9UNP0114SD_David_Bearman

- All right, that is what we're going to be talking about. This isn't a laughing matter. It's not Cheech and Chong medicine. General Barry McCaffrey called this Cheech and Chong medicine in 1996, after the voters of the states of Arizona and California approved the legalization of medical marijuana in those states. Cannabis is medicine. It's not a joke. And let's get into that. There are at least 12 states where it's legal. Maryland, whoops-- That's great. Okay, Maryland is questionable because there you can use it as a defense after you've been found guilty. 

It doesn't sound like that's real legalization. Briefly, in the Chinese oral history their materia medica goes back to 2637. And either the second Chinese emperor or the mythical Chinese emperor, also the God of pharmacy and agriculture Shaun Nen is said to have discovered the medicinal properties of cannabis. Sir William Osler, of course, in his textbook of internal medicine written in the 1890s in two subsequent editions, last one written, I think, in 1916, all included the advice that cannabis was the best treatment for migraine headaches. If you are interested in reading more about migraines, Ethan Russo, who was a neurologist in Missoula, Montana, and is now the North American medical director for GW Pharmaceuticals wrote a 60-page article in the Journal of Cannabis Therapeutics that explores the medicinal use of cannabis for the treatment of migraines. He attempted for five years to get government approval to do research on the use of cannabis for migraines. And the government refused to cooperate. Cannabis, of course, was in the United States pharmacopoeia from 1854 until 1941. Now, let's get on to modern research, because that's what you are concerned about. Before the modern research, in 1937, at the Marijuana Tax Act hearing, Dr. 

William Woodward, who was the chief lobbyist for the American Medical Association, said that the AMA was strongly opposed to this legislation and that the AMA knew of no dangers from the medical use of cannabis. In 1949, there was a study done showing that marijuana was useful in relieving seizures. I have a number of patients who have seizures who get relief from cannabis. One of those was a young woman in her middle 30s, who had an AV malformation, and had had a cerebral bleed, at the age of 17, and another one at the age of 27. The same neurosurgeon had saved her life twice. She was hemiparetic. Her history was that she had recurrent, and unable to be adequately treated seizures every day. However, she said if she stayed just a little bit high she never had a seizure. And many seizure patients have found that if they are regularly using marijuana, they don't have seizures. If for some reason their supply of marijuana is interrupted they start having seizures again. 

This is compatible with the mechanism of action of cannabis, which I hope to have time to get into later on. There were studies that were done in the 1970s and 1980s in eight states, which demonstrated that smoked cannabis was effective in treating nausea and is an appetite stimulant. In 1985, the federal government worked cooperatively with Roxane Laboratories to get Marinol to the market. They were concerned at the relatively large number of AIDS patients who were gaining relief from marijuana. And they wanted to have a pharmaceuticalized option. Marinol is not marijuana. It's not pharmaceutical marijuana. It is synthetic delta-9-THC. Cannabis, as we will see later on, has 483 cannabinoids in it. I'm the number one prescriber of Marinol in Santa Barbara County. 

It does help some people. And it does not help some people. In my clinical experience, marijuana is preferable to Marinol, but Marinol certainly does have clinical uses. And those clinical uses go beyond the FDA approval. And you know that you can prescribe drugs for off-label indications as long as you have a defensible reason, either from research or a strong anecdotal evidence, to write prescriptions off-label. As a matter of fact, 40% of all prescriptions are written for off-label indications. The endocannabinoid system is the largest neurotransmitter system in the brain. We know practically nothing about it. It was first characterized in 1992 by Raphael Mechoulam, the Israeli scientist who isolated THC in 1964. In 1999, GW Pharmaceutical, a phytochemical company, that's a company that makes medications out of plants, started doing research with a tincture of cannabis. 

Their product is now being sold in Canada by Bayer. In 2000, the California Marijuana Research Center was started at the University of California-San Diego School of Medicine. They have administered in excess of 18 FDA approved smoke marijuana medical studies, several of which have appeared in peer reviewed journals. Dr. Donald Abrams is somebody who fought with the FDA for nine years to get a study with smoke marijuana. Finally, when he designed the study to determine if it actually harmed people with AIDS. They approved his study. He found out it not only did not harm people with AIDS, but that it facilitated weight gain. It was more effective than Marinol, and of course more effective than the placebo. Dr. 

Ware is at McGill in Canada. And I always think it's ironic, I mean the Canadian border is just less than 125 miles from where I grew up. You can go to Canada and you can get legal marijuana, you can get legal tincture of cannabis made by GW Pharmaceuticals. Dr. Ware's area of interest is relief of pain with cannabis and cannabinoids. Dr. Donald Tashkin is a very good researcher at UCLA. He is a pulmonologist. His research demonstrated that cannabis was a bronchodilator. He also found in a study, that I think he was surprised at the results, that the incidence of lung cancer in people who smoke cannabis was less than the incidence of lung cancer in people who smoke nothing at all. 

And so it may actually be a preventive in terms of cancer. There's a very good article by Robert Melamed, who is a professor of biology at the University of Colorado, Colorado Springs branch. And Dr. Abrams had a recent article that appeared in the Journal of Neurology in the February issue showing that there was a 34% decrease in neuropathic pain in people who had AIDS. For those of you who have a real interest in learning more about this, there's a great organization called Patients At A Time. It's run by a nurse whose area of expertise is drug abuse treatment, which is one of my areas of expertise. They have put on conferences every other year since 2000, including world class researchers. Their upcoming one will have Abrams, Tashkin and Ware presenting, as well as four of the five federally legal medical marijuana patients. You may not be aware that the federal government sends out 300 hand-rolled marijuana cigarettes a month to four medical marijuana patients and 300 every three weeks to a fifth. Originally, there were 15 people in that program. 

But several of them have passed away, because they had significant illnesses. Anyway, I wish I had more time to tell you about that conference. Suffice to say I think it's worth your looking into. Now, if I'm able to get you to think differently about cannabis, it may have to do with the fact that you are two generations younger than I. It took me about 20 years from first finding out about medicinal cannabis from my father, who is a pharmacist up in Rice Lake. We were talking about prohibition. And he was telling me that when he was a freshman in pharmacy school at the University of Minnesota in 1928, that one of their assignments was to make tincture of cannabis. It had nothing to do with cannabis. It had to do with making tinctures. How to extract the pharmacologically active ingredient in plant material. 

And he showed me this book, his 1927 edition of Remmington's Textbook of Pharmacy. And on pages 999 and 1000, it talks about cannabis. And it talks about the use of cannabis as an anodyne, which is an archaic word for pain killer. And that's still the number one indication for the recommendation of cannabis, whether it's in Oregon, Colorado, or California, the three states that I'm somewhat familiar with the statistics, somewhere between 60% and 65% of the recommendations are for relief of pain. And we'll get into that in a little bit greater detail a little bit later. At any rate, it took me about 20 years before I finally got away from being influenced by the propaganda that's out there. That this was just a ruse to deal with recreational use of cannabis. We need to separate talking about the medicinal use of a substance versus the recreational use of a substance. The fact that opiates, and I have a long experience, 40 years of experience involved in one way, shape or form, in drug abuse treatment prevention with opiate abuse. And the fact that opiates have some abuse potential does not stop us from prescribing that for pain. 

As a matter of fact, you have an organization here that started a support group for people with pain. In California, there was enough concern about physicians' lack of appreciation of treating pain, that in order to have our license in California, we must have 12 contact hours in end-of-life care and pain management. We have developed, in this country, an opiate phobia and often under-prescribe opiates. I have a lot of experience, about 800 opiate abusers that I've treated in my role as medical director of a methadone maintenance program, an inpatient methadone treatment program and an out-patient opiate detoxification program. So I feel relatively comfortable talking about that particular area. In 2000, I started focusing on making recommendations for the medicinal use of cannabis. I was comfortable with the fact that it was medically useful, but I had an education from my patients as to how useful it was. And I'll give you a few examples as we go on with this talk. Now, the AIDS patients were one of the first groups of patients that started using cannabis to any great extent. Of course, it was very helpful as an appetite stimulant. 

Abrams' research later demonstrated that in a double blind study. It's useful as an anti-nauseant and as an anti-depressant. And Abrams once said that yes, euphoria may be a side effect. But when you're treating people with AIDS or you're treating oncology patients, a little euphoria isn't a bad thing. And with cancer patients, again, the anti-nausea, appetite stimulant and antidepressant effect of the drug are very important. Now these things are not only evidenced by the clinical experience of myself and hundreds of other physicians. As a matter of fact, in Oregon, where they have a mandatory patient identification card program, 2500 physicians have made recommendations to one or more of their patients. So this isn't something that is a marginalized group of weirdoes that are out there, but are physicians who are listening to their patients. And I can tell you that you have instant rapport with your patients. Somebody comes in and tells you "Doc, I'm a paraplegic. 

I have excruciating pain. I was taking enormous amounts of oxycodone. It was causing me to be confused. It was giving me constipation. And I started using marijuana. A friend of mine told me, try this. And I tried it. I was able to dramatically decrease the dose of Oxycontin that I was taking. I was able to be focused. I wasn't confused. 

I could play with my grandchildren..." And you begin to appreciate the utility of this drug. And also, when the patient tells you that and you, as the physician, validate, yes this does have pain relieving characteristics. This is something that I know is helping you, you have really solidified the doctor/patient relationship. You are hearing the patient. You are listening to them. On the other hand, if you roll your eyes skyward and say, "I don't want to talk about that," that is going to have a chilling effect on the doctor/patient relationship. The use of cannabis as an anti-nauseant and appetite stimulant and pain reliever are documented by animal studies and culture studies. I recently attended the 17th Neuropharmacological Conference, October 31 to November 2, where there were presentations from all over the world, including two from the medical college of Wisconsin. And these basic science studies tend to complement our clinical experience. 

These are, in my experience, the top six conditions that cannabis is useful. Pain, of course, number one. Sleep is something that is very effective. And in many cases, it's to help treat insomnia in people who have pain, nausea. Some people think that it has a specific anti-arthritic effect. Interestingly, there are a number of people with these arthritic conditions, or autoimmune diseases, that we don't know much about that it's good at relieving. I mean, fibromyalgia, restless leg syndrome, complex regional pain syndrome. Many people who have found no relief from anything else find that they do get some relief, and in some cases, a lot of relief from cannabis. I'm going to talk about ADD and ADHD a little bit later. But it has a rather remarkable effect on that. 

When I was at this conference, I was sitting at a table with some of the honchos, of course everybody there was a PhD. And I was saying that I have a number of patients that I've treated with cannabis for ADD and ADHD. And they've said, you know, it helped me graduate the Maritime Academy. And then I said there was one of my patients who said it helped me get my PhD. Well all of these PhDs at the table laughed knowingly. Nobody there admitted that it helped them get their PhD. But they seemed to understand what I was getting at. Okay, and of course the migraine headache thing. This was something that Dr. Osler was right about then. 

And he's still right. Other conditions, seizures, glaucoma. The question of how long it decreases your inner ocular pressure is one that I haven't been able to nail down. In discussions with just clinicians, some studies indicate four hours. Other studies indicate as much as 21 hours. It decreases your intra ocular pressure by about 25%. So people begin to worry about increased inner ocular pressure when it's at about 19. And 25 is generally considered, if you're over that, you absolutely have glaucoma. So let's say that your inner ocular pressure was 22, and you could decrease it by a fourth, you'd be down around 16 or 17, into the safe range. So this is something that is very helpful. 

Also people prefer either eating, or tinctures, or smoking, or vaporizing, as opposed to putting drops in their eyes. So this is a reasonable alternative. I mentioned the fibromyalgia, and that sort of thing. Of course, diabetic peripheral neuropathy is another kind of peripheral neuropathy, just like the AIDS peripheral neuropathy. I have several diabetic patients who have found that this is the only thing that gives them relief. We did a little study with Crohn's Disease. We made a questionnaire and then sent it out to several patients of Dr. Tod Mikuriya, who recently passed away, but has given more recommendations than any doctor in the United States. At one time, he was in charge of marijuana research for NIMH in the late '60s. However, he thought he was there to do research on the medicinal utility of cannabis, and NIMH thought he was there to authorize research on the dangers of the medicinal use or the recreational use of cannabis. 

So this was not a marriage made in heaven and it didn't last very long. But at any rate, Dr. Mikuriya, myself and Dr. Hergenrather sent out questionnaires to our patients. And what we found was, is that people were able to, who had Crohn's Disease who were seeing us-- Granted this is a self-selected patient population. Nevertheless, for them, they were able to either dramatically decrease their reliance on steroids, stop their steroid use entirely, decrease or stop other medication used for treating their Crohn's Disease. They had fewer stools. They had more solid stools. They had less abdominal pain. There is also animal research that backs up this clinical experience. 

Depression is one of the top reasons that patients give for using cannabis. I had one patient who had something called cyclical vomiting syndrome, which I had never heard of until they came in. I now have, I think, three patients with this. It's sometimes referred to as migraines of the stomach. And it is unexplained virulent vomiting. And this particular patient was disturbed, because when he went into the emergency room they looked at him as somebody who was an opiate-seeking individual, and that this was self-induced vomiting. He was treated punitively by the emergency room physician, rather than as a patient. His cyclical vomiting syndrome is almost completely relieved by his use of cannabis. And I suspect this is because of the CB2 receptors in the gut, and the fact that when they are simulated, they slow down the speed of peristaltic contraction, and therefore the speed of transmission of waste through the gut allowing more time for water to be extracted from the stool before it is released. Okay, now the mental health diagnoses are probably the most controversial. 

Nevertheless, there are a number of patients who find relief from depression, anxiety, stress, obsessive-compulsive disorder, bipolar disorder. I don't know whether or not you place Tourette's in a mental health issue, but Tourette's. There's a researcher at UC Irvine named Daniel Piomelli. He was the chair of this Neuropharmacology Conference in San Diego. He has invented a number of pharmaceuticals that interfere with the metabolism of the two naturally-occurring cannabinoids that we've discovered so far. One is called anandimide and the other is 2AG. And I've forgotten what the 2AG actually stands for. And he sees the endocannabinoid system as being intimately involved in dealing with attention deficit disorder, Tourette's, bipolar disorder, panic attacks, and that sort of thing. And that if you increase the amount of the naturally-occurring cannabinoid, or if you take an external cannabinoid, that you're going to benefit. You're going to treat those conditions. 

And certainly, clinically, this is what we found in California. Now, let's see if I can find one other. Something that you may want to purchase, or Google. I don't know the URL, but there's a newsletter called O'Shaughnessy's. It comes out about twice a year. The editor of this used to be on the editorial board of Scientific America. And he wrote the newsletter for the UCSF medical complex. He's a very sophisticated writer and very dogged and very diligent. And this particular issue discusses the various conditions that ten of the top cannabis-recommending physicians in California, and I'm included in this, have found. And this might be something that'd be worth while to look at. 

Also in the archives, there's a discussion about PTSD, ADD and ADHD. I'm going to touch on those briefly in terms of my take on why it works to help treat those conditions. I just wanted to take a minute to talk about a couple of clinical cases. I already mentioned the first one with the person with seizures. The second one was the woman who saw me two weeks ago. A woman in her early 60s. She has a 20-year history of daily migraine headaches. She recently visited her 84-year-old aunt in Canada and had a migraine headache. And the aunt said, "Here, have one of these cookies." And she said she had no idea that my aunt used marijuana. 

She didn't have the whole cookie, she had a part of the cookie. And she said that she didn't have a migraine headache for two days after eating a part of one cookie. She was in seeing me to get a recommendation so she could use cannabis on a regular basis and hopefully avoid her migraines entirely. I had a patient who had back surgery. He was a scuba diver. He asked his orthopedic surgeon, can I go scuba diving? The orthopedic surgeon said yes. I don't know anything about orthopedic surgery, but I probably would have said yes, too. He went scuba diving, something went dreadfully wrong. And he became a quad for nine months, and then a para, and had excruciating pain from T10 on down. 

And he said that cannabis was the only thing that prevented him from committing suicide. I have any number of pain patients who find that the use of cannabis has made their life tolerable. Several of the federal medical marijuana patients have made the point, "I didn't get this disease so that I could legally use marijuana. I would gladly stop using marijuana if I didn't have this disease." Remember that when a patient comes in and says this to you. Now, that doesn't mean that if you are making recommendations for medical marijuana that you should give them to everybody, that you should hand them out like candy. In my office we screen people on the phone. We want to know what their diagnosis is. We want to know what treatment they've gotten. We want to know what the last time was that they saw a physician. 

And if somebody calls up, we're three or four miles from the University of California at Santa Barbara, so if somebody calls up sounding for all the world like a sophomore over there at UCSB, and they say, "I can't eat and I can't sleep." Our next question usually is, "Have you been worked up for this?" Because we don't make an appointment for somebody for sleep disorder unless they have had a work-up at a sleep disorders clinic. So they usually say two things. First they say, "No." And then they say, "I don't believe in doctors." We don't make an appointment to see that person, because we don't think that they meet a reasonable criteria for having a recommendation for medical marijuana. There's no sense for having them come in and waste my time, and me to waste their time and money and for them to go away angry. Better that we say no, we're not going to make an appointment for you. Now on PTSD, this is probably one of the most important reasons for you to be here today. 

We know that 30% of the people coming back from Iraq, at least, are going to have post traumatic stress disorder. And I can tell you from seeing patients from the Vietnam era, the first war in Iraq and this war in Iraq, that this is a very serious condition. People are hyper alert. They're startled. They have nightmares. They have anger. And we, the American people, have put them in harm's way. And by under-funding the Veterans Administration, we have not adequately dealt with them. Furthermore, the federal government has prevented the Veterans Administration from being able to recommend cannabis for the treatment of PTSD. Now, we have a VA clinic in our community. 

They refer patients to me. The husband of our mayor is a doctor. He works at the VA clinic. A year or so ago, we were walking through a restaurant and they were having supper there with their son. He called me over so he could introduce me to his son, and say this is one of the top marijuana-recommending doctors in California. He has suggested to some of his patients that maybe if they saw Dr. Bearman, he might recommend cannabis for the treatment of PTSD. One of the founders of Patients At A Time, and there's some flyers up here for that conference, is Al Burn, who's a retired Lieutenant Commander in the Navy who has PTSD. This patient here lives in Bishop, California, which is just about 10 miles past the end of the earth. He lives 20 miles outside of town at the end of the road at the last house. 

And he says, "I try to avoid going into town altogether, and not more than once a month, because I can't stand being around people. And if it wasn't for marijuana, I'd start killing people." There's a lot of people that have been traumatized as a result of war. And there are other people who have been traumatized as a result of rape, or kidnapping, or growing up in a dysfunctional family where they've been physically or sexually abused. And cannabis is useful in relieving some of those conditions. ADD, ADHD, I told you the story about the PhD guy. Crohn's Disease, I've mentioned that. In terms of pain management, people tell me, "When I started using cannabis, I was able to either A, stop using the opiates that I was using, or decrease them by 50% to 66%." It has fewer side effects than opiates. And this is for the patients that I'm seeing. 

Again these are self-selected patients, so I'm not saying that this is a universal situation. Nevertheless, there are all kinds of studies, and studies with mice who presumably have no political agenda showing that they are able to deal with hot plates, in terms of tail flick, or whatever other kinds of things that they are studying. In 1997, there were seven such studies that were presented before a neurology conference that was held in New Orleans. And it was front page story in the LA Times, and that's how I became aware of it. But these studies were done at such radical places as the University of Minnesota, Wake Forest, University of Texas, and that sort of thing. In addition, there were discussions of pain at this recent conference that I came back from in San Diego. Since cannabis is useful in treating abdominal problems, there's little or no abdominal pain. There's no nausea. We know that with morphine, something like 22% of people who you give morphine to are going to have nausea and vomiting. There's less confusion and dizziness. 

They're able to drive. They're able to play with their children and their grandchildren. This decreases their perception of pain in some instances. In other instances it allows them to concentrate on other things rather than their pain. As I mentioned, it decreases their reliance on opiates. Suffice to say that you have pros and cons, but you have the former surgeon general, you have the editor of the New England Journal of Medicine. And most importantly, you have the 1999 government commission, government paid-for Institute of Medicine report that says marijuana is medicine. They do take some dispute with smoking as a mechanism of action. But fortunately, there are a number of other mechanisms of action. In terms of safety, every western government study ever done has recommended the legalization of recreational use of cannabis. 

So one would think that the medical use might be safe. There was a two-year hearing presided over by the chief FDA Administrative Law Judge, Francis Young. And in his findings of fact, he said that cannabis was one of the safest therapeutic agents known to man. That's the FDA's chief Administrative Law Judge telling you that, not Dr. Bearman. Marinol, which has more side effects than cannabis, because it does not have the mitigating cannabinoids in it that cannabis does, has been approved by the Food and Drug Administration. It's one of the few, if not the only drug, that has been upgraded from a Schedule II drug to a Schedule III drug. And Sativex has been approved for research in England and Spain. And it has been approved for sale, and has been sold in Canada by Bayer since 2005. In December of 2005, the U.S. Food and Drug Administration approved a Phase Three, as you know that's with people, clinical trial to determine whether or not tincture of cannabis-- And you know, tincture of cannabis is made by putting the flowering tops of plants in alcohol, leaving them there for a couple of days, straining off the plant material and left with the alcohol infused with the cannabinoids and some of the phenoids and flavonoids that are in the plant that have the therapeutic value. 

And that has been approved by the Food and Drug Administration for the Phase Three clinical trial. They just started that in July of this year. But I have every reason to believe that Sativex will be available in this country in four or five years depending upon how fast or slow the FDA process moves. Okay, we know that it's efficacious. I'm not going to go into this. Now, in California we had a number of laws and court decisions that sort of clarify things. Basically, it is legal for me to recommend cannabis. It's legal for me to talk to patients about cannabis. The federal government was enjoined from harassing or intimidating physicians from giving medical advice, including medical advice about cannabis. I mean, what the federal government wanted is, if you're patients asks you, "Doc, do you think that cannabis is good for me?" 

that we should say, "I can't answer that," or "Well, I don't know," or something like that, rather than what we did know. If you think that it's not good for them, say so. If you think that it is, say so. The Ninth Circuit Court of Appeals has a permanent injunction against the federal government that prevents them from interfering with doctors and exercising our right of free speech, and our patients, from interacting with us and asking us any medical question that they want, including do you think that cannabis is a medicine that might be useful for me? And you need to form your own opinion as to whether or not you think it is. But you really have an obligation to your patient to give them a straight answer. And you have to be careful so that you are not influenced by the hysteria that has been abroad in our culture for years and years, and that you base your decision on the training that you're receiving here at the University of Wisconsin, and the additional training that you'll receive when you go to clinical conferences, so that people are actually talking about facts rather than about emotion and hysteria. Okay, I'm going to-- Bearman v. the Los Angeles County Superior Court was a case involving me. The Medical Board in California has a poor reputation amongst physicians that long precedes the re-legalization of medical marijuana. 

They wanted to subpoena a patient's records over the patient's refusal to waive their right to privacy. They found a very pro-government superior court judge who granted the subpoena. We appealed to the appellate court. We got a 3-0 decision in our favor. The reasoning in the decision was stronger than if I had written it myself. They said the Medical Board, that they had no complaint. Their job was a investigate complaints. They had no complaint about me. What they had was a letter from a forest ranger saying, "Is this ethical? Is this legal? 

Do doctors know what they're doing?" Do doctors know what they're doing? Yes, I think we do. Okay. We are now suing the Medical Board of California a second time to get the money it cost to sue them the first time, since they had no right to come after the records in the first place. Oh, by the way, because we appealed the case, they were trying to fine me $1,000 a day for each day that I didn't turn the records over. And my fine would have been $115,000 if I had lost the case. In the appeal, I had an Amicus Brief from the California Medical Association. These things are important. You need to understand what your responsibilities are as a physician. 

And protecting the sanctity of the doctor/patient relationship is one of your responsibilities as a physician, having nothing whatsoever to do with whether or not you ever make a recommendation for the medicinal use of cannabis. Okay, so let's talk about what the Medical Board guidelines are. They don't sound bad, but the fact of the matter is that they're moving a target and the Medical Board sort of makes them up as they go along. We need to do a good faith history and physical. The patients needs to be a bona fide patient. We need to review their records. And we need to have a plan. Now, unfortunately, there are some doctors that are running mills out there. What we refer to as HMO-style medicine, and we don't think that that's right. We're trying to marginalize them by forming an organization called the American Academy of Cannabinoid Medicine. 

And we hope to have that off the ground by the first of the year. Okay, my criteria is this. It's is hypothetical. If we hypothetically assume that the Medical Board of California is reasonable, which is quite a reach, and we further assume that they had the power and authority and ability to randomly select any one of my patients to say, "Dr. Bearman would you explain to us why you made this recommendation?" that I'd be able to do so in a manner in which they'd be able to understand. I got into this, because I do expert witness work on recreational drugs, and have since 1972. Most of those drugs, most of those cases, more than 300 where I've testified at trial, have not been marijuana cases, but 30 or 40 of them were. So, I'm always thinking in terms what is the attorney on the other side going to ask me? And that's the way that I approach the history with the patient. 

I want to be able to be on solid clinical grounds when I make the recommendation for the medical use of cannabis. As I mentioned, we screen people on the phone. We want them to bring in their old records. If they don't bring in their old records, we'll do a history and physical. And if they qualify, we'll say we will give you a recommendation as soon as we get your confirming medical records. I spend 45 to 60 minutes with a new patient. Do all of these things there. I want to spend about two or three minutes here and then give you about six or seven minutes for questions. 483 chemicals in cannabis. Some people say well, you know, these plants, these herbs, they're complicated. 

We don't understand them. True enough. And that's one of the things that took me 20 years to sort of accept this. That manufactured medications are modern. We know all about them, we think. Our experience with manufactured medications go back to just before 1900. Aspirin being the first synthetic. Our experience with herbs and plants go back, what a few thousand years? A few million years? We have quite a bit of experience with them. 

And we shouldn't-- apriority assume that manufactured pharmaceuticals are somehow superior to plants. And in fact, there are certain branches of medicine that are going into the Amazon, that are a talking to Shamans, that are taking a look at these various medications. Okay. The endocannabinoid system, as I said, is the largest neurotransmitter system in the brain. We don't really understand it. It tends to moderate sensory input. And I think this is the important thing. I'm going to kind of end talking about this and then just slip through the rest of the slides and let you read them. The way that I believe that it works is in freeing up dopamine that is trapped in dopamine transporter. For some reason, there's an excessive amount of dopamine transporter in a number of these conditions. 

And so, we don't have enough dopamine. And what the endocannabinoid system is important for doing is when it's released and stimulates the next neuron on the other side of the synapse, it causes dopamine to come back to the neuron that just released, that just stimulated the next neuron. It depolarizes it and it makes it more difficult for that neuron to be stimulated by the next neural impulse coming along. Recognize that this is why clinical impression of what's going's on from people that have done basic research. I'm sure that to the extent that I'm wrong, Dr. Kozee will educate me after this. When I explain to my patients that I think that this is what is going on, they say, "Yeah, that is. I'm able to focus. I'm able to concentrate. My attention deficit disorder goes away or my depression gets much, much less." 

Okay, so this is that schematic that your familiar with. But basically, the concept that you need to keep in mind is the concept of retrograde inhibition, and that the post-synaptic neuron is going back and affecting the pre-synaptic neuron, so that the next neural impulse coming along will have a harder time stimulating that. And so we're having fewer, slower moving neural impulses to the midbrain, the reptilian brain. So people who have problems with anger associated with PTSD, instead of having the amygdala, the rage center, overpowered, and by rapidly moving anger impulses, you have the same anger impulses, but fewer. And the neocortex has an opportunity to say, "Don't call that person an SOB, they're likely to get angry," and so you don't. And you have a different outcome of that interaction than if you called him some dirty so and so. Okay, let's just kind of flip through these and see what we have. This says, in words, what I've been trying to convey. This talks about cannabinoids and PTSD. This, again, says the same thing over again about enhancing the retrograde inhibition. 

Decreasing the sensory input. This is talking about the dopaminergic system. Talking about its involvement in the attention deficit disorder. This, again, talks about this, and, you know, this is getting into the basic science stuff where my eyes begin to glaze over. These are some actual quotes. The second quote came from when I was being interviewed by a reporter for USA Today on the use of marijuana for migraine. This was after Kareem Abdul-Jabbar had been arrested. He had gotten a recommendation from a physician whose practice I was sitting in on while he was out of country. I was talking to this reporter, and she was regaling me with her experiences with recreational use of marijuana in college. And after about 20 minutes of sort of chuckling and laughter, the waitress came over and told us about the benefits her son had gotten. 

This was a completely unsolicited comment. And of course, you don't have to smoke marijuana. You can vaporize it. It has 70% fewer irritants than smoking it. You can use it sublingually, as the Sativex is. You can take it orally. The Sativex is a spray. It's in a metered sprayer. The Sativex people want to get this approved by regulators. They don't want it to be abused. 

That's why it's in a metered sprayer. It's a combination of 50% from a whole plant extract high in THC and another whole plant extract high in CBD. The THC for the therapeutic value, the CBD because it tends to dampen down the euphoria. Marinol is an oral route of administration. A little bit different when you eat marijuana than when you smoke it, because 85% of it is metabolized on the first pass through the liver. What does that mean? I don't know. It means that your getting different chemicals. We have not studied this enough to know if it has any significance, or whether or not there are certain conditions that are going to respond better to the respiratory route of administration than the oral route. The respiratory route does allow you to titrate the dose. 

Its onset of action is going to be in 15 to 30 seconds. The sublingual onset is going to be in 15 minutes. And the oral onset is going to be 45 minutes to an hour. Recent developments. The chief Administrative Law Judge of the DEA ruled in a case involving the University of Massachusetts that the DEA should sell a license to grow marijuana to this professor of botany who's an expert in medicinal plants, so that he can study the various constituent components of different strains to determine which of the chemicals or combination of chemicals are best suited for the various conditions that I've been telling you about. Of course I mentioned the Journal of Neurology article by Dr. Abrams and the FDA Phase III study. Where are we at now? Lester Greenspoon, who wrote, Marijuana the Forbidden Medicine, is saying we're at the juncture as to whether or not we're going to have pharmaceuticalization, or whether or not individuals are going to be allowed to treat themselves. In other words, will the traditional American rugged individualism prevail or will the corporations dominate? 

Dr. William Woodward, I mentioned, said that the AMA knows of no dangers from the use of cannabis in the 1937 Marijuana Tax Act hearings. Dr. Joycelyn Elders, former U.S. Surgeon General, has come out in favor of medicinal cannabis. This is what Judge Francis Young said. I mentioned him talking about the safety of cannabis. Rodney Dangerfield wrote a book called, It Ain't Easy Being Me. In that book he has a picture, it's not quite that one, and it says, "Here I am looking at the best piece of mail I ever got." And the rest of the caption is, "A letter from Dr. Bearman telling me to smoke more pot." 

Now, I didn't tell him to smoke more pot. I told him that I approved of his use of cannabis. And his wife spoke at the Patients At A Time conference we had in Santa Barbara. And I couldn't believe this. She said that after he got this, because he seemed somewhat disinterested, like he was sort of mollifying his wife, he showed his letter to everybody. And when he passed away, she put his letter in his casket. So we know that Rodney will not get arrested up in heaven, or wherever he's telling his jokes. And I'm going to stop with that.