A rural Canadian doctor prescribes cannabis for the first time

Canadian ER doctor Tiffany Keenan’s discovery of medical cannabis started with a documentary on TV, something indicative of how many doctors are still uninformed about medical cannabis and the science behind it. She did more research, and soon began prescribing cannabis to patients in her private practice.

Most of her cannabis patients are over 50 and they’re not looking to get high, she says. They’re looking to relieve pain and prefer CBD-based solutions.

“Especially in smaller towns, the word kind of gets out that people are getting relief from this and then they tell their friends,” Dr. Keenan tells The Cannabis Enigma.

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Treating chronic pain with cannabis, Dr. Keenan explains, means that patients can sometimes stop taking more dangerous medications. “What I’ve been so encouraged by is that the patient’s when they start even just using CBD based preparations, they’re able to come off of — many times — opioids.”

Even in a country like Canada, where cannabis is legal for both medical and recreational use, many doctors still have a lot to learn, particularly about the endocannabinoid system, Dr. Keenan adds, referring to the body system that interacts with cannabinoids.

“In Canada now, even though the medical product is legalized there, still many physicians are uninformed that we have this amazing system that has so many receptors all throughout our body with this great potential to help,” she say

Full transcript:

Michael Schaeffer Omer-Man.: What was your journey as a doctor coming to a place where you began prescribing cannabis to patients? What was your journey coming to that?

Dr. Tiffany Keenan: Well, a few years ago I wouldn’t be having this conversation with you because I thought that if people wanted to smoke cannabis they could go and buy it [laughs]. But about a year and a half ago, I was watching a documentary series on television and during that documentary there were many people telling their stories of how medical cannabis had changed their lives. And I’m very much holistically based in my practice. I focus on nutrition, you know, mind, body, spirit, trying to really use a lot of plant-based medicines when I can. And I said, well this is quite interesting that this medical cannabis now is out there. It’s being used.

It has been, you know, physicians have been prescribing it in Canada for over 12 years. And then I said, well, it’s gonna be legalized in our country in October, so maybe I need to learn a little bit more about it. So I contacted some of our local, our licensed producers of medical cannabis and I had one of them sit down with me and, and discuss, you know, the basic indications of how physicians are using medical cannabis and, because patients were starting to ask me if they could get prescriptions. So basically I’d watched the documentary, started to do some of my own basic research and then because of patient demand, I began prescribing medical cannabis.

M.S.O.: For what types of conditions?

Dr. Keenan: So initially it was for chronic pain. Even now that’s the majority of my patients, they’re generally older, like 50, , age and up. They’re coming for — oils is what they want to use. Patients generally don’t want to smoke it. They want something that’s not gonna make them high. So the majority of what I use with my patients even now is still CBD-based preparations. And then things have just kind of started to grow. I think, you know, in, in areas, you know, in, especially in smaller towns, the word kind of gets out that people are getting relief from this and then they tell their friends and so on and so on. And so my practice has started to grow, which is the reason that I’m gonna be expanding my practice now.

M.S.O.: And how do you see it as a treatment compared to other options that are available to you that you’re able to prescribe, that you were able to prescribe in the past. What are the benefits that are making you embrace this?

Dr. Keenan: Low side effect profile. So that’s really important. You know, so many times with opioid medications in particular, you know, people have a lot of side effects. The sleepiness, the dizziness, constipation, just not feeling well. And what I’ve been so encouraged by is that the patients, when they start, even just using CBD-based preparations, they’re able to come off of many times of opioids [laughs] and you know, sometimes I wonder, you know, other physicians, everyone’s not on the same page in Canada yet about the use of medical cannabis.

But when you see a patient that’s been taking long-term opioids come off of that prescription, then I definitely know that there’s a benefit to that patient. And then to our healthcare system overall, you know, in terms of costs, people are not on a lot of higher dose, more expensive preparations. So the pain, it’s low side effect profile and that I can use it across a wide range of age groups. You know, I do have a few children right now that are using for autism. Again, these were parents that came to me and I’m able to give them some medical knowledge to instruct them as to how they can use this for their children. And so far with my two patients, they’re getting good results with their children as well.

M.S.O.: It’s a little bit of a Wild West of, I don’t want to say industry, but of a world, you know, in relation to the way that other medications and medical treatments are… the process that they go through and approvals and trials. Cannabis doesn’t really have a lot of that behind it. Does that provide challenges or opportunities even?

Dr. Keenan: I guess a little bit of both. You know, first one I look at it, you know, we have new drugs they need to be approved because they’re synthetic substances that were created in the lab. Cannabis has been growing for 1000s of years. It’s always been there [laughs]. It’s not a new thing. It’s just a new way that we’re approaching it for a medical use. So you’re right, are we going backwards sometimes to say that we need the studies to show there’s benefit?

It’s been documented that there’s been benefit for conditions for 1000s of years, but now we’re medicalizing it. And so yes, it does create controversy because many physicians are looking for a randomized controlled trial to show what this does versus, you know, drug X does versus placebo. And it’s becoming much more difficult to do that with medical cannabis in human type experiments. And also there is the topic of it is a plant, how do we standardize a plant? And I’m learning so much here at CannX. So you know, I’m just not really knowing the basic science of the plant itself and how it can be changed. So I think we have a lot of safety in knowing that there is something that’s been around for 1000s of years, but now we have to really look at those specific components to know the specific indications for those medical conditions.

M.S.O.: I want to just jump back to something you said in the previous question about it helping patients get off of opioids and other painkillers that has effectively led to one of the biggest health crises in North America in recent years. Do you see more potential like for that to be used to help mitigate or even prevent addiction, either preventatively by stopping people from having to take these medications in the first place or, there’s even quite a bit of talk here at the conference about using it to help people get off of those medications after addiction has already become a problem. Your thoughts?

Dr. Keenan: Oh, I’m super excited on that. I live in, my areas, has a lot of problems with substance abuse, opioid abuse — tons of people that are on methadone and Suboxone, which are replacements for addiction. One of my key goals of coming to the conference was to learn more about that. I have one patient right now who I am, uh, using, uh, medical cannabis. He’s on methadone, he’s on a weaning dose of methadone and he wants us to help in his replacement. And you know, I’d been reading some reports from physicians that are using it in North America to do just that. And many physicians are able to get their patients off over 50% of their other opioids and replacement, huge potential. You know, I think that’s one very big aspect of the market. And also from a physician standpoint to think that we can get people off these long-term, chronic opioid replacements by using medical cannabis.

There’s so much stigma with methadone and Suboxone, the replacements. It really, I think it affects the quality of life of people because they still often have to go to pharmacies on a regular basis to get their dose of the medications. We still have a lot of reluctance in Canada to get patients off of these. You know, when opioid replacements were used, they were meant to be for a 30 day protocol. Patients get weaned off of it to help with the withdrawal symptoms. But now people are on these medications for years and years. So I’m really hoping that this is gonna be one aspect of medical cannabis that’s gonna prove to be more effective. And I know when I go home I’m going to use this more and more with my patients.

The other thing that I’m really interested with medical cannabis is weight loss. So I’m, I studied as nutrition in my background and I, I do a lot of work with obesity medicine and what I’ve had over the past couple of months, I’ve had several individuals that come in and they volunteer to me. “Doctor, by the way, I lost weight when I was using medical cannabis,” and they were on just CBD based preparations. And um, after the conference I’ve kind of, we’ve seen a few other cases that we’re seeing that weight loss can be a side effect and I think even more than our opioid crisis is our obesity epidemic.

So if there’s methods that we can find out, what is that trigger point for obesity that’s in the, or the weight loss, that’s kind of the, what is that role. And I was at an obesity conference in Nashville last October and one of the presenters got up and spoke about the receptors that we have for our endocannabinoid system and how that, that’s what they’re looking at is kind of having blockers that can cause people to lose weight in the end.

So I think that’s a huge aspect that can be increased because opioids are here and it is a huge problem. But, you know, obesity, the, it’s an epidemic in North America — 35% plus. And with it comes diabetes and I think diabetes is the one condition that’s really going to bankrupt our healthcare system, especially in Canada. You know, we have a fully funded health care system and the cost of treating diabetes are rising exponentially. So if we can find some methods that are helping to improve that. And I’ve, I’ve been encouraged, one of the doctors today was discussing the program that they’re doing with diabetes here in Israel.

And I’ve actually messaged him to hear a bit more information about that. So I think there’s a lot more aspects of, of medical cannabis that can be of benefit even beyond the pain. So we have autism, obesity, opioid reduction, and it’s a pretty exciting field to be in. I’d like to say I’m at the ground level, but I’m not because the plants have been here for so many 1000s of years. But to see the field, how it starts to develop.

M.S.O.: Absolutely. My, my last question is, you’re working in emergency medicine.

Dr. Keenan: Mm-hmm.

M.S.O.: Do you see any applications in that field? My understanding is that as far as the pain dimension goes, [cannabis] tends to lean more toward chronic pain and less toward acute pain. But has your increased interest and use, you know, prescribing cannabis, has that affected your emergency practice as well?

Dr. Keenan: The big role in emergency… So, I, I definitely, I’ll bring it up to patients too, especially if there’s a cancer patient or a pain patient that may be in, especially if it’s a chronic pain patient, they’re already on a lot of opioids and they’re still telling me they’re not getting relief.

But from an ER standpoint it’s traumatic brain injury. I see a lot of people with concussion and I was really interested in the talk today by Dr. [inaudible], from Canada. She’s done a lot of work on PTSD but also traumatic brain injury, because we see so many concussions in the ER department. And I advocate for patients like informing them that of all the stress that their brain is undergoing, that things that they need to watch out for. But we don’t have a lot of treatment that we can give patients that have had a concussion.

And looking at some of the early evidence that’s there now, and when we look at the evidence, even just in animal models of what it can do, the neuroprotective effect it can have on the brain. So I will be discussing the possibility of benefit for patients that come into my ER for the use of CBD after they’ve had a concussion. And when I see the long-term consequences, I think if we can get patients early on when the brain is just undergoing that, that early on damage, I know that we can have greater long-term outcome for those patients.

The other thoughts I’ve had for it is in acute anxiety. You know, when they come into the ER department now, you know, many people come in, they’re having a panic attack. So we’ll give them maybe an Ativan or some type of benzodiazepine for them to relax. And I’ve really wondered about is there a way, if we had something that we could give them, whether it was an oil or a vaped preparation, that would work really quickly, how that would take effect in the ER department. It could be an interesting study [laughs]. I’m, I’m not sure what work’s been done acutely in the ER department, um, but, but we’ll see. But I definitely see many potential benefits and roles for sure.

M.S.O.: And one actual last question. Is there something that you’ve learned over the past few years or here at this conference that you wish you had been taught or told as a physician, you know, earlier in your career or?

Dr. Keenan: Well, just to learn about the endocannabinoid system. Really even as of a few years ago, I’m just learning this and in Canada now, even though the medical product is legalized, there are still many physicians that are uninformed that we have this amazing system that has so many receptors all throughout our body with this great potential to help. We know about our sympathetics and our parasympathetics and many of our other endocrine systems. But the endocannabinoid system is really one that we don’t seem to be as well educated about. So that would be the one word that I know I wanna spread with my colleagues when I go back home again.

M.S.O.: Thank you, Dr. Keenan.

Dr. Keenan: You’re welcome. Thank you.

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