Of Whip Its and Weed: A Wonderful Doctor’s Wise Words of Wizardly Warning

Interview

Posted February 23rd, 2017

Matt, Jake, and Scott talk to Dr. Josh Britt about the pros and cons of medical marijuana and the practice of doing “whip its.”

Jake

Matt

Scott

  • Tim

    I’ve been so busy listening to The Righteous Mind, A Short History of Nearly Everything, and the Decemberists that I haven’t commented here lately. So first off, thanks for the recommendations, Jake and Glenn.

    Since the pharmacology of mind-altering drugs is the focus of my daily practice and what I teach nurses, medical students, residents, and nurse anesthesia students, I was probably more critical of the information and the organization. But I don’t want to shoot anyone down. Kudos to you all for talking about this, for sharing your insights and perspectives.

    As a TBM, it’s simple to just do what you are told. The transition to making our own decisions is trickier. As I’ve been learning, the human mind is full of flaws. We think and feel like we are rational, but we aren’t. Some people are more impulsive and others are more deliberate. Your message is primarily for the impulsive folks who are reacting to their new freedom from orthodoxy, but it extends to the deliberate people who want to experiment.

    Once in EQ, the EQ president was teaching The Word of Wisdom, and asked me to explain why stimulants are bad. I told the group how we used caffeine to keep premature infants breathing on their own. How we use cocaine to anesthetize the nose and prevent bleeding. How the same pharmacologic mechanisms of ephedra are used to support blood pressure and cardiac output. Context is everything. Is propofol safe? Yes if you are fully monitored and have expertise and equipment for intubation/ventilation readily available. Are psychedelics safe? Maybe under certain conditions. But as I’ve pointed out before, I’ve taken care of horrible traumatic injuries in patients who were using psychedelics. It’s easy to forget that there is more to consider than just direct toxicity of the drug. If you can’t be reliably restrained, you need to consider the indirect risk.

    I could go on an on about this stuff, but I’ll wrap up with a few points I that I think are worth clarifying.
    1. The primary change associated with tolerance is receptor down regulation, not conformational change (change in the receptor shape). When your opioid receptors are activated, the cells make fewer receptors. There are other issues, too, like induction of metabolism, but the change in number of receptors is fundamental.
    2. Nitrous oxide is neurotoxic. It can cause permanent peripheral nerve damage. It is suppresses bone marrow (pancytopenia, anemia, thrombocytopenia, immune suppression). It blocks folate metabolism. It causes nausea. Many anesthesia providers have abandoned the use of nitrous oxide altogether. Your focus was good — it’s the hypoxia that kills users. But I don’t want to miss the point that even though the nitrous goes away quickly, there are serious effects of chronic use.
    3. One of the most common side effects of opioids is nausea. As an intern, I used Marinol (a cannabinoid) to treat someone with malnutrition from nausea and anorexia (lack of appetite). Marijuana is more likely to treat nausea than to cause it.
    4. It’s more about quality of life than pain control. Patients who have a PCA (the push button to give yourself IV pain medicine) have higher satisfaction than pain regimens that do not allow personal control. Pain scores did not determine satisfaction, personal control did. Cannabinoids aren’t great analgesics. But if they help a subset of people feel like they can deal with the pain, they may be a better option than opioids. Or they may reduce the risk of opioids by limiting the total opioid dose. This all goes back to what I talked about in my listener essay about pain.

  • Tim

    I’ve been so busy listening to The Righteous Mind, A Short History of Nearly Everything, and the Decemberists that I haven’t commented here lately. So first off, thanks for the recommendations, Jake and Glenn.

    Since the pharmacology of mind-altering drugs is the focus of my daily practice and what I teach nurses, medical students, residents, and nurse anesthesia students, I was probably more critical of the information and the organization. But I don’t want to shoot anyone down. Kudos to you all for talking about this, for sharing your insights and perspectives.

    As a TBM, it’s simple to just do what you are told. The transition to making our own decisions is trickier. As I’ve been learning, the human mind is full of flaws. We think and feel like we are rational, but we aren’t. Some people are more impulsive and others are more deliberate. Your message is primarily for the impulsive folks who are reacting to their new freedom from orthodoxy, but it extends to the deliberate people who want to experiment.

    Once in EQ, the EQ president was teaching The Word of Wisdom, and asked me to explain why stimulants are bad. I told the group how we used caffeine to keep premature infants breathing on their own. How we use cocaine to anesthetize the nose and prevent bleeding. How the same pharmacologic mechanisms of ephedra are used to support blood pressure and cardiac output. Context is everything. Is propofol safe? Yes if you are fully monitored and have expertise and equipment for intubation/ventilation readily available. Are psychedelics safe? Maybe under certain conditions. But as I’ve pointed out before, I’ve taken care of horrible traumatic injuries in patients who were using psychedelics. It’s easy to forget that there is more to consider than just direct toxicity of the drug. If you can’t be reliably restrained, you need to consider the indirect risk.

    I could go on an on about this stuff, but I’ll wrap up with a few points I that I think are worth clarifying.
    1. The primary change associated with tolerance is receptor down regulation, not conformational change (change in the receptor shape). When your opioid receptors are activated, the cells make fewer receptors. There are other issues, too, like induction of metabolism, but the change in number of receptors is fundamental.
    2. Nitrous oxide is neurotoxic. It can cause permanent peripheral nerve damage. It is suppresses bone marrow (pancytopenia, anemia, thrombocytopenia, immune suppression). It blocks folate metabolism. It causes nausea. Many anesthesia providers have abandoned the use of nitrous oxide altogether. Your focus was good — it’s the hypoxia that kills users. But I don’t want to miss the point that even though the nitrous goes away quickly, there are serious effects of chronic use.
    3. One of the most common side effects of opioids is nausea. As an intern, I used Marinol (a cannabinoid) to treat someone with malnutrition from nausea and anorexia (lack of appetite). Marijuana is more likely to treat nausea than to cause it.
    4. It’s more about quality of life than pain control. Patients who have a PCA (the push button to give yourself IV pain medicine) have higher satisfaction than pain regimens that do not allow personal control. Pain scores did not determine satisfaction, personal control did. Cannabinoids aren’t great analgesics. But if they help a subset of people feel like they can deal with the pain, they may be a better option than opioids. Or they may reduce the risk of opioids by limiting the total opioid dose. This all goes back to what I talked about in my listener essay about pain.

  • Eddy A.

    This episode was full of misinformation. I almost can’t believe this guy is a doctor after hearing some of the things he said.

    • Glenn

      Examples?

      • Eddy A.

        The way he described how methadone and addiction as a whole works. While he is correct that drugs and receptors are like a lock and key, methadone does not “beat” the receptor back in to shape, people are slowly weaned off as their own endorphines take back over. And that’s just ONE example. Like Rick said above me, this episode was filled with bad info.

        • Glenn

          Specific examples like this are far more helpful than trashing the entire episode and leaving us not knowing which parts you think are flawed and which are not.

        • Tim

          Methadone has a stigma because of its use in treating heroin addiction. Which is too bad, because it can be very useful in specific situations.

          Methadone is used for its specific properties. The first is its long half life. The second is its dual actions. Methadone is called a chiral compound, meaning that it is made up of two mirror images of the same molecule that cannot be superimposed on each other. The right hand molecule (the R-enantiomer) acts on the 𝜇-opioid receptor, and the left hand molecule (the L-enantiomer) blocks the NMDA receptor. At very low doses, NMDA receptor blockers tell the neurons in the spinal cord not to turn off the opioid receptors. At slightly higher doses, they block pain signals (nociception), and they may be more effective for nerve pain (neuropathic pain) than opioids alone. Severe burns and spinal surgery for nerve root compression are two specific contexts where methadone is used.

          I’m not aware of any NMDA receptor antagonist effects that sensitize the body to opioids per se (“beating the receptors back into shape”), just that they prevent tolerance and may be helpful as part of a comprehensive plan to wean someone from opioids.

          • Eddy A.

            You guys put on a good show that I enjoy, but you need to have people like me or this guy ^^ that know in detail what they’re talking about…. receptor subtypes, stereoisomers, this is all a very complicated subject. While doctors are obviously educated (they did make it through med school) some don’t know shit when it comes to addiction medicine and its interactions with pharmaceutical science.

  • Rick

    As a health professional who work with chronic pain, treatments and medications this was bad info.

    • Glenn

      Can you provide examples?

    • Me, too. My brother fell from the deck of an aircraft carrier to the steel deck of a barge back in the seventies screwing up his neck in perpetuity. He does far, far better on medical marijuana than he did on the opioids the Navy was always trying to push on him. Opiods actually rendered him suicidal a couple of times. He’s much better off without them and the medi-juana helps a lot with the pain. I’d really like to know what’s wrong with it.

  • Tim

    I’ve been so busy listening to The Righteous Mind, A Short History of Nearly Everything, and the Decemberists that I haven’t commented here lately. So first off, thanks for the recommendations, Jake and Glenn.

    Since the pharmacology of mind-altering drugs is the focus of my daily practice and what I teach nurses, medical students, residents, and nurse anesthesia students, I was probably more critical of the information and the organization. But I don’t want to shoot anyone down. Kudos to you all for talking about this, for sharing your insights and perspectives.

    Once in EQ, the EQ president was teaching The Word of Wisdom, and asked me to explain why stimulants are bad. I told the group how we used caffeine to keep premature infants breathing on their own. How we use cocaine to anesthetize the nose and prevent bleeding. How the same pharmacologic mechanisms of ephedra are used to support blood pressure and cardiac output. Context is everything. Are psychedelics safe? Maybe under certain conditions. But as I’ve pointed out before, I’ve taken care of horrible traumatic injuries in patients who were using psychedelics. It’s easy to forget that there is more to consider than just direct toxicity of the drug. If you can’t be reliably restrained, you need to consider the indirect risk.

  • Tim

    I could go on an on about this stuff, but I’ll wrap up with a few points I that I think are worth clarifying.
    1. The primary change associated with tolerance is receptor down regulation, not conformational change (change in the receptor shape). When your opioid receptors are activated, the cells make fewer receptors. There are other issues, too, like induction of metabolism, but the change in number of receptors is fundamental.
    2. Nitrous oxide is neurotoxic. It can cause permanent peripheral nerve damage. It suppresses bone marrow (pancytopenia, anemia, thrombocytopenia, immune suppression). It blocks folate metabolism. It causes nausea. Many anesthesia providers have abandoned the use of nitrous oxide altogether. Your focus was good — it’s the hypoxia that kills users. But I don’t want to miss the point that even though the nitrous goes away quickly, there are serious effects of chronic use.
    3. One of the most common side effects of opioids is nausea. As an intern, I used Marinol (a cannabinoid) to treat someone with malnutrition from nausea and anorexia (lack of appetite). Marijuana is more likely to treat nausea than to cause it.
    4. It’s more about quality of life than pain control. Patients who have a PCA (the push button to give yourself IV pain medicine) have higher satisfaction than pain regimens that do not allow personal control. Pain scores did not determine satisfaction, personal control did. Cannabinoids aren’t great analgesics — they aren’t good at blocking pain signals. But if they help a subset of people feel like they can deal with the pain, they may be a better option than opioids. Or they may reduce the risk of opioids by limiting the total opioid dose. This all goes back to what I talked about in my listener essay about pain.