Interview by Sheldon Baker
Bonni Goldstein, MD, is the medical director of Canna-Centers Wellness & Education, a California-based medical practice that educates patients about the use of cannabis for serious and chronic conditions, and the chief executive officer and co-founder of GoldsteinWellness.com. After years of working in the specialty of pediatric emergency medicine, she developed an interest in the science of medicinal cannabis after witnessing its beneficial effects in an ill friend. Over the last 16 years she has evaluated thousands of patients and has a special interest in treating children with intractable epilepsy, severe autism, and advanced cancers. Dr. Goldstein is the co-author of a number of peer-reviewed articles researching the use of Cannabis-Responsive salivary biomarkers to measure the impact of cannabinoids on children with autism. Her new company, Goldstein Wellness, helps healthcare practitioners integrate cannabis-based medicines into their practices. Her latest book, Cannabis is Medicine, is available in English, Spanish and Czech. (Adv Mind Body Med. 2024;39(2):32-36.)
Sheldon Baker is an InnoVision contributing editor. His freelance editorial content can also be found in several lifestyle publications, and as CEO of Baker Dillon Group LLC, he has created numerous brand marketing communications and public relations campaigns for health and wellness organizations. Contact him at [email protected].
Advances in Mind-Body Medince (Advances): What got you started pursuing cannabis medicine and treatment?
Bonni Goldstein, MD: Around 2007, I was working in the specialty of pediatric emergency medicine. I was at home during the day with a young child and working nights for many years. At that time, a friend reached out asking me about cannabis for help with side-effects of chemotherapy. She wanted to know if it was a real thing. I knew we had a medical cannabis law in California but I didn’t know much more. At that same time, I had taken a leave of absence from the ER as I was a bit burned out, so I had the time to delve in and I started reading about medical cannabis. I couldn’t believe that I had been a physician for so many years and had never heard of the endocannabinoid system. I saw my friend experience significant improvements in her symptoms and I decided to educate myself more and began working in a cannabis specialty office.
Advances: Education appears to be a key component of cannabis treatment.
Dr. Goldstein: No question. In most areas of medicine, people may or may not take the time to research the medications they’re prescribed. But with medical cannabis, there’s a strong desire for people to understand why and how it works. I think this curiosity stems from the negative propaganda and stigma surrounding cannabis that many of us have been exposed to for most of our lives. Because of this, patients often feel a need to educate themselves about cannabis to overcome those preconceived notions and make informed decisions about their treatment.
Advances: Based on your background and education you’re able to share such information with your patients.
Dr. Goldstein: That’s right. I love breaking down the science for a layperson into digestible bites, for instance explaining the “key and the lock” mechanism of how cannabis compounds work with our cannabinoid receptors. Most people don’t know that we produce our own inner cannabis-like compounds, part of a system called the endocannabinoid system, that works to maintain balance in our cells, what we call homeostasis. Some people may have a deficiency or dysfunction in these compounds, leading to health challenges. An external source of cannabinoids, which the cannabis plant gives us, can help promote homeostasis through this system, leading to beneficial effects.
Advances: I think you may be in the minority treating patients with cannabis and CBD.
Dr. Goldstein: Most physicians are still reluctant to discuss cannabis with their patients. And many patients may not tell their doctor that they are using cannabis. It is unfortunate that it is still a difficult topic for many to discuss. Unfortunately, without medical supervision, many patients don’t know what they are doing but we shouldn’t expect them to know how to use cannabis as medicine. My analogy is if I were to see a patient with pneumonia, I would not tell them to go to a pharmacy and pick a medicine to take. They would not have any idea what the latest research shows or what medicine might be the best option. Same with cannabis. There are a number of studies that clearly show medically supervised cannabis regimens are significantly more successful especially for serious illness, like epilepsy, dementia, chronic pain, cancer, and others. Having a medical professional supervise, educate, and recommend dosing like any other medicine can enhance the benefits and experience for the patient, and no question minimizes the risks of side effects.
Advances: Do you think people who use cannabis for some type of pain or illness are simply afraid to tell their doctor that they do?
Dr. Goldstein: Absolutely. I meet people who say they don’t care and they’re just going to say they use cannabis. There’s many who say they don’t know if they should discuss it or even bring it up. They don’t want their doctor to think they are stoners. There’s a lot of reluctance especially in the older population who lived through reefer madness propaganda.
If someone is nervous about how their physician might respond to questions about medical cannabis is to start with a simple question. Something like, “What do you think about medical cannabis?” This allows you to gauge their reaction based on your relationship with them. If you still feel uneasy after hearing their response, you don’t have to continue the conversation. However, it’s important to remember that a successful relationship with your doctor depends on open communication and not withholding information. On the other hand, doctors also need to be more open-minded and educate themselves about the therapeutic effects of cannabis.
Advances: Do you know if more doctors are following cannabis treatment, at least in California?
Dr. Goldstein: I think it’s everywhere because so many states now have laws allowing for medical cannabis, as well as legalization for adult-use. All practitioners should have some education about it. They should understand the endocannabinoid system and at least the types of products that are available and what medical use looks like. I do feel more and more clinicians are open to it, especially since the plan of rescheduling it from Schedule 1 to Schedule 3 has been introduced.
Advances: While cannabis and CBD is used for a number of serious ailments, as well as everything from anxiety to chronic pain, more and more are we are finding that cannabis can help alleviate other symptoms.
Dr. Goldstein: That’s correct. The reason is that the endocannabinoid system crosses all physiologic systems. Physicians and other practitioners learn in training about the separate bodily systems, such as the pulmonary system, the neurologic system, the gastrointestinal system and so on. Yet the endocannabinoid system is ubiquitous, located in and across all of those symptoms. This explains why cannabis can be used for example for conditions like irritable bowel syndrome, but also for dementia. It seems incomprehensible that a medication could have such a wide range of utility. Because almost all of cells of all of our systems contain components of the endocannabinoid system, they provide a good target for treatment with plant cannabinoids. Interestingly, these compounds also target non-cannabinoid or cannabinoid-independent receptors. We often call cannabinoids promiscuous compounds as they have many targets. This explains why one can achieve multiple therapeutic benefits from medical cannabis use.
Advances: Another area of your specialty areas is pediatric health. It’s been shown to treat autism, which is quite common in children. At what age are you able to prescribe cannabis for children, or can you?
Dr. Goldstein: Because some compounds in cannabis are still categorized as Schedule 1 on the Controlled Substance Act, I can’t write a prescription. But physicians can offer approvals or recommendations under California state law. Anyone under 21 is required to have medical approval in CA. In the process of treating children, I am quite specific with dosing, following not only the scientific literature, but my years of clinical experience. There’s now a significant body of published scientific articles looking at pediatric epilepsy and autism. The latest data on CBD for epilepsy is that it is currently considered an acceptable treatment for refractory epilepsy in pediatrics. I treated a six-week-old baby who appeared to have seizures in utero from a rare syndrome that was not favorable. I have treated a few children with autism starting around age three, which is often the age they are diagnosed. The vast majority of children with autism in my practice are children who are struggling with moderate to severe symptoms, including aggression, self-injurious behavior, sleep or focus issues, hyperactivity and severe anxiety. These families can struggle so much and cannabis has been shown in numerous studies to help with these symptoms. On average, there is about 75% caregiver satisfaction with cannabis treatment. Of course this is not a cure, but a very safe tool to help manage symptoms and improve quality of life for the child and the whole family.
Advances: If a woman during pregnancy has used cannabis, or the father has used it during insemination might that affect the child or fetus?
Dr. Goldstein: There aren’t any human studies that definitively prove cannabis use by a man affects his offspring. However, studies do show that THC use during pregnancy can result in low birth weight and potentially lead to preterm delivery. My perspective on pregnancy is that it’s a temporary condition with a defined endpoint, so it’s generally best to avoid all substances. That said, some women may face conditions like severe anxiety or chronic pain for which cannabis has been helpful in the past. In these cases, it’s crucial for the patient and their practitioner to carefully weigh the risks and benefits of using conventional medications versus cannabis, considering the effects on the fetus. The advantage of medicinal cannabis is that it can be tailored to the individual’s needs, doesn’t have to be used daily, and can be effective in low, controlled doses. Generally, my approach is to limit cannabis use during pregnancy unless there’s a strong medical reason and a thorough risk/benefit analysis has been conducted.
Advances: Do you have to get high on THC to relieve pain or is that a misnomer?
Dr. Goldstein: You don’t have to be impaired or intoxicated to benefits from medical use. I think many people like how they feel with cannabis because it has a beneficial effect on anxiety, providing relaxation and a positive effect on mood when used properly. As a clinician, I hear over and over that it helps take the edge off. I remember when I first started working in this specialty, patients seemed to be experiencing the same results, namely reporting they had less pain, better sleep, felt a sense of well-being and were able to participate more in their lives. I knew they weren’t meeting in the parking lot, conspiring to get me to approve their medical cannabis certification by telling me the same outcomes. What I was hearing was collective human experience of people using cannabis medicinally. Some reported enjoying the intoxicating effects, that it gave them a chance to step away from their pain, and others adjusted their doses to avoid that particular effect. The beauty of medical cannabis is that it can be customized to the individual. One other point that I think is important to add here is that while cannabinoids are changing your perception of pain, promoting sleep or reducing anxiety for example, behind the scenes, it is providing anti-inflammatory, antioxidant and neuroprotective benefits as well.
Advances: When a patient comes into your care, what’s usually the main focus?
Dr. Goldstein: I have two populations in my practice, pediatric and adult. In my adult population, the top three conditions I treat are chronic pain, insomnia, and anxiety. These symptoms run together and can be managed with various cannabinoids, not only THC or CBD, but also CBG (cannabigerol), CBDA (cannabidiolic acid, the raw form of CBD) and others. Cannabis, because it has so many physiologic targets, can help with multitude of symptoms, as opposed to conventional medicine, where separate medicines often are needed for each symptom. In the pediatric population, the two most common conditions are epilepsy and autism. A number of patients have both diagnoses. The third most common reason parents seek my help is pediatric cancer. These families often reach out when the prognosis is not looking good with conventional treatment or tolerating treatment has become difficult.
Advances: There are not many health professionals who specialize in cannabis. How do patients find you?
Dr. Goldstein: Most people find me online after searching for cannabis physicians. I can only take care of California residents due to my licensing. But there are many parent support groups online that share information about cannabis clinicians throughout the US.
Advances: Are there are potential negative interactions with pharmaceuticals?
Dr. Goldstein: Yes, there can be interactions between cannabinoids and other medications, especially with CBD because of how it’s metabolized. CBD shares a metabolic pathway with about 60% of pharmaceuticals, so there’s some potential for overlap. However, the chances of having a significant interaction are pretty low for most people. It’s usually only a concern when someone is taking very high doses of oral CBD, which isn’t common for the majority of patients.
One of the most notable interactions is with warfarin, a blood thinner. Both CBD and THC can slow down the breakdown of warfarin, causing an increased risk of bleeding. There’s also some evidence that cannabis might reduce the effectiveness of certain cancer immunotherapy drugs, so that’s something to be aware of. As for anticonvulsants, only a few have been shown to interact with CBD. These interactions aren’t necessarily absolute contraindications but rather considerations. It’s about managing these on a case-by-case basis to ensure patient safety.
Advances: It’s been my feeling for a long time that it’s pharmaceutical companies, rather than the government that doesn’t want to see cannabis approved for health benefits. What’s your thought about that?
Dr. Goldstein: It seems like both the government and big pharma aren’t exactly thrilled about medical or adult-use cannabis. For pharmaceutical companies, it’s really about the economics. They spend a lot of money developing new drugs, so they rely on patents to protect their investments and make sure they can recoup those costs. The full-spectrum, whole-plant form of cannabis is made up of hundreds of compounds that vary from one chemovar to another, making it tough to patent. In the U.S., we have a purified form of CBD available by prescription for three rare types of pediatric epilepsy, which I’m grateful for, especially for those who live in places where they can’t access cannabis otherwise. There is a study from 2018 that shows similar results between the purified CBD and full-spectrum CBD, but the purified version requires much higher doses, which leads to more side effects. So why should patients only have the option of the prescription version when the natural form can be so beneficial? It’s clear that because you can’t easily patent cannabis and it has the potential to replace a lot of pharmaceuticals, pharmaceutical companies aren’t exactly jumping at the chance to embrace cannabis medicine.
Advances: You mentioned some of the scientific function and what some of the science says. What other benefits does scientific literature say about using cannabis?
Dr. Goldstein: Cannabis is the umbrella term for many different products. There’s CBD-dominant products, THC-dominant products, combination CBD+THC products and also numerous other cannabinoids, such as cannabigerol (CBG), cannabidiolic acid (CBDA), cannabinol (CBN) and others. One of the reasons I wrote the book Cannabis is Medicine was to share information about all of these compounds and also to share the research on cannabis use for 31 different ailments. One area where we see significant benefits is in difficult-to-treat neurologic disorders. Per the latest published research, and as I mentioned, CBD is now considered an acceptable treatment for refractory epilepsy in children. A recent report in which 29 studies on the use of CBD for epilepsy were reviewed, the authors concluded it was safe, effective and should be an option. So yes, CBD works, and it has an acceptable profile, especially in refractory epilepsy.
I think that we have done a very poor job treating neurodegenerative disorders like Alzheimer’s. The evidence from human trials is compelling. Cannabinoids can be very helpful for those difficult symptoms like hallucinations, sleep disorders and difficulty with appetite, and it has minimal unwanted side effects when used properly. I’ve treated a number of these patients and what’s interesting is that although the families realize it’s not a cure, their loved one often can remain at home since the caregiver burden is significantly reduced. It’s very meaningful to me when a family can keep their loved one at home and not have too much difficulty with overwhelming behavioral issues. There’s a number of studies looking at the caregiver assessment not only in dementia, but also palliative care and pediatrics that shows that caregiver satisfaction is very high when cannabis is used.
And as I mentioned, chronic pain, insomnia and anxiety are often reported to be the most common conditions for which people use cannabis, and many of these reports document reduction or cessation of conventional medications for these symptoms. Other conditions that seem to respond to cannabis include autoimmune conditions, gastrointestinal conditions and side effects from cancer treatment.
Advances: Do most people have a positive response to cannabis or CBD use?
Dr. Goldstein: I find that overall, about 75% of people trying cannabis will report benefits. Of course it depends on the condition, the products trialed and also if there is medical supervision or not. There are many options under the cannabis umbrella and finding what works take time and patience and sometimes a fair amount of trial and error. Some people give up after trying only one product. Some are in the top 10% of high responders, with excellent results from any product they try. In my pediatric population, I see about an 80% response rate with about 15% not responding and less than 5% having unwanted effects.
For those on opioids, cannabis can provide a gateway away from these dangerous addictive drugs. We see high numbers, like 60-70%, for patient satisfaction and many can reduce or eliminate opioids. On the science side, opioid receptors and cannabinoid receptors can form heterodimers, meaning the receptors form a partnership on the cell surface and will work synergistically. Adding cannabis to a regimen of opioids may result in a reduction or elimination of opioids as there is synergy for pain relief. There’s no added respiratory depression or risk with the addition of cannabis to a regimen with opioids. It’s very safe.
Advances: Through all of your research what still surprises you or is there an aha moment?
Dr. Goldstein: That’s a great question. I’ll share a story about my dear uncle who will be 92 in a few months. He played lots of sports and also was in the army, where he unfortunately destroyed his knees. He loved to travel the world with my aunt and for many years, suffered with knee pain on these trips. Over the last decade or so, he has been unable to walk even short distances. Since he also has heart failure and stage-three kidney failure, he was reluctant to get knee replacement surgery. About two years ago, he told me he could barely walk at all. I started him on the raw form of CBD called CBDA (cannabidiolic acid). Research on CBDA shows it is a potent anti-inflammatory through multiple receptor and enzyme targets. I asked my uncle if he would be comfortable taking it, noting it was non-impairing, non-sedating and there were no issues with drug interactions with his cardiac medications. He went from barely being able to walk, to walking two miles every day without pain. He saw an orthopedist recently and after evaluating the X-rays that showed marked knee deformities and severe bowed legs. The physician said he was shocked my uncle could walk at all.
Advances: Thank you for sharing that story. Do you think one day cannabis will get the official approval to move from a Schedule 1 to a Schedule 3?
Dr. Goldstein: Over the past two decades, there’s been a tremendous amount of research published that supports the medical benefits and safety of medicinal cannabis. Given this evidence, I believe cannabis should be descheduled entirely. It’s such a valuable tool in a clinician’s toolbox.
Unfortunately, the medical community tends to be quite conservative, and many are still reluctant to embrace it. As physicians, we’re trained to be good students, and we all learned in medical school that cannabis is a drug of abuse. It’s hard to change that mindset. But as doctors, we have a responsibility to stay informed and open-minded, especially when it comes to something that can help our patients. I think all clinicians should be able to have an informed conversation about cannabis with their patients if they ask. That’s actually one of the reasons I wrote my book, to help bridge that gap and provide more information.
Advances: We covered quite a lot of ground, but anything you want to add, medically?
Dr. Goldstein: As a fairly conservative, “do no harm” physician, I find cannabis to be an incredible medication, especially when used under medical supervision in appropriate situations. I just don’t think it serves us well as clinicians to continue to deny what people are reporting and what we are seeing in terms of reduction of symptoms and cessation of riskier medications. We now have this great body of medical reports that support a trial of cannabis in patients who may be struggling because it is so safe and there are so many options.
Advances: What is the bast place to find Cannabis is Medicine?
Dr. Goldstein: There are multiple outlets that carry it. I tell people rather than support the big outlets, go online and see the multiple independent bookstores and websites that carry it. I also have some YouTube videos for people looking seeking extra information. My website is Canna-Centers.com.
Lastly, we didn’t touch on my new company, which is called GoldsteinWellness.com. It is a website to educate licensed clinicians about medical cannabis. Any licensed healthcare practitioner can sign up for a free account and have access to a multitude of videos, dosing algorithms, webinars, and a forum to be able to share information.