Matthew Fogel is a board-certified family nurse practitioner, an entrepreneur, business owner and published author. He graduated from Simmons University in Boston, MA with a master’s degree as a family nurse practitioner. Fogel is the co-founder of CannaCore, a company dedicated to cannabis focused education and patient empowerment. He is a fierce advocate for cannabis rights and his passion is for patient education and harm reduction. He currently practices as a pain management and physical rehabilitation nurse practitioner in Albuquerque, NM where he lives with his wife, Elizabeth, and their animal babies.
Q: What inspired you to write The Green Elephant?
A: The Green Elephant was inspired by my own health journey. I had a gastrointestinal (GI) bleed that the doctors could not locate. I became severely anemic and developed intractable nausea as a result. None of the pharmaceuticals that I had been prescribed helped relieve my nausea and vomiting. I had a friend who was a cannabis user who suggested that I try cannabis as a treatment for nausea. After a long discussion with my wife, I finally decided to try cannabis as nothing else was making a difference. About 15 minutes after consuming my initial dose of cannabis, I began to realize that for the first time in a long time I wasn’t nauseous! After this experience, I knew that everything I had ever been taught about cannabis was wrong. I began to read every cannabis study that I could get my hands on. My illness culminated with a trip to the Mayo Clinic, where my GI doctor, after being told how cannabis had helped me when nothing else was, wagged his finger at me. He told me that my cannabis use could be causing every single one of my symptoms including my nausea and vomiting. I was shocked at his response, not only as a patient but as a nurse at the time. How could this provider not even take into account what I was telling him? I didn’t want this happening to others and it led me to recognize that cannabis is the “elephant” in the room when it comes to health care providers and how they practice medicine.
Q: What is the endocannabinoid system?
A: You have many systems that make up your body and we all know about the big ones, like the cardiovascular system. The endocannabinoid system (ECS) is a body system whose function is immunity and balance of physiologic, emotional and cognitive function. This makes it a very important system, as it interacts with all of your body’s other systems. It responds to endocannabinoids, endogenous cannabinoids (those made inside the human body), like anandamide and 2-AG (2-arachidonoyl glycerol) to help maintain the body’s homeostasis. When the body’s demand for cannabinoids exceeds its ability to produce enough on its own, for example, when the body is under stress from an illness, the body can benefit from cannabinoid supplementation from outside of the body. Supplementation is achieved through consumption of phytocannabinoids, the cannabinoids found in the cannabis plant like delta9- tetrahydrocannabinol (THC) and cannabidiol (CBD).
Q: What is the difference between natural and synthetic cannabinoids?
A: The answer to this has two parts. There is essentially no difference between the two structurally, as synthetics are essentially carbon copies of naturally occurring cannabinoids. Functionally, they are very different for multiple important reasons. Naturally occurring phytocannabinoids are generally taken together, as that is how they develop in the plant. This is what is being described when saying a patient consumes “whole plant cannabis.” Consuming multiple cannabinoids at the same time causes a positive reaction referred to as “the entourage effect.” The entourage effect transforms the effects of cannabinoids on the body, making them stronger than they would be if consumed individually. The other important part of the entourage effect is balance. The cannabinoids balance each other out when taken as whole plant. CBD is a great example of this, balancing out the psychoactive effects of THC so that patients don’t get too high. Synthetic cannabinoids are usually more powerful than their individual natural counterparts, but they lack the balancing capabilities of the entourage effect. This can cause patients to not be able to tolerate the synthetic version because of side effects, or in the case of Epidolex, an anti-seizure medication, can cause seizures as a potential side effect.
Q: What health conditions can benefit from medical cannabis?
A: Many health conditions and illnesses can be benefited through treatment with medical cannabis. The laws vary from state to state, but currently there are about 40 medical cannabis qualifying conditions that are used in the majority of medically legal states. The symptoms of these qualifying conditions fall under the different beneficial effects of cannabis found in research and have enough research backing to make them eligible for a qualifying condition. An example of symptom and relief mirroring is cannabis’s anti-inflammatory effects making it beneficial for conditions that have inflammation as a hallmark like arthritis (osteo or rheumatoid), Crohn’s disease and ulcerative colitis to name a few. The neuroprotectant properties of cannabis can be beneficial for diseases like Alzheimer’s and Parkinson’s disease and the anti-emetic effects of cannabis can give welcome relief for patients with nausea like chemotherapy patients. The list goes on and on of conditions that could benefit from cannabis use. It is important to note that cannabis is not a panacea but rather an important therapeutic tool.
Q: In The Green Elephant, you mentioned that medical cannabis is gaining traction among health care practitioners. What advice do you have for practitioners who are considering using medical cannabis for their practices?
A: Many providers are concerned with how recommending cannabis therapy to a patient could potentially affect their license. Recommending cannabis for approved
conditions in medically legal states has no effect on a practitioner’s license. Providers should look into cannabis studies for themselves, research how cannabis has been shown to be beneficial for multiple conditions and then compare cannabis to pharmaceuticals prescribed for those same conditions. Listen to your patients when they tell you that they are finding symptom control and relief with cannabis, as subjective data is a catalyst for research, leading to more randomized control trials, something that the medical community desperately wants.
It all comes down to something practitioners have on their minds daily: harm reduction. Cannabis therapy plays a considerable role in patient harm reduction. Due to its relatively benign safety profile, even compared to over-the-counter medications like Tylenol, cannabis is something that should be considered more often. Why order an opioid medication for pain control, with its high potential for addiction, when cannabis can help treat the pain without this potential? Even commonly prescribed medications like Zofran have the potential (albeit small) to cause side effects including cardiac arrhythmias, so why not treat nausea with something natural like cannabis with a better safety profile?
Q: Should practitioners choose one particular delivery method over another for different health issues? Do dosing amounts change for different delivery methods?
A: Inhalation (smoking and vaping) as a delivery method can be very beneficial for patients who need fast acting symptom relief for issues like pain and nausea. Edibles have a slower onset which can help with longer symptom coverage of pain, etc. Inhalation has been generally frowned on by most providers due to the perceived potential for lung injury, leading even cannabis-friendly providers to recommend edibles as their preferred delivery method. The problem with those studies demonstrating lung injury issues are confounded by including cigarette smokers in their study participants. There are several recent studies that show long-term cannabis smokers have no higher lung cancer risk than non-cannabis smokers. Continued research is needed in multiple areas of cannabis therapy and providers calling for this research can help push cannabis research to the forefront.
Dosing methods do not change the milligrams consumed. The dosage (actual contained amount of cannabis in milligrams) of edibles and inhalants can be the same, albeit harder to actually measure when smoked or vaped. The most important thing to remember when starting a patient on cannabis therapy is to start at a low dose, usually about 2.5-5 milligrams, and go slow. This means having the patient wait several hours between doses before taking another dose, until they know how it affects them. Inhalation can take between one to two minutes, to up to an hour to take effect. Edibles can take from 45 minutes up to two hours to take effect. It is important for the new user to understand the importance of going slow and following this to avoid side effects from taking too high of a dose.
Q: Is there anything else you would like to add?
A: As a nurse for over 10 years and as a provider, I was once against cannabis in its entirety, let alone as a therapy. But after following the science available (much more than I had been led to believe existed) and experiencing the relief cannabis provided for me personally, I could no longer continue under my previously held prejudices. Just remember why you became a provider, and do not be afraid to investigate cannabis therapy for your patients.