Cannabis and psychedelics: stigmatized substances or powerful therapeutics?

Dr. Kevin Boehnke talks about cannabis, psychedelics, and the increasing body of evidence for their legitimization as therapeutics.

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Today on The Fundamentals is Dr. Kevin Boehnke, research assistant professor in the Department of Anesthesiology and the Chronic Pain and Fatigue Research Center. His current research focuses on therapeutic applications of cannabis and psychedelics. His goal is to rigorously assess appropriate use of these substances and to help address the public health harms caused by their criminalization.

You can learn more about Dr. Boehnke here, and you can follow the department of anesthesiology @UMichAnesthesia on X.

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Transcript

Kelly Malcolm:

Welcome to the Fundamentals, a podcast focused on the incredible research at the University of Michigan Medical School. I'm your host Kelly Malcolm.

Jordan Goebig:

And I'm Jordan Goebig. I was really excited to chat with our guest this week who's collaborating with U of M colleagues to lead efforts in better understanding the use of cannabis for pain management and other applications. There have been many collaborations and studies taking place at Michigan focused on pain management, but this will be our first, but hopefully not our last cannabis-centered podcast episode. As clinicians look for alternatives to opioids. This past year, Michigan Medicine published a study finding that while the prescription of opioids for patients post-surgery has declined, the decline is happening at a slower rate than several years ago. The study team notes that surgeons shouldn't completely eliminate opioid prescriptions post-surgery, but more work needs to be done to minimize unnecessarily large prescriptions.

Kelly Malcolm:

And this next study we're featuring this week is also about cannabis. It found that more older Americans are using cannabis than before the pandemic. With 12% saying they've consumed a THC-containing substance in the past year, and 4% saying they do so multiple times a week. This is all according to a study of people aged 50 to 80, part of the national poll on Healthy Aging.

Jordan Goebig:

For folks that want to know more about topics related to pain management, we have a significant amount of research stories written about this topic as well as a number of collaborative projects going on. We'll make sure to provide links in the show notes. Now, let's get to our guest.

Kelly Malcolm:

In the studio with us today, is Dr. Kevin Boehnke. Dr. Boehnke is a research assistant professor in the Department of Anesthesiology and the Chronic Pain and Fatigue Research Center. His current research focuses on therapeutic applications of cannabis and psychedelics. His goal is to rigorously assess appropriate use of these substances and to help address the public health harms caused by their criminalization.

Jordan Goebig:

Welcome, Dr. Boehnke.

Kevin Boehnke:

Thanks so much for having me.

Jordan Goebig:

Yeah, we're really glad that you could be here today. So I get to kick us off with the hard-hitting question of if you could tell us a bit about your journey to Michigan.

Kevin Boehnke:

Well, my journey to Michigan began as I guess an infant when I showed up in, I think it was Mott Hospital. Yeah, it started out then, and I did all my schooling in Ann Arbor, and then went to U of M both for my Bachelor's of Science and then my PhD in public health. And then after grad, joined the Department of Anesthesiology as a postdoc, and now I'm a faculty member.

Jordan Goebig:

Wonderful. So what led to your interest in studying pain management and cannabis?

Kevin Boehnke:

The thing that led to my interest in cannabis and pain management was, I was actually diagnosed with fibromyalgia, which is a chronic pain condition when I was 22. And this is often a diagnosis by elimination, it takes a long time to figure out what's going on. And I learned along the way about how challenging it was to get adequate care for my pain. And once I got that diagnosis, I ended up pursuing a PhD in public health. I realized, oh, well. One, there's a pretty big public health need on the pain side of things. And then also on the public health side of things, cannabis is becoming so much more available. So I attended a talk that was given at the School of Public Health by somebody from the National Institutes on drug abuse, and they talked a lot about cannabis and how it affects executive function and what happens when you drive under the influence of cannabis.

And I was sitting there thinking, "Well, what about all of the people who are using cannabis medically?" In Michigan, we have legal, medical cannabis. There's thousands of people who use it, why don't we see what their experiences are? And so I contacted Dr. Dan Clough, head of their Chronic Pain and Fatigue Research Center, asked him maybe we should do a study to figure this out. He thought it was a great idea. I put together a little survey and collaborated with some folks at a local cannabis dispensary to see what happened when people started using cannabis for any number of reasons, including pain. And many people said, we decreased our use of opioids. In some cases, totally stopping use of opioids as the result of cannabis. And our quality of life is better and overall use of medications is down.

So when I saw those results, I looked at them, I was pretty astounded, and then went to Dan and said, "Well, so is this something that we can actually do work on?" And he offered me a job.

Jordan Goebig:

Amazing.

Kevin Boehnke:

So the answer to that was yes. And so I finished my PhD where I was studying water quality, I was studying transmission of stomach bacteria that causes stomach cancer and switched into the pain and cannabis space and have been in that ever sense.

Jordan Goebig:

Wow, that's a pretty amazing journey. Quite a shift, but very-

Kevin Boehnke:

Definitely a shift.

Jordan Goebig:

Clearly very needed based on just that, it sounds like smaller survey and now there's a career, there's centers, there's collaborators all working with you on this issue.

Kevin Boehnke:

Yeah, there's a lot going on. I did not think from just doing this one-off side project, which is what I thought that was, that everything would've come to be as it is now.

Kelly Malcolm:

Very cool. So I know a lot of your research has been into how people use cannabis to alleviate their symptoms. Do we know fundamentally what is in cannabis that might lead it to relief pain for folks?

Kevin Boehnke:

That's a great question, and maybe to answer this question, we do have to step back a little bit and get more into the why we know what we know and why there's so much that we don't know, which is because cannabis has been criminalized for so long under the first, under the Marijuana Tax Act and then the Federal Controlled Substances Act in 1970, we have not been able to test for all the therapeutic properties of the hundreds of compounds found in the cannabis plant. So we know about Delta-9 tetrahydrocannabinol, THC, we know a bit about cannabidiol, CBD. But there's hundreds of other active components that are found in there that had we discovered the cannabis plant like say 10 or 20 years ago, and it didn't have all of this cultural baggage and challenge associated with it on the political and law enforcement side of things, I think we would've looked at it and said, "This is a pharmaceutical goldmine."

This plant has so much therapeutic potential and it's relatively safe. You can't die of a cannabis overdose, practically speaking, take a lot, a lot of effort to make that work. So all that being said, what we do know is that on the pain relief side of things, pain is not just the physical sensation of pain. So it also gets in the way of sleep, people who have chronic pain have more sleep disturbances. When you don't sleep well or you're in pain all the time, you also have mood issues, tend to be more anxious, higher rates of depression as well, and other sorts of things. And so when you take all of that together, cannabis can act on pain symptoms in multiple different pathways.

So one, it could be the sensation of pain itself. So there are some studies showing that THC can reduce the unpleasantness of pain. Similarly, in non-human animal studies, CBD can dramatically reduce inflammation. So those are some ways that it could directly interact with pain. But also CBD is associated with reductions in anxiety. If you take some, there's quite a number of studies at this point, including small clinical trials and surveys showing that people who take CBD report reductions in their anxiety after taking it.

If people are less anxious, they're less stressed out about their pain, that might reduce pain symptoms. Similarly, THC can help with sleep in some people. And if people are sleeping better, their pain gets better. So there's all sorts of different pathways that it can be interacting with pain symptoms, but so much depends on how you take it. Do you smoke it? Eat it? Use it topically? How much you take? So there's some studies showing that if people take too much, their pain gets worse. So there's a sweet spot. And then when you take it, if you want to use cannabis to help with sleep, smoking a joint in the morning probably isn't going to be the best way to help, but maybe having a capsule or something before you go to bed might be a better way to approach that.

Kelly Malcolm:

Right. So I mean, cannabis is undergoing a renaissance and image change with it becoming decriminalized in a lot of areas, but it still has all this baggage as you said. How has that really affected your research and the whole field that's looking at this plant?

Kevin Boehnke:

Yeah, it's a great question. I think the main thing that criminalization and cultural baggage does is it just blocks what's possible. So to give an example, I live in Michigan, you both live in Michigan, you can go into a dispensary and buy one of hundreds of products, and then you can go home and take it and do whatever you want with it. I as a scientist, can walk into that dispensary, but I can't purchase those products and use them in any kind of clinical trials, I can't often take them back to a U of M lab to even test them for quality or even do non-human animal studies to see how those might affect the body and might be helpful or harmful. And so what that means is all the products that are out there, we don't really understand how similar or differently they might affect people's pain or other symptoms compared to those that are pharmaceutically available.

And there's only a handful of those, which are synthetic THC, also called Dronabinol. CBD as Epidiolex, which has been tested in clinical trials and shows a very powerful anticonvulsant effects. So helping with seizures and people with orphan epileptic conditions like Dravet syndrome. And then a THC analog so it's very similar chemically to THC, but stronger called Nabilone. And those products don't have the same sort of formulations, those are typically taken orally, so you can't use a topical of Dronabinol or something like that. And so you're effectively not... While there's some chemical similarities between what's available pharmaceutically and what we can buy in dispensaries, there's such a greater variety in what's available in the dispensaries that it's tough to say that the clinical trials that are done with these pharmaceutical products accurately represent the sorts of benefits and harms that people might get from these generally available products.

Jordan Goebig:

Yeah, that makes sense. I feel like I do personally know of people who go to dispensaries, and they're going and they're getting stuff to manage pain and sleep issues and anxiety, and it feels like they're just trial and airing what they're getting. And so what you're doing and getting more access would help them if there were studies coming out saying, here, take this-

Kelly Malcolm:

This is your dose.

Jordan Goebig:

Take it. Yeah, yeah. Those sorts of things.

Kevin Boehnke:

Yeah, I think it would be helpful. And I think also one of the challenges there too is in a clinical trial, you typically test one product in a single way. But the studies that I and many other people have done show that people like to take cannabis in multiple different ways. Like, oh, they might want to have a tincture for pain in the daytime that has CBD, but then have a CBD edible or tincture or vaporizer at night to help them sleep. And including all that variability in the context of a classic clinical trial is not very easy to do. So I think to your previous question, one of the things that I'm pretty excited about with the current work that I'm doing is it forced me to be creative in a way that wouldn't necessarily have happened if all this stuff was legal in a way that would be easier to study and honestly would be better from a public health standpoint.

But for example, one of the studies that we're doing, we're teaching people, in this case, veterans with chronic pain, how to select and use the available cannabis products in the marketplace to help optimize their own pain symptoms. And so me with fibromyalgia is not the same as somebody else with fibromyalgia, is not the same as somebody with rheumatoid arthritis. So we're helping tailor people's treatment plans, I guess I shouldn't even say treatment plans. We're helping tailor people's choices to the specific symptoms and needs that they have, and then providing them with the support and feedback to help them not feel upset if they take too little and don't see an effect, or if they take too much and get concerned. We provide that sort of feedback and support that they would need to help them continue to move wisely forward with whatever cannabis they're trying to use as pain medicine.

Jordan Goebig:

So something that you had mentioned really briefly earlier was that there has been some studies showing that too much cannabis can also not help with pain management. Are there any other potential risks to using cannabis?

Kevin Boehnke:

Yeah, absolutely. I think one of the great falsehoods that's put out in the cannabis space is like, "Oh, this is a harmless plant." Anything that you put in your body could potentially have some risks, could potentially have some benefits. So one of the things that I always think back to from my PhD is the dose makes the poison.

This is a classic idea in toxicology. So yeah, there are plenty of known risks. So in the short term, things like dizziness, altered mood, sleepiness sometimes is not good, you get behind the wheel of a car, you don't want to be sleepy. For people who are inhaling cannabis, smoking or vaporizing, that's not good on the lungs, it's not good to inhale heated air. And then there are some other things as well. So there's obviously the risk of dependence, abuse, addiction that's lower with cannabis than with many other available substances like nicotine and alcohol and opioids. But it does still exist. So about 9% of people who use cannabis have some sort of dependence or addiction issue in their lifetime. And that goes up if people start using cannabis in adolescents, especially if they're using heavily or on a daily basis.

So certainly things that we should be aware of and cognizant of moving forward. But I will say that point though about it not causing a lethal overdose is something that makes it stand out compared to many, if not all conventional pain medications. We don't talk about it much in the context of the opioid crisis, but many thousands of people are hospitalized or die from using NSAIDs chronically like Tylenol or ibuprofen or aspirin. So obviously there's the opioid side of things too, but even these things that are over the counter still cause quite a lot of harm.

Jordan Goebig:

Yeah, nothing you said made me any more concern than a traditional American pharmaceutical commercial makes me feel. Honestly less concerned because there's some scary things out there that are-

Kevin Boehnke:

Said very quickly, five [inaudible 00:17:48] at the bottom.

Jordan Goebig:

Yeah, the quick thing at the end. No, but thank you for sharing that. So is there any evidence that cannabis could be better than opioids for pain management or other pain relief medications?

Kevin Boehnke:

So this is a space that, again, that cultural context that criminalization has really been challenging in that there's no direct head-to-head studies at this point in time. Those would be the sort of evidence that I would love to see that I think a lot of physicians and policymakers would love to see. But if you want to look at less direct evidence I'd say, the current data on opioids and chronic pain suggests that for most people, they're not a good choice. They're not the right choice. And when people take opioids for a longer amount of time, they'd have a higher risk of all the things that go with that. So including dependence, overdose. And of course, the side effects of opioids are also pretty rotten, like constipation for example, is really tough.

So on the risk profile, cannabis far outweighs opioids in terms of safety. When it comes to the benefits, the data are more mixed. But I think so often we put too much energy into saying what the reduction in pain is on a zero to 10 scale instead of looking at the overall global way that a pain medication affects somebody. And so putting somebody on a medication that has, even if it's an equal, causes an equal amount of pain relief, but one can kill you and the other one can't. It's pretty straightforward in my mind. When you start looking at other medications besides opioids, I think it becomes less clear cut, especially thinking about things like the possibility for abuse potential, thinking about intoxication, especially those products and dispensaries can be very high potency, THC or high concentrations of THC. And so using those and getting behind the wheel of a car or something, it just becomes less clear cut in my mind.

But I think as more and more studies come out, it'll be increasingly possible to get a better sense of where cannabis should fit in on that sort of treatment pathway. I think a lot of people right now, and I've seen some position papers on this, people say, "Okay, try everything else. And then cannabis and then opioids when it comes to medication." I suspect with more data, cannabis is going to move up that treatment pathway. But I think a lot of that is also affected not only by the quality of evidence for the things that we've talked about, but also still a lot of stigma and a lot of... If you look at, for example, a class of NSAIDs or opioids or something and what physicians get training on, and then you look at medical cannabis free pain, they don't get almost anything on medical cannabis free pain. So there's a big education gap there too.

Kelly Malcolm:

I imagine that obviously the opioid epidemic is still ongoing and it probably is opening people's minds to exploring other drug relief therapies. Do you feel like the opioid epidemic has impacted this field and looking into cannabis?

Kevin Boehnke:

Absolutely. And you can look at that in a couple ways. One is just looking at the news. There's so many articles and podcasts like this one or other things where people are talking about, "Well, when is cannabis appropriate to use? Can it be a substitute for pain medications or other medications? Is cannabis an exit drug versus a gateway drug?" Those sorts of conversations. The other place you can look at is the funding. So the National Institutes of Health have come out and said, "We believe enough in the therapeutic potential of cannabis that we're going to fund all sorts of studies." Including a recent study that I and Dr. Chad Bremmer in anesthesiology were awarded from the National Institute on Arthritis, Musculoskeletal and Skin Diseases. Wow, that's a mouthful. Looking at whether CBD might help people reduce their use of opioids after knee replacement surgery. So the funding is there in a way that it wasn't historically. Historically, almost all the money on cannabis from the government was channeled into looking at abuse, harm, addiction. It's still more biased in that direction, but that that's changing quite a bit.

Kelly Malcolm:

So I know that you are also interested in psychedelic compounds. How has this changing attitude about cannabis maybe opened the doors for research into psychedelic use?

Kevin Boehnke:

Yeah. This is a space that I think takes a lot of excitement. And for me, when I look at the legal landscape of what's happened in the US as of today, October 24, 2023, we have 38 states with legal medical cannabis, and I think 23 with legal adult use cannabis, and then the District of Columbia. And what this does is it has laid the groundwork legally speaking and precedent-wise, for establishing commercial markets for selling Schedule I drugs, which according to the Controlled Substances Act, these have a high addiction potential and no accepted medical use. Yet, we know the medical cannabis industry is a multi-billion dollar industry and explicitly as medical in the title, even though it's separate from the medical system. All this being said, that precedent that cannabis has set up, it's the exact same thing that people are saying about psychedelics like psilocybin containing mushrooms and LSD or MDMA. And the same states that started out passing those medical cannabis laws or the adult use cannabis laws, so Oregon and Colorado right now, have done the same decriminalizing psychedelics.

And if you look at the bills that are popping up both in municipalities and states across the country, it's very likely going to follow the same path in a lot of ways. I think there are a couple key differences, one of which is that... Well, I guess this isn't too much of a key difference because there's FDA approved THC back in the 1980s for HIV and AIDS and cancer related and chemotherapy, nausea and vomiting. But the FDA is designated psilocybin the active ingredient in magic mushrooms. And MDMA known as Molly or Ecstasy, both of these are granted breakthrough status to treat psychiatric conditions like major depressive disorder and post-traumatic stress disorder. So there's this parallel system that's showing up again with psychedelics similar to cannabis, where there's the pharmaceutical pathway and people are pursuing that.

But then the states are doing the same thing with cannabis as being like, "Well, we shouldn't be locking people up for this. We know that there's some science suggesting that this can be helpful medically." And for your mushrooms, they're mushrooms. It's just like cannabis is a weed, it's pretty easy to grow these things. And the momentum is following the same groove. And you can see that also by events like in Ann Arbor of a Entheofest or Hash Bash. Hash Bash was there, it's been going on for decades. People meet on the diag, advocacy speeches, smoke cannabis, music. And then Entheofest 2021, we have decriminalized psychedelics in Ann Arbor, and now there's a local advocacy event on the diag. There's mushrooms being handed out or sold there, and speeches and other things going on. And many of the cannabis players are also in psychedelic space too. So there's just a remarkable amount of overlap in how those models are proceeding.

Kelly Malcolm:

And you particularly are interested in using psychedelic therapy for what conditions?

Kevin Boehnke:

Free fibromyalgia.

Kelly Malcolm:

Okay.

Kevin Boehnke:

So things come full circle.

Kelly Malcolm:

Yeah.

Jordan Goebig:

Okay. So before we end things today, we wanted to make sure to give you an opportunity, you've done a great job of actually weaving in some of your work as you've been answering our questions already, but are there any specific upcoming projects or publications that you want to discuss or any collaborations that you want to give a shout-out to and talk about?

Kevin Boehnke:

Yeah. Gosh, I don't want to have a 15-minute segment on this, but there's just so many wonderful colleagues and collaborators and mentors at U of M who I would shout out. But in the interest of time, I'll focus on the specific study team. So the Chronic Pain and Fatigue Research Center has just been such a wonderful space for me to get my understanding of the cannabis space of psychedelics, of pain from more of an academic to complement my lived experience angle. The Michigan Veterans Cannabis program that is funded through the state of Michigan is just a fantastic group of collaborators. And I think some of the work that we're doing, that trial of teaching people how to use cannabis for chronic pain, I think is one of those spaces that really fits neatly in this gap of how do we work skillfully in the space while cannabis is criminalized, but is so widely available.

So I am really appreciative of that team. The CBD following knee replacement surgery is another excellent study and collaborative group that I'm grateful to be a part of, as well as then there's so many little side projects here and there. But the last one I'll mention too is... I guess this isn't much of a side project this is my first NIH funding, but looking at the effects of CBD versus THC in folks with knee osteoarthritis to understand whether those might affect different types of pain differently, and the study team for that has similarly been truly wonderful.

Kelly Malcolm:

Do you want to say anything to other researchers who might be interested in getting in this space or medical professionals who are maybe getting their training now and want to be able to speak from an informed physician about cannabis for their patients?

Kevin Boehnke:

So I think I would say a few things. One is listen to your patients, them coming and saying that they're using cannabis is often an act of courage. There is stigma associated with this use. We're still locking up hundreds of thousands of people when the US for doing so, for using cannabis. And so to acknowledge and honor that authentic showing up in that relationship, I think is super important. And then by listening and saying, "Well, how are you using it? What are you using it for? If you want to use it medically, let's talk about that. If you want to use it for some other reason, that's fine too." It's legal in Michigan. So maintaining that openness I think is probably the most important step. And then if somebody is choosing to use it medically, treat it like any other medication. So come up with a treatment plan, come up with some suggestions of how they might track their symptoms, what constitutes treatment success and failure, and then also ideally getting a sense of what they're actually doing now so then it's possible to modify that skillfully in the future.

So that I think on the patient side of things and in those interactions. When it comes to the, what I would say to researchers in this space, if they're trying to get into it, it's a lot more crowded than it used to be, but there's still so many questions that could be answered that we don't have the answers to. I think one of the guiding principles that I've had for myself is like, "Yes, this is interesting science. It's fascinating from all the perspectives of zooming in to understand what's happening in the body." But I would encourage people to not let that take up too much of their view and still be able to zoom out so they can still see the big picture.

Like one, this wasn't possible to study in this way for many decades, and the people who put in the work, certainly not me, many people push this forward on the advocacy side of things and the policy side of things in the scientific side of things, doing just tremendous lifts to make this possible. And so acknowledging and honoring that both through the sorts of questions asked, but also by saying, "We should not continue to lock people up for this. This is unjust policy." And both from a public health perspective as well as the scientific and compassionate and medical perspective, we should be doing something different.

Kelly Malcolm:

Well, this has been extremely enlightening and we really appreciate you joining us and fighting the good fight all for our patients and just society in general because it's sort of an injustice that's just gone on too long around cannabis. So thank you.

Jordan Goebig:

Yeah, thank you so much for coming. I'm looking forward to chatting more with you in the future about some of the other topics we touched on today. This has been really helpful for me, and I expect that our listeners will feel the same way.

Kevin Boehnke:

Thanks so much for having me. It's been delightful chatting with you all.

Kelly Malcolm:

The Fundamentals is produced by the Michigan Medicine Department of Communication in partnership with the University of Michigan Medical School. Find us and subscribe wherever you listen to podcasts.


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