Dr. Michelle Weiner, DO, MPH

Dr. Michelle Weiner, DO, MPH

Dr. Michelle Weiner, is an Interventional Pain Management Physician board certified in Physical Medicine and Rehabilitation. She completed her residency and fellowship training at the University of Miami. Her specialty is focused on prevention, treatment, reversal of health deterioration, increasing function and managing pain. Dr. Weiner focuses on diagnosing and treating spine and musculoskeletal pain as well as chronic migraines at the Spine and Wellness Centers of America

Dr. Michelle Weiner Explains How Cannabis Transformed Her Practice And How Edibles Help Her Patients

Cannabis Edibles and Drink Review had the pleasure of sitting down with Dr. Michelle Weiner.

CEDR:  Dr. Weiner, what led you to cannabis as a niche and how has your practice evolved?

Dr. Weiner: Since I’m a pain management physician. I initially had ideas of really trying to improve quality of life and take away patients’ pain, and what I found was pain management consisted of repeated injections and poor management of chronic pain. 

And honestly, we have a huge opioid epidemic. So, when cannabis became legal, I took it as an opportunity for me to have a more holistic approach to pain management. And it was very interesting, because I learned about the endocannabinoid system, which I hadn’t learned in medical school. I began to understood how much all of these symptoms that we have can actually be related to an imbalance in our endocannabinoid system.

Since cannabis is such a natural plant, I thought it was a great option to start to use as a substitute for the patients who were having pain, to try to decrease their medication. And that was initially the research I did. What I found was that cannabis is a natural option for pain and for so many other conditions. It was a way that I could actually empower the patient to take ownership over how they were feeling, not just to take a medication that was prescribed, but really to help them listen to their body and understand where the pain was coming from.

There is so much overlap between mental health and chronic pain that it also improves people’s anxiety, depression, and sleep. So, for the past six years, I’ve started getting more involved. I was the chair of the advisory committee through the Florida Department of Agriculture, so that we can help people get access to good quality cannabis in Florida and help make the guidelines so that everybody has safe products.

What I realized was a lot of patients were taking cannabis to optimize their health and prevent disease and not just to treat chronic diseases. And I like the whole idea of personalized and preventative medicine and the fact that it gets to the root cause safely and effectively. My practice has evolved to really not doing as many interventional procedures, much less opioid management and using CBD and cannabis to optimize their health and empower them to take hold of their own health and really understand their body, which is something that Western medicine doesn’t teach, and Americans are not used to. They just want a quick fix, and cannabis takes some time to treat and to understand how it affects each person. But once people understand it, it’s really something that can be used for so many different conditions.

CEDR: What is your take on the fact that the endocannabinoid system is not being taught in medical schools?

Dr. Weiner: It’s unbelievable. We’ve known about it since the early 90s, and it’s still after 30 years, taught in about 14% of medical schools, mainly around the concept that the endocannabinoid system is a system in our body that is affected by cannabis which is a schedule one drug. And a schedule one drugs means that it has addictive potential. There’s not enough evidence to say that it has a therapeutic benefit. And because it’s put in schedule one, it makes it very difficult to get pharmaceuticals approved and to do research.

Physicians obviously like to see good solid clinical trials. It’s sad because patients are going to be taking it. And so, physicians and future physicians have to understand how drugs interact with cannabinoids and how to safely use cannabis. The answer for most physicians is there’s not enough evidence and it becomes a cycle of there’s not enough evidence, but really, it’s because it’s a schedule one drug and it’s difficult. The endocannabinoid system actually plays a role with all the other organ systems in our body and also has a lot to do with the bioavailability of many other pharmaceuticals that we consume.

CEDR: How do you see patients most effectively incorporating edibles into their regime?

Dr. Weiner: Edibles took a really long time in Florida to get approved, and a huge issue with that is because of how attractive they look to kids and also the fact that there’s so much inconsistency and variability with absorption and metabolism. And since we have approved edibles, I can’t even tell you how different my consultations are with patients. It’s so common that I’ll get a new patient who will say, “my friend gave me this gummy because I couldn’t sleep. And I’ve been on Ambien and I’ve never slept so well in my life.” The reasons why I do like the edibles are, first of all, we’re trying to vape and smoke less, obviously in general, but also especially during COVID. And there’s actually an article that came out last week in World Psychology that stated people who are using substances such as tobacco, cannabis, opioids and alcohol are actually at higher risk of covid after vaccination.

In general, edibles are easy to consume, because most of them come in five or ten milligram doses. They are just very simple. A lot of people don’t want to take a pill. The whole reason why they’re trying cannabis is because they’re sick of taking capsules and they’re sick of using pharmaceuticals. But edibles comes with many issues. There are a lot of factors that dictate how fast the onset of an edible will be and how long it will last. And because it’s fat soluble, it varies with when the patient last ate something with fat or oil in it and what they ate, and then there are many other factors (similar to pharmaceuticals) in terms of absorption.

Edibles have a longer onset, but they also last longer. So it’s great for sleep or for a chronic condition. For individuals who are first starting off, I generally don’t begin with edibles because they want consistency, they want reliability, they want it to be treated like medicine, and there are too many variables when it comes to the edibles.

CEDR: To what degree is it possible to have an edible that’s more sativa leaning versus indica or hybrid?

Dr. Weiner: A lot of the difference between Indica and Sativa is really based on the terpene profile. The terpenes are like the essential oils of the plant that guide the effect. The biggest issue is that the terpenes all have a different boiling point in which they are degraded. So, if you want to make an edible that is Indica or Sativa or to have that actual effect, you need to retain the terpenes. But during the extraction process, most of them get destroyed. So, what some companies do is they actually make like a terpene distillate, and they put it into their edibles. There’s a company called Wana, and they sell edibles at Muv. And those are the ones that really can give the person more of the effect they want, which is important because if you’re just taking a 10 mg THC edible for sleep, maybe you’ll get high and fall asleep, or maybe you’ll feel relaxed and fall asleep. I really think the terpenes make the entourage effect and really dictate the feel of the of the product.

CEDR: Is it possible to attain a “smoker’s high” with edibles?

Dr. Weiner: The reason why people love flower is because the whole plant has all the cannabinoids and terpenes in it, the way that it was grown. And so that’s what we call the “entourage effect” where everything is synergistic, where the flower gives you that full mind body / type of experience. And everybody really wants that in another form. And the question is how to retain the cannabinoids and terpenes without destroying them to put into an edible. It’s a very difficult process.

CEDR: is there a strategy you can share with respect to not continually increasing the amount of edibles a patient consumes while still achieving a consistent result?

Dr. Weiner: Edibles typically have low bioavailability. So, if someone is taking more and more milligrams of an edible, it’s just basically because they’re not absorbing it. For someone like this, there are more effective ways of using cannabis. A nano emulsion, a water-soluble form will increase the bioavailability, therefore probably leading to eating fewer milligrams over time. I think that people who vape or smoke often will also build tolerance quickly because they are frequently activating their cannabinoid receptors or saturating their cannabinoid receptors, therefore needing more over time.

A good model to not build tolerance once someone is comfortable with cannabis is layering, where someone takes a 1/3 an edible or uses a tincture and can use a faster acting route like flower, vape or a nano emulsion-like powder or drops so one has immediate and long term relief. Incidentally, there are about 20% of people who just don’t metabolize the oral form of cannabis.

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Virtual Reality Effects on Pain Perception: Implications for Pain Management

Current Status: Pending

Literature suggests that the use of virtual reality distraction for adjunctive pain control has been successful. In clinical settings and experimental studies, participants immersed in a virtual reality experienced reduced levels of pain, general distress/unpleasantness and reported a desire to use virtual reality again during painful medical procedures.

There has been research into the use of virtual reality distraction for adjunctive pain control with significant success. There has been growing evidence for the use of EEG for the measurement of pain. It has also been suggested that virtual reality could be used an alternative to marijuana and opioids for pain management. Further implications have been seen specifically among chronic pain sufferers. This is especially interesting since there is a reduced risk of addiction as is seen associated with marijuana and opioid use. This study aims to investigate the effect of virtual reality distraction on pain perception.

Additionally, we intend to create a body of open source content for potential use by other investigators utilizing similar tools. 

The intervention has the potential to relieve chronic pain sufferers of their pain with a non-invasive mechanism and minimal risk. The participants may experience a temporary decrease in the perception of pain during the course of the experiment or a distraction from said pain.

Pending IRB approval at UM

Seniors Over 60 With Chronic Pain Using Medical Marijuana

Current Status: Active

 

The purpose of this study is to identify what is effective and safe for older adults with chronic pain to develop an understanding of what educational materials are required for facilitate access to appropriate products at medical marijuana treatment centers (MMTC). 

Survey older adults (> 50 years) with chronic pain who have MM access cards and receive their product from state-approved dispensaries to document: demographic/health data; patterns of use; product specifics; pain effects on daily life; pain-related medical conditions; education prior to MM purchase; helpful and problematic effects of MM use. 

The proportion of Florida’s population that is 60 and older is growing more rapidly than other components of the population. Musculoskeletal disorders with associated chronic pain are a common problem in later life. Symptom management in older adults, including chronic pain management can be challenging (Briscoe, 2018). Medications, especially opioids, can increase the risk of confusion, constipation, falls and injury (Briscoe,2018). Medical marijuana (MM) is often recommended by doctors in the treatment of these medical conditions, guided by state law that defines qualifying conditions.

Medical marijuana use among older adults is growing at a rate more rapid than younger age groups (Lum, et al, 2019). The 2016 National Survey on Drug Use and Health estimated a 2.9% prevalence of marijuana use among this older population. However, the survey did not ascertain if use was for medical or recreational purposes (Han et al., 2016). Older adults may have important differences in pathophysiology, pharmacological interaction of medications, comorbid conditions, and toxicological responses to cannabis.

There is little evidence to evaluate the differences associated with medical marijuana use among older adults, such as individual reasons for use and problems arising with use (Haug et al., 2017).

Chronic pain is a major public health problem. Approximately 178 million (41%) adults in the U.S. age 18 and older suffer from at least one painful health condition (Nahin, et al, 2019).

In Florida, there are 327,492 medical marijuana card holders and chronic non-malignant pain was the No. 1 diagnosis for which patients are registered (The Florida Department of Health, Office of Medical Marijuana Use, 2020). Yet, it is not a qualifying condition, creating challenges for physicians wishing to support patient use of MM for chronic pain.

Chronic pain accounted for nearly 34 percent of diagnoses at certified dispensaries (The Florida Department of Health, Office of Medical Marijuana Use, 2019).