and take with
dinner. If by bedtime you are not falling asleep, you can add a hit of Indica
smoke or vapor. If you're not feeling any hang-over effects in the morning,
then you know the prior dose was not too high and you can increase the dose.
Once you have determined your correct dose for edibles and sublinguals, you
have the option of medication with edibles some days and sublinguals or
vaporizers other days.
determine the proper edible dose for you, collect as much information as
possible before medicating. Read the package and see what the recommended dose
is. Then ask everyone until you find someone who is familiar with the dosing
of the product you are considering for medication. Dosing varies greatly from
one company to the next, including variances between specific products. Some
companies put "X's” to indicate strength, ranging from 1X to 50X.
Generally, the more "X's” the stronger the edible, but every baker and
batch is different. There is no standard. For example, "2X” does not
mean that it is twice as strong as "1X” and "10X” is not twice
as strong as "5X.” The strength of edible is directly related to the
part of the plant that is used to create the edible. In general, edibles made
with concentrates (hash) are more potent than edibles made with bud, which in
turn are more potent than products made with trim. Edibles made with
concentrates (hash) tend to be more potent/stronger than ones made with
marijuana butter. The bottom line is you have to ask and know your dose before
medicating with edibles. Once you're sure you know the right dose, cut it in
half because you are probably wrong and there is always tomorrow when you can
raise the dose. I recommend you don't take any more edible until the next day.
You can always add some smoke or vapor if needed. Also, when you medicate with
a new edible product, make sure you don't have to drive the next morning, just
in case you are hung-over.
edible companies produce products that are fairly standardized, so once you
are very familiar with a product you may become comfortable. However, other
companies are not so well standardized. Until you know the company very well,
be careful because the "2X” brownie you buy one day from a company may
not be the same potency as the "2X” dose brownie you get the next time
from the same company. Remember to use caution every time you dose with each
Medical Cannabis comes in many forms from ointments to oils, lotions to
alcohol solutions. Topical Cannabis in alcohol solutions is an old home remedy
in many areas of Mexico. I always suggest that patients place a small amount
of topical medication on their forearm and leave it for 2 hours to make sure
you don't react to anything in the medication before you put it all over.
Topicals seem to work the best for small joints like the hands and pains close
to the surface. Pick the right base for the job. Alcohol is drying, oils are
oily, and ointments are sticky. Some patients with arthritis in hands may rub
oil on joints then put cotton gloves over at night. Topical Cannabis should
only have topical analgesic effects. There should be no sedation on the
central nervous system. Many patients medicate with cannabis topically during
the day, in addition to other forms of medication at night.
As you can see, medicinal cannabis is a very versatile, feasible
medication. You are only limited by your knowledge and your imagination. If
you go to Resources on my website, you will find links to websites for
cannabis books, if you desire to expand your knowledge.
2011 Aury Lor Holtzman MD