Jordan Tishler, MD, is one of those physicians who will spend an hour with a patient.
This hour is actually part of his onboarding process: getting curious about the patient's medical history, outlining the nuances for treating their condition, making sure they have the support and direction they need, and answering all of their questions.
And with new patients there can be a lot of questions – because the Harvard-trained Dr. Tishler specializes in medical cannabis. In fact, most physicians in the Boston area will refer patients to his clinic InhaleMD if they suspect cannabis would be helpful.
Early Success with Medical Cannabis
One of the clinic’s first patients was a lawyer in her 40s, who had suffered a horrific car accident and was now struggling with a range of problems. In addition to the chronic musculoskeletal pain, she also had a lot of difficulty even putting thoughts together due to the head injuries.
“With all the pain and the many cognitive issues, two things had happened,” Tishler remembers. “One, she wasn’t able to return to work, and the other thing was she had become entirely dependent on a couple of opioids: tramadol and oxycodone.”
Tramadol can be a particularly concerning drug, Tishler explains, because unlike other opioids, if you withdraw from tramadol too quickly, it can cause seizures.
In addition to not being able to return to work, these health challenges were taking a toll on other aspects of the patient’s life. With her husband traveling pretty much all the time, their two adolescent daughters were also starting to have trouble – one struggling at school, the other suicidal – their mother simply unable to give them the attention and guidance they needed.
“And so we started her on some gentle cannabis medicine, a small dose, and worked her way up to something that was effective,” Tishler recalls.
“Slowly, her mood got better, her thinking got better, her pain got better, and we were able to get her off all of the opioids completely for a period of time, although later on in her course she needed a little bit more opioid again, but even still it was a tiny fraction from what she had been on previously, and so it’s still a significant win.”
The patient was able to go back to work, was able to take care of her children – both daughters are thriving now – and she is still on a maintenance dose to this day, to help keep the pain levels in check.
Lessons Learned in the Cannabis Clinic
Today, InhaleMD works with about a thousand patients, and Dr. Tishler has brought some of his biggest lessons learned to the online Cannabis Patient Care Certificate Program.
One of the biggest things Dr. Tishler has learned is that – contrary to common belief – most patients require small doses of cannabis to best treat their ailments.
“This is an important point, one of the things that the advocates and politicians often get wrong, is this idea that cannabis patients need more cannabis and higher potency cannabis,” Tishler notes.
“In my experience, it’s completely the other way around, that recreational users tend to be the ones who are seeking greater numbers of ounces and higher potency strains, while my patients do well on really small doses – five to 10 to 15 milligrams of THC, maybe once or twice a day, depending on what’s wrong – as compared with recreational users going through hundreds of milligrams per day.”
Tishler is all for cannabis legalization; however, in the scramble to legalize, this is one important conversation being overlooked: how adult-use legalization will interface with patient care.
“We really need to step back for a moment and give some thought, so that we can develop policy that supports everybody, that allows for both recreational use but also something that is a little more specific and functional for patients,” he suggests.
Ignoring this patient care dynamic can create very real challenges and harms to medical patients. Many patients will sadly give up on medical cannabis without the proper support, the right products, or when they feel stigmatized in a recreational market.
This message has become an important part of the platform for the Association of Cannabis Specialists (ACS), which Tishler initially founded as a means to connect with and educate other doctors and clinicians who are taking cannabis medicine seriously – a group that includes both referring physicians and physicians who choose cannabis as a specialty.
Appreciating the Role of Cannabis Specialist
The ACS has grown much faster than Tishler anticipated and has become a venue for establishing answers to a lot of the current challenges with cannabis patient care today.
“First of all, models that are proposed in the California style, where any physician can recommend cannabis doesn’t make a lot of sense because most clinicians want to do well by their patients, and they are not going to get into it if they really feel unprepared to do it right,” Tishler explains.
“Couple that with the idea that if I spend an hour with each patient, just talking about the illness and cannabis, while most primary care people have 10 to 15 minutes to talk about everything, whether it’s blood pressure, Pap smears, breast exams, cholesterol, or whatever it is – they have to shoehorn all of that into a 10 to 15 minute visit, then you want to shoehorn in this complicated new area of cannabis that I spend an hour on? That just doesn’t work.”
So what we realized, Tishler continues, is you can’t just kind of assume doctors will deal with it, it’s not going to happen. You have to set up the cannabis doctor as a specialist, somebody who’s got the knowledge and expertise, and does this fundamentally.
“And then you go and educate the primary care folks, so they become what we call the referring clinician,” Tishler notes.
“They need to know enough about cannabis to know that it’s legitimate, and to know that there are cannabis specialists, and they can turn for help in managing the patient. It is a very successful model, and that’s what we’ve put forward, and it’s working for my practice.”
A Cautionary Tale Spells the Importance of Cannabis Education
A couple of years ago, Tishler had two patients come in within a month of each other, both complaining of garden-variety back pain.
Incidentally, they’d both had liver transplants. If it weren’t for Tishler’s policy that he review every patient’s medical file before seeing them, he would have never known this.
Anybody who’s had an organ transplant must take a certain medication for the rest of their life, to prevent their body from rejecting the organ.
As Dr. Tishler puts it, the dosage window for this medication is very narrow. Interfering with that precise dosage can lead to disastrous consequences.
It was a good catch for both patients because Tishler was able to warn them off CBD, which any budtender or well-meaning friend might naturally recommend without realizing the potentially dangerous interactions CBD can have with other medications.
“It turns out that CBD, at least in the high doses, meaning therapeutic doses, will interact with these very dangerous anti-rejection medications, and depending on the particulars, you could either lose the organ or lose a patient, neither of which is acceptable.”
It’s an important cautionary tale that Dr. Tishler shares every chance he gets.
With cannabis and CBD quickly becoming a legitimate part of society, patients and doctors need to be able to have these dialogues together – overcoming any stigma and misinformation along the way.
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