Have you heard about using cannabis as medicine? Does that thought intrigue you? Or maybe it scares you.
When it comes to cannabis use (or really any medication) it’s important to get the facts before you try it.
In today’s article, we have the privilege of interviewing Dr. Lori Zucker, PT, DPT, MA.
About Dr. Lori Zucker, PT, DPT, MA
Dr. Zucker is an adjunct faculty member at Rutgers University, a cannabis educator and co-owner of YogiAnatomy.
In addition to teaching, Dr. Zucker is chiefly a clinician. She owns a private practice in Livingston, NJ where she sees patients one on one using integrative and life-style medicine techniques in addition to standard physical therapy practice.
She has also had the great good fortune to be an invited speaker for the California APTA on the subject of cannabis, for the APTA Combined Sections conference on the subject of cannabis, and
for several Podcasts focused on cannabis.
Read below to learn more from Dr. Zucker, as she helps enlighten us and debunk some misconceptions about cannabis.
1. Please tell us about yourself. What’s your background and
how did you develop PTCannabisinfo.com?
My business partner (Ellen Anderson) and I developed a continuing education business to teach integrating yoga into physical therapy practice (YogiAnatomy).
We found that we very much enjoyed teaching healthcare professionals something
that could enhance their clinical practice.
About 5 years ago we noticed that legal cannabis use was gaining momentum across
the country. At that time it was primarily medical marijuana.
Nothing about marijuana was being taught in schools, there was very little access to scientific information for healthcare practitioners so we decided to form PTCannabisinfo to educate healthcare professionals on the subject of cannabis.
We have a website focused on education including basic terminology, distilling some scientific findings, and explaining the differences between cannabinoids. We also have an Instagram account for the same purpose. We teach some continuing education workshops and partner with other cannabis educators to bring this information into the mainstream.
2. Let’s start with some basics, why do you teach about
cannabis?
To me, teaching and providing information about cannabis has several purposes.
As a clinician, we all know that pharmaceuticals come with side effects that some of our patients
can’t tolerate. We all know that at times, the medical profession runs out of pharmaceutical or surgical options for some of our patients.
Cannabis can be an option for these patients when there is nothing left in the pharmaceutical or surgical bag of tricks.
As a clinician, my focus is on problem solving, partnering with my patient to find reasonable, safe, tolerable, and affordable solutions for their complaints/issues.
Cannabis isn’t usually my first suggestion but it is definitely one of the options I’m willing to discuss.
I have many examples but here is one:
My friend and patient is 88 years old. He has a hip replacement, 2 knee replacements, and spinal stenosis.
He’s a practicing attorney and likes to be very active. He played tennis and golf until his stenosis interfered with his ability to walk even a few blocks without pain. I sent him to 2 different pain management doctors who tried epidurals and facet injections without much success.
Nobody will operate on him given the nature of the surgery. Acupuncture didn’t help, pharmaceutical medications were tried with little success.
That was when I talked to him about the possibility of trying cannabis.
In his case, 2.5 mg of THC with the goal of decreasing pain. He began taking one 2.5 mg mint of THC in the morning with very positive results.
About 6 months later he added a second 2.5 mg mint in the afternoon. Today, he can go on vacation, walk for about ½ mile, dance at his grandchild’s wedding and manage his symptoms.
3. Let’s talk a little bit about the stigma and history of cannabis use
Another goal of mine in teaching about cannabis is to debunk the stigma of cannabis as a gateway drug and the “just say no” campaign to malign cannabis.
The history of cannabis as a medicine begins in ancient times, traverses through the 1800s, where cannabis was found to be useful as an alternative to opium, and into the 20th century.
In the early to mid 1900s, while cannabis was still a viable and accepted medicine in the United States pharmacopeia, political forces moved to label cannabis as marijuana (originally Marihuana), a dangerous drug infiltrating the US from refugees from the Mexican revolution.
Research consistently demonstrated that cannabis is not a gateway drug, it is a useful medicine and yet politicians swayed public opinion to be fearful and distrustful of cannabis as medicine.
Teaching healthcare professionals and providing a website for interested people can begin to break down prejudices.
4. What medicinal purposes does cannabis serve?
This is a great question and one that is not easily answered based on the available research.
Remember, with cannabis being federally illegal, it is harder for scientists to do the most stringent and therefore the best types of research on cannabis.
Most of the research comes out of Canada, Israel or other European countries where cannabis research was legal.
To date, the science tilts in favor of cannabis for pain control, sleep, nausea caused by chemotherapy medications, increased appetite, and seizures from some severe childhood disorders.
There are many studies looking at cannabis on a cellular level (in a laboratory) for all manner of diagnoses and patient complaints.
Scientists are looking at how different cannabinoids (the various chemical components of the cannabis plant) interact with known receptor sites in our bodies.
From this data, there is speculation on how cannabis might be able to help things as varied as cancer cell genesis, cognition, bone growth, cell regeneration/healing, neurologic pain, inflammation, etc, etc.
While the research is promising in many areas, it’s not always reliable to demonstrate something at a cellular level or in an animal model and then transfer those findings to us.
The majority of my patients seeking cannabis are trying to help themselves with sleep, pain, anxiety, and stress.
5. How does this topic pertain to older adults?
This is another good question. I suppose it depends on what age you consider older adults.
For anyone who was a teenager in the ’60s and ’70s, cannabis is likely to be familiar.
At that time, smoked marijuana was probably about 12% THC. Somebody remembering back to their earlier years might make a mistake and think that smoking a joint today is just like the “old” days.
This would be a mistake. Today’s joints are far more potent, anywhere from 18% to 28% THC (sometimes more) which means that each puff contains much more of the intoxicating cannabinoid, THC, than in the ’60s and ’70s.
Medicinally, cannabis may prove to be a very useful medication for older adults.
I’ve had patients who struggle with sleep but no longer are candidates for typical sleep aids like Klonopin, Ambien, Lunestra, Trazadone, etc.
These pharmaceutical medications all come with side effects that may not be helpful and they are often difficult to get prescriptions.
Small amounts of THC (2.5 mg) in combination with CBD and/or CBN might be a better option for older adults to facilitate sleep.
THC (delta-9 tetrahydrocannabinol), CBD (cannabidiol) and CBN (cannabinol) that come directly from the plant are naturally occurring chemicals as versus synthetic chemicals. Many people prefer to take something that is naturally occurring as versus another pharmaceutical.
This doesn’t mean that THC, CBD, and CBN don’t also have side effects or impact our systems, it’s that with legal cannabis use, a person can choose an over the counter use of cannabis as versus getting a prescription for a pharmaceutical.
In an older population, arthritic pain, stiffness, and sleep issues are not uncommon. Cannabis might be a useful option for these types of symptoms.
6. There is a lot of talk about THC versus CBD, can you talk a little about each and describe the roles they play in medicinal cannabis use?
THC – tetrahydrocannabinol
This is the intoxicating cannabinoid (ingredient) in the cannabis plant.
It’s chemical make up is very similar to our own endogenous neurotransmitter Anandamide (first discovered in 1991-1992).
Anandamide and THC (distilled and discovered as an active ingredient in cannabis in 1964) appear to interact with the same receptor within our bodies.
Anandamide was named by one of the researchers who discovered it within our bodies. He chose to use the Sanskrit word Ananda, meaning bliss.
He was a yogi and understood that THC and the neurotransmitter he discovered often help people to feel euphoric and blissful. He added the “-mide” because this is a typical ending for chemicals within our body.
Sometimes people use the word “psychoactive” for THC, but keep in mind that the other cannabinoids in cannabis might also impact the brain such that they are also psychoactive, just not intoxicating.
THC used at very low levels (1 mg, 2.5 mg, or even 5 mg) might not cause intoxicating effects for most users, but levels of 7.5 mg, 10 mg or higher almost always have some intoxicating effects.
A person can become accustomed to ingesting THC and therefore require higher doses to get the same effect.
THC is illegal federally and still considered a schedule 1 drug by the Federal Government.
In the 1970s, during the Nixon administration, many drugs were placed into a scheduling system
to connote their addictiveness, use, etc.
There are 5 levels.
Schedule 1 drugs are considered to be highly addictive with no known medicinal properties and high potential for abuse.
Marijuana was placed in schedule 1 alongside Heroin, Ecstasy, LSD, etc. despite the long-known history that cannabis had a low potential for abuse as compared to alcohol (and other drugs) and
was used for centuries as a medicine.
THC is legal within each state that has legislation allowing it to be used either through a medical marijuana program or through recreational marijuana.
In each state there are different rules and regulations. THC is not legally allowed to be sold or
transported across state lines given that once you cross state lines, you’ve entered into federal jurisdiction.
What this means for a our patients is that if they are using cannabis legally in their state but go on vacation, it is essentially illegal for the person to travel with their cannabis medication.
Additionally, if a patient purchases a product that works for them but the price in their dispensary is much higher than in a different state, it is impossible to order the same product from a dispensary in another state. Mailing something also falls into the federal domain and it remains illegal for THC products to be mailed.
Another concern with federal legality is that the purchase of cannabis cannot be made with a credit card.
Most credit cards are federal as they exist in many states. As such, a cannabis dispensary cannot use the credit card system for payment as Federally mandated banks can’t support something that is
considered illegal.
This means that our patients have to have cash to purchase their cannabis, even if it’s for medicinal use.
There are some state banks, within a state where cannabis is legal, that are beginning to allow credit use for cannabis but the vast majority of people have credit cards that aren’t issued by a
bank that is only local within one state.
CBD – Cannabidiol.
CBD is the other most common cannabinoid in a cannabis plant.
It is non-intoxicating but there are receptors for CBD in our brain so some people do consider it
psychoactive.
CBD became Federally legal after the 2018 Farm Bill was passed in December of 2018.
This bill corrected a problem that occurred after the 1937 marijuana tax act.
Prior to that time, people regularly grew cannabis plants. Within the cannabis family you have marijuana plants and hemp plants.
Hemp is part of the cannabis family of plants and has been grown in this country since settlers arrived.
In fact, hemp was a required plant for all growers in the early days of the colonies due to it’s many, many uses ranging from animal feed, hemp for sails, oil, paper, industrial additives, soap, etc.
After the 1937 marijuana tax act, the use of cannabis as medicine began to decline. Cannabis was still legal and it was included in the US pharmacopeia but the purchase of cannabis medicines was
highly taxed both for the pharmacy to carry it and for the individual to purchase it.
With the added expense, cannabis fell out of favor.
By the 1950’s cannabis came out of the US pharmacopeia and when marijuana was placed as a schedule 1 drug (1970), hemp was suddenly illegal to grow.
Any hemp seeds, hemp candles, hemp paper, hemp clothing, etc found in the US after the controlled substances act went into effect were produced in Canada or other countries and imported.
The Farm bill of 2018, separated hemp plants from schedule 1 status, thus allowing farmers to grow hemp legally in the United States.
The definition of a hemp plant is a plant in the cannabis family that has no more than 0.3% THC.
Anything over that amount of THC is considered marijuana and would not be legal federally. So, growers can now plant, cultivate and harvest hemp plants that express CBD and other cannabinoids provided there is less than 0.3% THC.
It is legal to manufacture products with CBD and the other cannabinoids, it is legal to sell these products across state lines, it is legal to travel with them and it is legal to imbed CBD or other cannabinoids into already existing products.
This is why we are suddenly, in the last 3 to 4 years seeing CBD infused water, CBD infused lotions, shampoos, lip gloss, soft drinks, etc.
There is almost no research on this kind of use for CBD and I typically tell my patients not to spend any additional money for a CBD infused product in the hopes of having some symptom relief.
There are CBD lotions, creams, gummies, joints, etc that can have medicinal impact but these products should be made by reputable businesses that provide detailed labeling and certificates of analysis (COA).
The COA will tell a consumer exactly what is in the product they are purchasing including cannabinoid profile, any heavy metals, pesticides, etc.
Remember, cannabis coming from a plant is a botanical. Botanicals tend to pick up whatever is in the soil or surrounding areas. Somebody taking a botanical or plant-based medicine would want to make sure that it is safe from pesticides, etc.
CBD research is limited but patients typically use CBD for anxiety and stress, sleep, healing, pain and inflammation.
CBN – cannabinol
CBN is a very interesting cannabinoid. The name cannabinol is also part of THC, delta-9 tetrahydrocannabinol. This let’s you know that these 2 cannabinoids are related in some fashion.
As it turns out, a typical cannabis plant has very little CBN expressed naturally. CBN is produced when THC gets a little old and dried out. The fresh THC is exposed to the air and oxidizes over time.
As that oxidization occurs, the THC becomes CBN. (Growers are now using plant husbandry and other procedures to grow plants that express much more CBN but it’s still a tiny portion of the plant).
So, CBN is thought to have many of the medicinal properties of THC with very little intoxicating impact. This is why sleep products often include some CBN to help facilitate sleep without
needing as much THC and risking the intoxicating effects of the THC.
CBG – Cannabigerol
This is another cannabinoid that is being commercially promoted. It is legal to sell products with CBG as it too can be produced from hemp plants with little to no impact of THC.
Cannabigerol is often known as the “mother” cannabinoid. It is present in the early stages of growth of a cannabis plant.
Depending on which chemicals are present in the plant, the CBG will differentiate into THC or CBD
precursors. Some commercial companies are selling CBG products and making health claims given that it’s the “mother.”
There is very little research on the health benefit of CBG as it is often found in very small amounts and it is expensive to extract for research purposes.
A cannabis plant produces acidic versions of THC, CBD, etc in the form of THCa, CBDa, etc. If you picked a cannabis leaf off a plant and ate it, nothing much would happen because you are eating the THCa version of THC and it’s not active.
There may be medicinal benefits to these cannabinoids but you won’t get intoxicated or high from THCa.
There must be a source of heat to convert THCa to THC or CBDa to CBD. In ancient times teas, smoking or steam was used. Today we have many ways of inhaling cannabis.
7. Is cannabis only consumed through smoking?
Smoking is not the only mode of administration for cannabis.
Smoking is the most common but in recent years many other means of ingestion have emerged.
Smoking, vaping, bongs, and other inhalation methods generally afford a quicker way for the cannabis to be introduced in the body and the effects are usually quicker onset and quicker to
leave the body.
The cannabinoids enter the blood stream through the lungs.
Generally you can expect onset of effect for an inhaled product to be 15 minutes or less. The maximum impact of the cannabinoid will usually be about 45 minutes and then it will begin to fade away.
Edibles include gummies, chocolates, mints, popcorn, cookies, taffy, etc, etc. are chewed and swallowed. This means that any edible is processed through the digestive system.
The cannabinoids enter the blood stream through the digestive system. The onset of effect is considerably slower, typically 45 minutes to 2 hours, depending on what was eaten, what’s in your
stomach and how fast you personally digest things.
Any THC product that moves through our digestive system goes through a degradation process such that delta-9 THC becomes 11-hydroxy THC.
11-hydroxy is more potent than delta 9 THC so the intoxicating impact can be much greater and/or less predictable than smoking.
The impact of edibles can last for several hours after ingestion (and onset of effect) depending on what was eaten and how many milligrams were ingested.
From a medicinal standpoint, this might be desirable for longer lasting pain impact or even to facilitate sleep through a long night.
Edibles have no odor and are very portable.
Cannabis is lipophilic, it likes fats, for digestion. So, edibles like chocolate, cookies, and other
products with fats are digested more easily than products that have less fat.
The fat content can impact onset of effect and digestion.
Edibles can be THC alone in varying milligram doses, THC and CBD combines in various doses, CBD alone in various doses and/or a combination of cannabinoids including CBN.
Tinctures are another way to ingest cannabis.
These are typically oil based liquids that are placed under the tongue and are absorbed into the blood stream by the extensive blood supply in the mouth.
Onset is typically anywhere from 15 minutes to 45 minutes and the impact is longer than inhalation but shorter than edibles, usually about 2 hours or so.
Tinctures are easily titrated (provided a person has the physical ability to manage the dropper) to the smallest amounts as a person can use a single drop, a full dropper or partial dropper full.
Tinctures can come in all degrees of dosages and combination of cannabinoids.
Medicinally tinctures can be attractive as the onset is faster than edibles but a person doesn’t have to inhale or smoke.
Tinctures are portable and don’t have the same odor that smoking or vaping has.
Patches are available for both recreational and medicinal purposes.
Patches are typically applied to the body in a place that has a good blood supply, often on the inside of the arm or thigh.
The active ingredients, in this case THC and/or CBD, enter the blood stream through osmosis through the skin.
Onset is uncertain, dosing is variable and length of effect depends on how long the patch is worn and the skin conditions.
Patches might be a good option for a person who is having trouble with swallowing and someone who isn’t a candidate for smoking.
Lotions and creams are typically applied over an area of pain or stiffness to relieve a symptom. The efficacy is questionable based on the research but many, many patients find relief of arthritic joint pain or muscle pain with the local application of CBD, THC or THC/CBD creams.
If THC is an ingredient in the lotion or cream it must be purchased through a dispensary, as it would still be federally illegal.
It is highly unlikely that an application of THC in a lotion or cream applied to a body part would cause intoxicating effects.
Suppositories are typically used in circumstances were other forms of ingestion aren’t possible. They are not known to be used recreationally.
There is little information regarding time to onset of effects and length of effect in the literature.
8. While many people have heard of cannabis being used for medicinal purposes, there are also adverse health risks/side effects that are associated with cannabis (impacting cognitive function, anxiety, etc.). Is cannabis truly a safe drug to take?
The adage regarding cannabis is, “start low, go slow, stay low”
When using cannabis as medicine (this differs from the group of people who want to use cannabis in place of a glass of wine or a drink – essentially to feel good or get high) it is always good to use the least effective dose to manage symptoms.
There are several research papers that discuss protocols for pain in addition to practitioner expertise.
Based on this article, the practitioner will likely start with CBD for a few days and assess the impact.
If the impact is not yet satisfactory but there are no unpleasant side effects, the dosage of CBD might be increased.
If there is some improvement but not enough, THC might be added.
The person guiding the patient might suggest adding anywhere from 1 mg of THC to 2.5 mg of THC every 3 days until the patient is satisfied with the results. (Bhaskar, et. al, 2021.)
Much like any medication, cannabis has some side effects, some contraindications, and some considerations for everyone.
For older adults, it might be even more meaningful to know about some of these given that there may be some medical conditions requiring other forms of medication.
We’ve already mentioned many times that THC can have intoxicating effects which include dizziness, balance impairment, lightheadedness, etc.
Euphoria may be a desired effect but if it comes with balance issues a person might not care for that.
THC might also cause some mouth dryness. If combined with other medications that cause dry mouth, THC might not be tolerated.
See info graphic below by Caroline McCallum.
The adverse effects are shown for THC in the most left hand column showing the
most common, common, and rare. You can also see in this box the adverse effects for a THC/CBD combination.
These you’ll see are not particularly concerning. This is because CBD will attenuate the effects of THC so a person who is struggling with THC might add some CBD and experience less side effects.
There are many things that fall into the category of considerations for cannabis use.
For older adults, it makes sense to consider all factors and then make an informed decision.
That being said, (older age) is not a frank contraindication.
Below is a list of circumstances in which cannabis would be considered a contraindication. Relative contraindications would also be appropriate for people under the age of 25 and those with previous substance abuse disorders. These are relative contraindications because there are some circumstances where it is appropriate to use cannabis for people under the age of 25 (cancer, severe spasms, etc.).
9. Is cannabis suitable for everyone?
There is no medication that’s suitable for everyone.
This is a concern with the commercial promoting of CBD.
Putting CBD into your ice cream, water and other products may result in a person ingesting too much CBD inadvertently.
We know from the research on children with epilepsy that high doses of CBD (In excess of 200 mg per kilogram of body weight – for a typical 75 kg adult a person would have to be ingesting 15,00 mg of CBD) can cause liver issues.
While these are very high doses of CBD and it would be unusual for a person to take this much, somebody could make a mistake if CBD is added to multiple drinks, foods, and desserts throughout the day.
The real issue with cannabis is this: thinking about cannabis as medicine, what other medicine was voted on by the general public to legalize? What other medication was legalized by a State legislature?
Our drugs, both prescription and over the counter, are FDA approved and monitored. But not so with cannabis.
So, you can add CBD to your morning coffee. If you are using CBD to help with some anxiety, would you add a little Ativan to your morning coffee?
We need to reconsider how cannabis is being used as medicine.
10. Which providers can a client ask about cannabis? Which providers can prescribe cannabis?
Nobody prescribes medicinal marijuana at the present time. Medical professionals, mostly MDs, certify that a person is eligible for medical marijuana in a given state. Each state has their own list of medical issues that qualify for a medical marijuana card.
The doctor certifies that you have one of those conditions and you are eligible.
Thereafter, the doctor doesn’t necessarily discuss dosing, how to get the cannabis, products, etc.
There are some doctors who are more knowledgeable but often a person takes that medical marijuana card and goes to a dispensary where a budtender helps a person choose a product.
If somebody lives in a state where there is recreational marijuana, you can simply go into the dispensary and purchase cannabis much like an over the counter medication.
This being said, in the US there are a few THC pharmaceuticals that can be prescribed by a physician and will be reimbursed by insurance.
Marinol is a synthetic THC product that has been on the market for at least 20 years.
It’s a THC concentrate that does not come from a plant, it is made in a pharmaceutical lab.
There is dronabinol and syndros, also THC products made by pharmaceutical companies, FDA approved and reimbursable by insurance.
Epidiolex is a plant based CBD product that is now FDA approved for childhood seizures.It too is physician prescribed and insurance covered.
It is the only botanical cannabis product FDA approved in the US.
There is another product under consideration by the FDA called Sativex.
It is already available as an approved medication in Canada, Europe and other countries.
Sativex is a 1:1 THC:CBD product made by GW Pharma. The FDA is very slow to approve it given the data coming out from all the other countries.
11. Is there anything else you would like to tell readers about cannabis and the work you do at PTCannabisInfo.com?
I would like to make a distinction between medical marijuana, recreational marijuana and adult use marijuana.
We prefer the term cannabis to marijuana as marijuana has its roots in racism but sometimes it’s easier to use the more familiar terminology.
MMJ, medical cannabis is just that.
A person is certified to have a medical condition that allows them to have a medical cannabis card.
This often allows a person to pay reduced taxes on whatever they purchase and have access to higher doses or more product than a person who comes into a dispensary without a medical card.
Recreational marijuana is for those who simply want to go out and party, have a good time, and get high. No judgment here – cannabis is being used much like alcohol.
Adult use is the term we like to use for people who have symptoms they are trying to manage much like a person who purchases over the counter like Tylenol, ibuprofen, Salon patches, Lidocaine patches, etc.
Adult use refers to people with symptoms using cannabis to help heal.
Thank you so much to our guest, Dr. Lori Zucker, PT, DPT, MA for answering our questions about cannabis! Remember to check out her website HERE for even more information!
Have the Strength to Live Life to the Fullest!
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Disclaimer: The views and opinions expressed in this article are those of the interviewed guest and do not necessarily reflect the views or positions of TheSeniorCenteredPT.com.
This was incredibly informative. Thank you for doing this!