AURY LOR HOLTZMAN, M.D.
 #1 RECOMMENDED So. Calif. MARIJUANA DOCTOR

Medical marijuana can be very effective in controlling your symptoms if used correctly. The more you know the more likely you will be able to medicate effectively. Review my blogs

 
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Welcome

Thank 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.

I 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.

Marijuana 101

What is marijuana? 

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.

The 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 cannabis.

Which medication is right for me?

When 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.

I 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, Cannabis does not increase suicide risk.

The 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.

Patients 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.

Most 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.

Anyone 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.

Sativas 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

How to Medicate

No 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.

I 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.

When 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.

For 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.

Cannabis 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.

It 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.

The 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.

To 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.

Some 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 edible.

Topical 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