Dr Attam Singh: those are negated by the fact that the actual chemicals that we are using, the cannabinoids and stuff, do not have any effect on those areas. So in actual fact, the science and the pharmacokinetics and the dynamics when we work it out, the safety profile actually when we look at it is really good, and the risks of any serious side effects in the immediate phase is really, really good. So we don't really have those concerns where we would sort of have with opioids. So hence the reason why nowadays people are thinking maybe we are sort of in the phase of suggesting that actually, instead of taking these long-term opioids, maybe we should be trying something else, and cannabis may well be the area that we need to go down.
Dr Rupy: Welcome to the Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests while we discuss the multiple determinants of what allows you to lead your best life.
Dr Rupy: On the podcast this week, I welcome again to the show Dr Attam Singh, a clinical associate of the London Pain Clinic. Dr Singh first joined us back in April for one of our COVID-19 special episodes and I'm delighted to have him back on the show today. He is a consultant in pain medicine, he's very experienced in both the assessment and treatment of pain, and he also specialises in musculoskeletal and neuropathic pain of either single or multiple origin, providing personalised, holistic approaches to treating and performing interventional procedures actually when necessary. More recently, he has become one of the few registered practitioners using the cannabis plant and its constituents, namely THC and CBD, which we talk about a bit more in the podcast, in varying proportions to treat a variety of conditions and more specifically in his case, pain. Now, CBD is something that I'm asked about constantly online and offline by colleagues and patients alike and that's why I've been meaning to do a series of episodes on CBD and this is going to be one of them. On the show today, we talk about the cannabis plant, what it is and where we find the useful chemicals, THC and CBD more specifically, the difference between synthetic and natural sources of the plant chemical CBD, the endocannabinoid system, I'm glad I was able to pronounce that in one go, the entourage effect, you'll know exactly what that means at the end of the podcast. We also talk about the lethality of cannabis compared to other drugs of both medicine and recreation, the complexity of chronic pain patients and why CBD has a role, as well as the difference between prescription and OTC preparations and the delivery mechanism of CBD as well. I really hope you can catch the recipe that I made for Dr Attam on YouTube. This is just the podcast bit where we talk about his speciality and experience, but I think you're going to enjoy the recipe as well. It's a delicious mushroom recipe where I add lentils and spicy tomatoes, sweet paprika, it's a delicious one, you'll find it on YouTube. And remember you can check out the newsletter where we give weekly recipes at thedoctorskitchen.com, sign up now and for now, on to the podcast.
Dr Rupy: So, thank you so much for coming back on the podcast, second time. We were introduced by Dr Amy, who's based in Sydney, who's a wonderful practitioner, GP, also practices a bit of functional medicine, is an interested in CBD as well. I wonder if you could just tell us a little bit about your background, medical history, not your personal medical history, you know, your history in medicine and and how you got into pain medicine.
Dr Attam Singh: I think like all of us who who have done medicine, it starts pretty much from a young age, doesn't it? I mean, my dad's a GP, get sort of pushed into that environment of medicine and, my brother and my sister got nothing to do with medicine. And so it was pretty much on me to be that doctor. But it was voluntary, it was voluntary and it was something that I was want always wanted to do. Got through training in London and then I think the real main thing that I wanted to do, particularly anaesthetics, was being in A&E. And then we just noticed that that when anything difficult or problematic happened that requiring immediate sort of doctor intervention, everybody in the A&E department wanted the anaesthetist to be there. And so that's where I kind of felt that anaesthetics was the way forward because as soon as the anaesthetist turned up into the resuscitation environment, they were all going, my God, yes, he's here. Thank God. And it was, it was so, it was so, it was so, it was a massive relief for the whole of the entire department when the anaesthetist turned up. So I went forth and did that for after I did medicine for three, four years doing the MRCP and stuff like that, you know, spending some time on the respiratory wards. And then during anaesthetics, I think, noticed that pain was a major part of the role and pain management was the major part of the role that the anaesthetist had to do. And I kind of liked the idea of the procedures. I liked the idea of sort of getting involved and doing your own sort of operations in a way. And I like the practical aspects. And then with my background of doing medicine, I think the ability to sort of communicate and talk and speak with patients sort of backed that up. And and I'm sure as as most sort of doctors are aware, chronic pain patients can be quite difficult because they have a multiple number of different problems going on. And I think from there it really took off. I spent some time in North London at the Royal Free Hospital, did my training there, then I went to America for a bit and did in Ann Arbor, did some anaesthetics as well as sort of shadowing some of the team, the pain team around there. And it really just grew and then coming back to London after sort of some sort of like the fellowship up in America, just thought this is definitely something that I want to pursue. And yeah, eventually just started to get the consultant post and developed from there. It's it's without a doubt, it's the most fruitful part of my job. And in the simple way, it's it's kind of, you know, the most rewarding because you get to see the results of your kind of interventions, your processes, your management plans. And you know, it's very easy for somebody to recover from say from a chest infection, but to recover fully from a chronic pain condition can be very, very problematic. And when you intervene with something and they even have a degree of improvement, the response you get from the patients is just unbelievable. So it's, you know, where people may well think it's not rewarding, you know, it can be quite problematic and it's a continuous cycle of trying to help patients which have difficulty in dealing with their own problems. I find it very, very rewarding in other senses.
Dr Rupy: Absolutely, yeah. That really does resonate with me because as a GP, I think, and I think a lot of GPs who listen to this podcast would agree that chronic pain patients are perhaps some of the most complex in terms of the foundations and and and why and what the root cause of their chronic pain. And I thought, I think maybe to give the listener some breadth of of the different types of patients that you see, where does chronic pain have an intersection or the different conditions and and what types of patients do you see in clinic where they've been suffering from pain for a prolonged period of time?
Dr Attam Singh: I think when you kind of look at the the areas where I have worked and done pain medicine, I think it kind of, there are very similar, there are very similar sort of bunch or groups of patients, I would say. You know, you will always meet your quite elderly patient with a multitude of arthritic parts of their body. You might well get, you know, quite severe osteoarthrities and and and various musculoskeletal problems with the elderly population. And that's right the way throughout the the places where I have done pain medicine. But clearly when you try to sort of, you know, I now work up, you know, I do work up in the in the Hertfordshire area and also I work down in central London. The types of patients that one gets with those type of locations does, you know, vary quite a bit. Where in West Hertfordshire, you probably get the slightly older patient who has been, you know, getting on with their life but always had this chronic lower back pain that seems to be quite difficult to treat. They've got on with it, but now they've reached a kind of standstill with their problems and now they just want some help. And what we see is is that, you know, these are very kind of communicative, maybe even very, you know, motivated patients who really do want to get on with their problems and deal with it, but they have very much a wide social sort of support system and that they can actually be, you know, they have lots of help from everybody else. You may well go into central London and in places maybe even the Royal Free, which was more kind of Northwest London. The areas do vary and the kind of type of patients that you see may well be slightly more complex. So they may well have been from, in particularly London, from different countries, they might have experienced different problems and they might have quite a variety of different psychological inputs and sort of backgrounds. And so when you start to kind of break down what exactly do these patients have, they become a bit more complicated and they do tend to sort of have, yes, a pathological problem that you need to deal with, but the social aspects and the psychological aspects that this patient may well sort of suffer from makes that delivery of pain management process so much more difficult. And so it's it's it varies significantly from actually the location that you are working in that determines the type of patients that you see and in particularly Northwest London, we saw quite a lot of abuse, a lot of alcohol, alcohol abuse and and and things like that. And with all the social status making a major, major input into the type of problems and pain problems that we saw.
Dr Rupy: Yeah, yeah. And before we we double click on hemp, marijuana, CBD as a treatment for chronic pain patients, I wonder if you can give us some insight into the suite of tools that you currently have at your disposal in treating in chronic pain.
Dr Attam Singh: I think if you go throughout the kind of the kind of medical pain sphere, you'll get varying degrees of types of um processes that people sort of institute to try and deal with their patients. What I mean by that is that there are a number of pain physicians who tend to be much more holistic approach on how to deal with problems, maybe some exercise-orientated regimes, maybe medication regimes and and and possibly psychological input, which I feel is a very, very important part of dealing with, you know, chronic pain problems, particularly the complex ones. Medications out there can include things like so we all already know, paracetamol and non-steroidal anti-inflammatory, simple analgesics, but of course, out there now with more kind of discoveries and more studies, there's the anti-neuropathics dealing with nerve type pains. And this is ever expanding. And I think, you know, that definitely is a major part, sort of medication control is a major part of our sort of input. And a lot of patients that we see is just is just that. I think when we talk about exercise as well, we kind of feel that that is an integral part. And you know, when you look at some of the podcasts out there, there's huge amounts of information to talk about how one can improve one's ability to mobilize and pain levels just by exercise alone. Now, I'm I'm I'm putting it very basically, but yes, I mean it's physiotherapy, acupuncture, you know, osteopathy, even chiropractors, all this all joins together to giving quite important sort of um management processes for patients. And then there's quite a few of us in the pain sphere who also intervene. And this is what I was talking to you about sort of the technical bits is that we do have sort of processes by which we can intervene with injection therapy and things like that into various parts of the body to try and relieve specific areas that we can see that can be quite sore or painful. And I think that's starting, it's always been there, but obviously with regards to that, there are possible sort of forms of side effects, complications that can occur. So in a way that we would definitely treat these patients, we would always try to intervene in a much more less interventional sort of way initially, dealing with things that are very much attainable and have the least possible complications and side effects rate. If those processes do not then sort of work and the patient still seems to be struggling, then we start to move into the more interventional. And I think that's the probably, you know, that's the way I look at things and I'm sure that's the way that most people look at things is you start working your way down the list to try and see a little bit more intervention to see if that can work. But clearly, it's it's it's towards the bottom of the list and it's something that most pain physicians will look at.
Dr Rupy: Yeah. And so recently, it seems that the UK have now added another tool in the form of CBD. Although I'm quite naive when it comes to the nomenclature of what everything actually means. So I think why don't we start off with a few definitions about where CBD comes from, what plant it's extracted from, and and how long we've actually known about some research on on the plant and its impact.
Dr Attam Singh: So, yeah, I mean, I think it's just on everybody's tip of their tongues now. It's it's everywhere. I mean, you see it in sort of areas of drinks, food stuffs. I was even reading, just listening to a podcast that there's shops in sort of Brighton that just deal with CBD infused products and food. So, what cannabis is basically derived from a plant, cannabis sativa, and it is the sort of, it's the kind of bud of the plant that where cannabis is taken from. And I'm sure, you know, most people have seen a cannabis plant. It's the little, it's the flower on top of the leaf is the product that we use when we're talking about medicinal cannabis. The plant is is is is grown everywhere, really. It can grow in sort of tropical, temperate environments. But in essence, it's the sort of unflowered, sort of unseeded flower that is the where the majority of the cannabis product is found on the plant. We take that sort of bud as such, and then by processing it through a variety of different chemicals, possibly, I think the majority of the ways that are done, it's using carbon dioxide, we're able to sort of extract the essence of the kind of cannabis itself and and draw it into a much more usable format, which is now oil. I think the majority of stuff that we see nowadays in in shops and in medicines, it's more of an oil. And then they possibly, and then what sometimes they add to it is more of a carrier oil to it to give it more of an ability to be absorbed and to be taken in a much more pleasant way. And it is that what we see as the essence of sort of cannabis. Now, if we go into it a little bit more, the actual plant, because it's a naturally occurring substance and it's not really, there are synthetic forms of this sort of cannabis sort of plant as such. There's synthetic analogues of the stuff that is found in the plant. What we see is the actual plant itself and it contains a variety of different products or different chemicals. The two main ones that everybody talks about is THC and CBD. They're very kind of long words. I won't go into try and explain it or try and in any way try and pronounce it. But it's those two kind of endocannabinoids that we always talk about. And it's the kind of variation between the percentages of either that gives us the actual effects that we want when we start to use it.
Dr Rupy: And can you define what exactly an endocannabinoid is for?
Dr Attam Singh: So an endocannabinoid is basically works on the sort of endocannabinoid system. Now, this system is something that's been there all this time, but only more recently has been determined to be such, you know, have such an effect. And when we look at these endocannabinoids, which are these chemicals, they basically replicate some of the products that are already made within us. So there are two main chemicals in us which endocannabinoids sort of kind of work exactly like. And and those are and again, they're very complicated. There's one called 2AG and then there's one called anandamide. And and basically these endocannabinoids, which are basically found in the plant of cannabis, basically do exactly what those chemicals do within the body. And those chemicals within the body, anandamide and 2AG are actually produced within the system. So what we're doing is we're using things that are basically produced by a plant that basically replicate what we already have in our body. So by, so for example, if this endocannabinoid system, which is found in a variety of different parts of the body, and I mean in such a wide part of the kind of system, if we can sort of manipulate that system, it is why that's why its effect is so broad. So if by ingesting or taking it or inhaling those endocannabinoids, we are basically giving an increase in the stuff that actually is within your body and therefore we can help to regulate the endocannabinoid system.
Dr Rupy: And so that EC system or endocannabinoid system is quite integral to pain perception and pain pathways?
Dr Attam Singh: Yes, absolutely. So we talk about where these endocannabinoids sort of take effect. And and in majority of cases, we talk about in medicine, there must be receptors. And it just recently, I think, you know, about 30, 40 years ago, started to develop where these receptors are, and we started to name them. And there's two main, there's a cannabinoid receptor one and there's a cannabinoid receptor two. And basically these endocannabinoids attach onto these receptors and start doing various things. Now these receptors, it's important where they are. They are predominantly in the peripheral nervous system, so in your hands and your legs and your arms, but also it's found within the brain. That's where the majority of the receptors, but also these receptors can be found in other parts of the body. They can be found in sort of blood cells, they can be found in other tissues, they can be found in fat cells, they can be found in the liver and stuff. So hence, where this drug actually attaches to depends on, you know, gives the results that we're looking for. And I think that's that's that's where we're at at the moment. The two caveats that I have to put into into all of this is that we've only really, sorry, we've only really found the two main ones that we feel to be the most sort of important endocannabinoids in in the cannabis plant. But there's more than 100. And so the point of the matter is is that we have at this stage only two main endocannabinoids that we're working on and seem to be the ones that are giving us the effect that we want. But clearly there's a lot more research to be done on the various other compounds that we find within the cannabis plant that we use medicinally now that we need to work on to try and find out how those interact with the body's physiology.
Dr Rupy: Yeah, because from my very basic understanding of the plant, you've got the different phytochemicals that you find. So, you know, you've got terpenes, for example, and you have the the two main psychoactive substances, THC and CBD, but there's also CSG, CBG, a whole bunch of other names of which we haven't fully appreciated perhaps.
Dr Attam Singh: Absolutely. And this is what we I think this is what you're this is what we're talking about is that I think when we start to look at it, I think what what has been determined is is that the specific chemicals of THC when synthetically made don't have as good an effect as the actual plant extract itself because of all these things that you mentioned. So there is certain certain things what we call like the entourage effect and I'm sure that's something that has been mentioned before. The effect of terpenes and flavonoids and the other possible phytocannabinoids and endocannabinoids that we are aware of, together they make the benefit and make the effect of what we're looking for. And and it's just the fact that we have a lack of knowledge of what they sort of do to the body. That's what basically we need to find out more about. And you know, I always put the analogy is that, you know, we use anaesthetic drugs. And we know the way that they work and the, you know, the way that they sort of be are absorbed and the way that they sort of have an the way that they sort of interact with cells, but the actual mechanism of their action, we just don't know. But we're still happy to use them and they still decrease your consciousness and they work brilliantly, but we're still we're still in that stage at the moment. We're starting to work it out, but I think we're still in that stage of exactly how they interact. We still don't know.
Dr Rupy: Yeah, it's quite interesting that, isn't it? Because I always think of the anaesthetist as someone who's very regimented, who knows exactly the correct titre and dose to give patients and understands the mechanism of action and the the the kinetics of how it's working in the body. And and we have this new substance of which we don't really fully appreciate the the broader mechanisms and what you described as the the entourage effect, which I I think is really interesting because, you know, it's it's not just the synthetic component of the CBD and the THC and smaller amounts. It's all the other, you know, plethora of the other orchestra of of of nutrients that you you find in there that can be having effects both peripherally and centrally. So how do we get over that?
Dr Attam Singh: Ignorance, no. I think so I think exactly that. I think I think when we start to look at it, I think, um, it's it's and and I think maybe this is possibly where we're getting into the stage where people are a little bit reluctant to use something that they're not happy with. And I think in the majority of other medical specialities when dealing with, I don't know, aspirin or, you know, another non-steroidal, we clearly know the way that it works on the system and we feel happy that we can work out what to do if we don't take it or what will happen if we do take it. This kind of where I and I completely understand, you know, anaesthetists have a reputation for being very particular and very, very oriented to know exactly the mechanisms of how things are working and we're very technically oriented. So to think that we're in we're using something which we don't fully know all that we need to know about it to make to give it to a patient, but we're still do it. And I and I keep on using the analogy of propofol and anaesthetic drugs is that we're happy to use it and it works brilliantly, but the mechanism we're still not completely sure. I think that just goes to show that we're in this environment where we can see the benefits, we can see it works. We should not be denying our patients the benefits of this particular drugs. Yes, we do need to do more work on it, research and studies on it, but we should not be denying our patients the possibility of using it and gaining benefit from it when we're dealing with such an important thing like chronic pain, which which as you are aware can have such a marked effect on a patient's quality of life.
Dr Rupy: Are there any other mechanisms of action that are perhaps hypothesized as to why the collection of THC and CBD molecules are having an impact on chronic pain beyond the endocannabinoid system?
Dr Attam Singh: I think it it it I think all that sort of information as in where this THC and CBD works, because of that fact that it has the effect of THC in particular has an effect on CB1 receptors and CB2 receptors and works as a, I'm going to agonist, which basically means it just activates your receptors. In actual fact, CBD, it's we're still to reach that stage where we don't think that it works on as an agonist on those receptors. So it has some other effect. So where people would say, oh, it works on the cannabinoid, in actual fact, CBD doesn't typically do that. So some people actually would suggest that it has different effects on the other system, possibly on on other chemicals and, you know, even at certain stages, it was purported that it might have an effects on COX-1 and COX-2 inhibitors, but, you know, that has been that has been refuted. So there is that to be thought about that actually we are getting to a stage where we're starting to develop actually maybe it's not as clear as we originally thought. And where particularly the CBD, which is the stuff which you now get in most shops in, you know, in in various pharmacy, actually fact doesn't work as we thought that it possibly would. It was working in some other way by inhibiting maybe some of the enzymes that are involved with sort of stimulation or excitatory sort of stimulation, maybe works on the enzyme that breaks down these other naturally produced chemicals and that gives you the effect of, you know, THC. It it's still there to be discovered. And I think at this moment in time, we're so we're so we're so geared to working out what the clinical benefits are. At the same time, we still need to do the basic science research to work out what is this doing? What is that doing? And and in particular, when we talked about, you know, flavonoids and terpenes and stuff, what effect does that have? But we're so, because there's so much to be worked out, it's it there's so much going on. I think that's what's keeping it interesting, what what, you know, what is it exactly? And that's why so many people are so so interested with it.
Dr Rupy: Yeah, yeah. I I I like like to think of the analogy of the entourage effect as something like vitamin E. You can either, you know, take it in a high dose in a supplemental form or you can have it in your dark green leafy vegetables or your butternut squash or whatever and you're getting a huge collection of other ingredients as well that may have benefits on a number of different systems.
Dr Attam Singh: Completely. I mean, you know, without we always talk about sort of like, I always think about it as a co-factor, you know, something to add in to help everything work together properly. Without it, it doesn't really work as well. May well work, but when you add in something that sort of, you know, it addresses all the bits and puts everything together nicely and then it works beautifully in a much more efficient way. So that's maybe where these entourage or terpenes work.
Dr Rupy: Yeah, yeah. And and um when it comes to the psychoactive effect of of the plant, I'm assuming it's THC that has the psychoactive component and CBD is.
Dr Attam Singh: So, yeah, I mean, you know, everybody gets concerned about the psychoactive and that's possibly one of the reasons why people are a bit more resilient and resistant to its use. So, THC is, yes, there there is a suggestion that, you know, what we I think terminology is an issue sometimes because even CBD is determined to be psychoactive, but it doesn't have the euphoric effects that sort of is seen in THC. So, yes, it's the concentration of the THC that is caused the majority of the more kind of sticking points and stuff that causes the, you know, the the lightheadedness and the kind of, you know, high sort of feeling. So, at the moment, it's about trying to work out what sort of levels work the best. But let me be clear, sometimes in certain cases and certain individuals, depending on what they have, sometimes a slightly higher THC component is important.
Dr Rupy: Yeah, yeah, absolutely. I think there's some research looking at high levels of THC in a combination product for people with PTSD or have issues with rumination or even, and I don't know whether I'm right in thinking this, but whether THC has the appetite upregulation as well.
Dr Attam Singh: Yeah. See, I think I think that's that's the important bit. When I think what we need to consider is is that actually when we look at the science of it, you know, I just basically mentioned, THC is the one that actually activates those CB CB1 and CB2 receptors. So in actual fact, it has some really very good beneficial effects. When we look at the combination of it with CBD, it can be used for certain things. And exactly that, when we're looking at, say for example, the spasticity in multiple sclerosis, and this is just an example, the combination of THC and CBD together in a kind of a balanced solution, that in particular is something that we kind of want. And so in actual fact, the combination of those two and the levels of them are pretty much the same and we use that specifically for multiple sclerosis patients and and in that sort of effect, we're getting the benefit of THC. So in essence, I think what I try to say to patients is that, you know, and and to people is that do not disband the idea that THC is the bad thing. It's the kind of demonized part of the chemical of the plant. We need it sometimes. And in certain cases, THC itself when balanced quite nicely with CBD works very, very, very well. Thinking about things that, you know, specific, well, multiple sclerosis is one, but if we're talking about, for example, you know, insomnia or inability to sleep, at low levels, you know, THC is quite good for anxiety. And I think that's the case. I think when you start to get the slightly higher levels of THC, since we're talking about it, you kind of get to the effect that it might be anxiogenic, as in it might cause anxiety. But if you get it right and given at the right time of the day, because everybody leads quite an important and quite a busy lifestyle, if you're getting it at the right time of day when they are looking to sort of fall asleep, maybe even sort of rest, if you get the right dose and the anxiety that is sort of associated with its potential benefits, you might well get the fact that actually the combination of both might be beneficial for this patient.
Dr Rupy: Yeah. And and on that note actually, I was going to ask about the doses of each and what what is the proportion of THC to CBD and how that might differ from a product that you can buy from a random store on Camden High Street or something.
Dr Attam Singh: So yeah, so you know, CBD has been around for quite some time and I think yes, Camden seems to be that place where you get those kind of foody substances. But what we would say is is that the to be able to sell it in on a shop floor, in a in a shop, I think the THC content has to be quite low. I think it's in the region of about 0.2%, something like that. And that allows it, the CBD content can be whatever it wants to be, but in essence, if you want to sell it over the counter, it has to be within those limits, the THC content. Which is why afterwards, when we look at prescription, prescription sort of medications, which are sort of carefully controlled percentages, that THC content can be anything it wants to be. Because for example, there are certain, you know, as we talked about, you know, anxiety and possibly, you know, sleep and insomnia and things like that. And in particularly patients with chronic pain, you do want that THC content. So that actual THC content can be quite high. You can even get the ratio where there is 20 times the amount of THC to CBD. So you're getting to the stages where actually there's minimal amounts of CBD, but you know, this psychoactive component that everybody's concerned about is quite strong. The doses that we would the doses vary from patient to patient, but they, you know, as as as you know, and I would stress this, I think in this country, we do have, we're very immature at that stage to work out the clinical aspects of it. And I think, you know, having only just been sort of, you know, an unlicensed prescription since November 2018, we are still very, very early on in the stages, but you know, in America and Canada where, you know, a lot of this has been going on for quite some time, they've sort of sort of thought about what sort of doses we're getting up to. But in CBD sort of levels, I think the optimal doses are in the region of about about 80 to 100 milligrams in a 24-hour period, whereas THC, you're getting to sort of half of that because of this fact that it can be quite anxiogenic, it can make you feel a bit anxious, it can have those psychoactive or euphoric effects. So the amount that is recommended for THC is considerably lower.
Dr Rupy: Right, yeah. And and to that point, how how lethal are we talking with regard to CBD and THC products? And and how do we compare that to some of the other over-the-counter medications that we have like paracetamol or even alcohol?
Dr Attam Singh: Yeah. I I think I think that's the that, you know, I think we touched upon it is that, you know, we we as doctors in this country, we we kind of conservative, we're concerned about side effects. And you know, we can only look, you know, we only have to look across the way to to opioids and the way that that has been dealt with, you know, the oxycodone and and all that sort of problem that has occurred. We are very conservative and we are concerned about the safety profile. And this is potentially a patient, this is potentially a drug that patients are going to take long term. So we we we are concerned about the safety profile. And in actual fact, when you look at the studies, the one of the major problems from regarding the safety profile of cannabis is is is the actual studies show the majority of side effects occurring as a result of recreational abuse. So the it's it's the long-term effects, let's just say. And the problem with that, recreational cannabis in particular is we are unsure of what that contains. And I'm sure, you know, the the the stuff, the quantities, the concentrations that we know of of THC and CBD are just we don't know. And nowadays, I'm sure, you know, they're they're they're laced with other products and you know, LSD or whatever other kind of recreational medications that that, you know, dealers or drug dealers have. The effects of those drugs and the studies that have occurred as a result to detect safety profiles of those of cannabis is is is is is from those type of patients as well as those type of drugs. So there's a lot of confounding factors. And particularly when we talk about recreational cannabis users previously, they may well have, you know, social, you know, psychological and mental health issues anyway. So in essence, when we look at the the studies actually look at the kind of conclusions of the studies, the effect is is that, you know, we have to be careful about its use, you know, they can have severe psychotic effects on on particular individuals when taken in the long term, okay? But we forget to look at the actual essence of the study, which did take out people who are on other drugs, people who were taking, you know, recreational cannabis rather than the GMP recognized medications. And so the influence of those studies have given us a kind of a kind of like a, you know, scared us a little bit to use it. The problem with what we're using now is that this is much more engineered, refined and carefully sort of organized cannabis medications with clear distinctions of exactly what's in the product. And patients who previously were, you know, you know, in the other studies, maybe, you know, recreational abusers of other sort of recreational drugs, are people like you and me who basically have medical problems who need it and are taking it for a particular purpose. So the long-term effects or studies with regards to the safety profile of cannabis are still lacking of of actually the right drug given at the right time for a right particular condition. That unfortunately is still lacking. So we're going to have to wait a few more years before that sort of safety profile comes out. And we're talking about years of use. We have six months sort of evidence to say actually it doesn't cause anything problematic, it's not an issue. But we want years, we want 20 years worth, 30 years worth. And because of it's only recent introduction, we just got to wait a bit of time for that.
Dr Rupy: Yeah, exactly. Because to your point earlier about how chronic pain patients in particular are going to be on these medications for a prolonged period of time, you don't want to find, you know, five years down or 10 years down the line that in the same way someone taking corticosteroids is more prone to having adrenal issues or weight gain or a whole plethora of effects on their bones, etc. So that that's super interesting. And I wonder if there we do have any evidence about the combination effects of recreational use of marijuana and alcohol or other drugs.
Dr Attam Singh: You know, and this is where I think where we're where it's really important to incorporate, you know, randomized control studies with real world sort of science and real world data, which we're getting from parts of the world, be it America or Canada. And it is this is where, you know, and I'm, I would like to say we, you know, maybe an expert in this country, but you know, you've got physicians in America and and Canada who are prescribing it for many, many years. So they really know, you know, from a personal basis how well their patients are dealing with long-term use of this cannabis. And, you know, the the the general sort of consensus is that it's extremely safe. It's an extremely safe sort of medication. And the concerns that one would possibly have with, say for example, opioids, it doesn't really fit the same bill. It's and and and I think one of the most important things to work out and to sort of like if you go down to the science bit of it, is that actually opiate sort of receptors are dotted around all over the place in the body, but in particular in the brain. And in particular at the the respiratory centres and also the sort of cardiovascular or cardio respiratory centres basically. And when you stimulate those receptors enough, the problems occur with opioids where people stop breathing, their heart rate drops and they suffer what we call cardio respiratory arrest. And that's where the long-term use of long-term use of opioids, that's where the problem occurs. What is noticeable about the sort of like the the the actual basic science of and and the receptors that are CBD CBD oriented, they are all over the brain, they're all in the nerves and everywhere else, but in particular in the brain stem, which is where the majority of the cardio respiratory sort of centres are, there is no receptors. Or there's very minimal. And so what we say is is that the risks of developing those kind of complications with regards to, you know, stopping you breathing and then people choking and then suffering cardiac arrest, those are negated by the fact that the actual chemicals that we are using, the cannabinoids and stuff, do not have any effect on those areas. So in actual fact, the science and the pharmacokinetics and the dynamics when we work it out, the safety profile actually when we look at it is really good and the risks of any serious side effects in the immediate phase is really, really good. So we don't really have those concerns where we would sort of have with opioids. So hence the reason why nowadays people are thinking maybe we are sort of in the phase of suggesting that actually, instead of taking these long-term opioids, maybe we should be trying something else and cannabis may well be the area that we need to go down as a as a much more of a safer product rather than sort of opioids.
Dr Rupy: The opioids, yeah, exactly. And with regard to the psychoactive components of it, is there a way that you choose to screen patients that might have a history of schizophrenia or other mental health conditions before you start prescribing?
Dr Attam Singh: You're you're absolutely right. I think I think given the fact that we do sort of, you know, as soon as something comes out, you want to sort of start to sort of use it on everyone. And I think the way sometimes we sort of have been sort of it's been advertised, it seems like the drug for everything. And I think that's a bit scary when you consider what everything is. But um, yes, so I think, you know, we're we're all kind of new in this sort of like field with regards to particularly in this country. And I think the way that sort of like the British Pain Society has sort of thought about it is is that they try to make it quite um kind of broad oriented to make sure that, you know, we're in a phase now where this is being prescribed, but possibly there are some precautions and caveats that we should be putting in front of people to consider as being something that, you know, maybe issues that we may well not use cannabinoids with. And exactly that, I think when we start to consider patients who have a previous history of abuse, medication abuse, I think we have to be very, very cautious. And and patients with possible, you know, uncontrolled psychosis and things like that, we do have to be careful that we do not use it in these patients. Now, these are all relative because you're very, very careful, if you, you know, if you know, obviously, as you mentioned, it can be used for anxiety, depression and, you know, sleep issues and PTSD. Well, clearly we're entering the field of mental health, but then on the other hand, we're saying we've got to be aware of psychosis and things like that. So we just need to be careful to think that, yes, it is something that we have to be aware of, but in a carefully controlled environment, you can use it for this and it can you can use it in patients who have a, you know, a history of abuse. It's a relative contraindication, but it's not an absolute contraindication. I think that's what people, you know, who have had much more experience are saying to us is that we do have to be concerned and as a doctor, you have to take it by case-by-case sort of basis. But in essence, what we're trying to do is just like, right, let's keep it out there. These are the sort of things that we need to be sort of red flagged, we need to be aware of. And you know, and it just isn't about, you know, psychological or mental health issues. We have to be careful with patients who have uncontrolled angina or cardiovascular disease because of the effect it can have on your heart. It can cause you to have a bit of a tachycardia. And so we have to be careful about that. And also the suggestion is is that we don't use it on patients who are less than 25. It's again, it's a it's a thought, it's a it's an idea and we have to take it by case-by-case basis.
Dr Rupy: Yeah, and I think, you know, to your point about how recent the legislation has changed, it's led to a lot of anxiety amongst GPs who are being asked about, you know, the impact of CBD or whether they can get it on the NHS, etc. I wonder if there are resources that are specific for practitioners who are interested in the subject to sort of engage with as a first point of call just to sort of familiarize themselves with the the products that are out there.
Dr Attam Singh: Yeah, I think so I think at the moment, the majority of people's sort of interest comes from now listening on on media. There is so much out there. And I must admit, a lot of the stuff is really good. And I've listened to quite a bit and I think, you know, anybody who has any semblance of interest in social media and stuff, it's it's it's there for you to read about. What seems to be happening now and more is that the licensed providers who actually produce the medicinal cannabis that is okay for prescriptions and is can be prescribed to patients in an unlicensed manner, let's be let's be clear. They're starting to do their job, which is basically education. And there are multitude of webinars, sort of conferences, sort of courses out there. And and actual fact, what we are noticing is actually some of these licensed producers with their um with their sort of individuals and sort of medical liaison officers, they're starting to go out there and starting to explain in a very non sort of biased way, the actual benefits and sort of the cautions with its use. And I don't know about you, Rupy, but you know, I do find that I'm getting approached by a multitude of people just to say, look, would you be able to come and explain things? And you know, and only just the other day, there was a huge sort of webinar that I that was done and it was very, very interesting and it was for everybody. And it was at such a good level that I think a lot of people who are not medical would be able to understand it. But it's a long process and there is definitely education is the way forward. And I and I do feel for GPs because they get given this sort of kind of this box and you're but you're not allowed to open it. In in essence, you said this is what's out there for these patients, but you can't prescribe it. So it's I do, I am sure with the proviso of a specialist, I think there will be some connection between the secondary care and the prescription of it and GP services. So it will be coming closer and I'm sure we won't be seeing in the too too distant future that actually GPs will be able to prescribe it or possibly continue the prescription after the initial initiation of it by a a specialist.
Dr Rupy: A specialist, yeah, exactly. And I wonder if you could speak about the current products on the market that consumers can buy right now and specifically on their potential efficacy, their safety, and whether people should be engaging with these products or or not. Because I'm seeing ointments, sprays, vapes, everything with CBD attached to it. And I think it's going to become one of those things that's so ubiquitous in society in the same way caffeine is, you know, caffeine being the most widely available psychoactive substance that we have across the globe. And it's in everything from drinks to chocolate to, you know, food products, etc. So I wonder if this is the way we're going and whether we're there from a safety profile currently.
Dr Attam Singh: So I think I think so I think we have to take our lead from other countries that basically have gone down this route and and seeing what the complications and problems that have been. At this moment in this country, as I mentioned, you know, CBD at whatever concentration can be given. It's it's thought of as I think a food supplement. So there are certain restrictions on what one can sort of do with regards to it. And there are certain processes by which the person who wants to provide it as part of who has to go through in order to be able to allow it to happen and to and to sell it. The the I think what we what we need to consider is actually as a general rule, CBD in actual fact is a very, very safe type of medication. And and in and what I have found with patients when I do speak to them and I do broach the subject, oh right, so have you ever thought about cannabis? Well, when we're way down the line of having tried a lot of other problems, a lot of medications and treatments, they go, oh yeah, I picked some up from the other shop the other day and it was all right. I don't think it really helped, but you know, I went to sleep fine. So I think it's it's definitely out there and people are taking it as part of their sort of normal routine and it may well not be for the typical problem that I seem to be dealing, which is chronic pain. So when I look at it and see the concentrations in these products that are out there, in actual fact, the majority of these concentrations are quite low and the effect that they have is is relatively quite good. And and and I think the majority of symptoms that I gather from most patients who have taken it have said that it makes them feel quite relaxed. It makes them feel quite well, they feel quite kind of enthusiastic, should I say, and they sleep really well. And those are the three main things that I find that seems to sort of be the main thing about its use. I am aware that the the concentration of CBD at the moment has been increased and now I'm seeing products of 30 to 40%. So it's very, very high. But again, if used in a carefully organized environment, I find there to be not very much in the way of complications, side effects or adverse effects. People must be aware that there are simple side effects that can occur with everything. I'm sure the same would be the case if you were to have a couple of glasses of alcohol. But the majority of side effects that they say is they may have a bit of dry eyes, dry mouth, and they do feel quite relaxed and possibly mildly sedated. Now, drowsiness sounds very, very severe, like you're can't walk and you're going to trip over things, but drowsiness in a in a mild form. And those are the main things. They may well mention they may have some gastrointestinal symptoms, be it sort of loose stools or something like that when it gets to the to that effect. But in essence, it's very, very well tolerated. When we start to look at the effect of, you know, we're slightly moving on to the effects of using THC, that's where the things, the psychoactive component may well have a degree of influence that I think we haven't quite seen in this country yet, you know, because of the fact that it's not legalized and we can only be prescribed on a on a prescription basis. And I think when we go to when you go to America or possibly certain states of America and Canada and you see the way that it's being used on a recreational point of view and it being infused into drinks and into foods, in actual fact, the the the the first initial studies and the thoughts is that actually it doesn't have that much of a kind of a negative effect on society. In actual fact, um the the you know, the amount of admissions into A&E or or or things or road traffic accident has in no way increased in its in in in those areas where the infusion of THC content, which is obviously the psychoactive component, has been okay, has been done. And I think there's massive, massive multi-billion companies now that are, you know, putting themselves forward. In particular, I think the biggest one I know is Corona beers. Those are now being started to sort of like be infused into drinks and stuff. And I think the effect of it is is is not what the major concern was is that everybody was going to drink this drink and just turn out on the street and start having a fight and stuff. It's it's not it's it's not happening. But we still have to be cautious. And and having been to um Canada and look located these places where this is available on the street, um in the shops, it is very, very, very well regulated environments. I mean, the shops are fantastic. They are very clean. Um there is they're not scattered around everywhere. There are still kind of regulated in certain shops. Um and and and yes, I mean, the potential is is that is this going to happen here? Um I think in some format, recreational medicinal recreational cannabis will be available. But you know, let's be clear, the UK is not Canada. And so it will have all of its problems that come with the UK. We do have to be concerned about what the potential of that is when it comes to the point that we're thinking about legalizing cannabis.
Dr Rupy: Absolutely, yeah. I think it's a really good point you make about not comparing, we're not comparing apples to apples here. It's a completely different society, completely different culture, and the way they interact with all recreational drugs is going to be different, particularly in the cities in the UK. So that I just on the point about driving, is there any upper tolerable limit of CBD that's currently available in the UK right now and and the advice on whether you should drive or not?
Dr Attam Singh: CBD is is okay. To use CBD and to drive is is okay. It's just obviously you have to be concerned on what it's infused with if it's with alcohol or whatever that there is available, then you have to be concerned about that. It's the THC content that is still the concerning bit. So if you get CBD from the shops over the counter, that's fine from what I'm aware, but this can this is changing. It's the THC content when we prescribe it as medicinal sort of purposes, that's where the problems arise. And again, you know, the the legislation is, you know, and and legality of driving with it, it needs to catch up a bit because like with opioids and, you know, patients can be on morphine and various other things, the actual sort of thought process is is that if you are in aware impaired psychologically or mentally as a result of taking it, you shouldn't drive. And there are sort of guidance to say that if after taking CBD and THC, you know, medicine, you should wait a few hours before you get into a car and it's not recommended that you sort of operate heavy machinery after you've taken it. If they do catch you, and this is something to to be aware of, they they can sort of take samples and check for your THC content and they can suggest that that is inappropriate and you can be booked or prosecuted as a result. However, providing them with evidence of its, you know, why you're taking it and providing a prescription and your papers, that will all help your case. So at the moment, there's a bit of a grey area with its with the THC use, but CBD at the moment, it's it's okay.
Dr Rupy: Okay. And and specifically through the lens of pain management, what sort of excipients, I guess, or modes of delivery are there available that you find are the most effective?
Dr Attam Singh: Again, I think this is a developing area. I think the main main sort of ways and that which we are delivering it is in an oil format. It seems the most easiest thing to do. And I think, you know, CBD or or on its own or THC and CBD together, the majority of formats in which we provide it is in an oil format. And in that way because the produce or the CBD and I and I use CBD in a broad tense, in a broad sense, I mean cannabis as such medicinal cannabis, which contains either THC, CBD or CBD on its own. It's a much, the way that we prescribe it is in a titratable manner. So we are all very concerned about the side effects and how it affects patients. And I think this is true right the way throughout pain medicine. We always start a medication in a very low dose. And I think that's important to see how it reacts with the body. If you find that initially it's just a very intolerable reaction, to stop a very small amount is very, very easy. So in the essence of using oils, we can then increase the amount that we want to give in a very kind of titratable and easy manner. So hence the reason why we use oils in the first step. And I think that by delivering it underneath the, well, people say you have to put it underneath the tongue. In most cases, people just drop it on the tongue. It's very difficult. And and and when you take it is important. And it's not really to do with the timing, it's more to do with whether or not you're eating or not, because that sort of aids the digestion and and absorption of it. So it's not, I think it doesn't matter whether or not you do it with food or without food, it's more to do with if you're going to do it, just do it regularly with or without food depending, you know, in your own specific way. And I think that's important because the absorption of it is altered by food. So we normally start them on a very low dose, maybe a drop or two, maybe 0.1 mil or 0.2 mil initially, then every three to four days, we just build it up and carefully we get to a point where we feel that actually the symptoms have improved and then we kind of stick on that. The one thing that I would suggest or what I would say about the medication itself is that it takes a long time for it to work. These receptors are probably not really at their full functioning in the body because they've been neglected for whatever reason, which is why you've probably come to come to us with whatever medical problem that you may well have. Those need to be formed and the stimulus for them is pretty much endocannabinoids, CBD and THC. So it's got to get into the system. These receptors have got to sort of make themselves available and that just takes time. So in actual fact, from from from sort of clinical experience, we notice that actually even at the same dose, we see an improved, we see a much more improved effect after maybe two months, three months. So in actual fact, it's the body turning itself open to the actual, you know, cannabis itself that we see that actually even at the same dose, the effects are improved maybe two, three, four months later.
Dr Rupy: Interesting. So it's almost like the reverse tolerability, right?
Dr Attam Singh: Absolutely. Yeah. We don't get very much tolerability in tolerance in in this type of medication, but clearly, you know, this may occur after 30, 40 years. We just don't have the evidence. What we do notice is that actually the body responds to the drug that it's being given with cannabinoids and actually that does seem to actually take effect maybe even three, four, five months later.
Dr Rupy: Yeah, that's fascinating. And and do you think there's any sort of future application for different modes of delivery like inhalation or aerosolization, maybe in the same form as a as an aerosol that you'd use for asthma?
Dr Attam Singh: Yeah. I I I think, you know, you know, when you look at some of the science behind it, you know, sometimes, you know, some studies have shown that it's kind of bronchodilatory in actual fact. But the problem is is that when we start to consider other formats and, you know, and I I move away from oils, you can get it in soft gels, which is again is it's more kind of like eating a tablet. But again, the when we talk about inhalation, the concern is is that we may well be suggesting you should go and smoke it. And because you can actually buy flower as well. You can actually buy the bud. So we may well get into the to the to the to the we may well find that actually the flower is quite a useful part of the delivery system. And we would suggest that the best way to get the good bits of that flower is via a vaporizer. So the reason why we may well say that's a good way of doing it is because of its quicker onset. And exactly that, you you get a quicker onset if you are sort of reaching a sort of a pain plateau on a normal basis with the tab with the with the oils or the gels, and then the pain, there's some breakthrough pain where the pain is excessive or they've got a specific very spasmodic type of pain that really just comes on and off. It is those sort of problems and those sort of pains that actually we think maybe something like vaporizing the product, you know, the the flower may well benefit the patient. So there are certain instruments out there right now. I think the majority of them are used for the various oils out there, but you can use it for the flower itself. And in actual fact, the benefit of it is that it just works really, really quickly, whereas it does take a bit of time for the oils to get into the system, pass through metabolism and for it to work. So sometimes it's necessary. And I I've heard of people, I've heard of people in actual fact, not not not none of my patients, but in actual fact, they are going to do a speech in front of hundreds or whatever, thousands of people. And just before they go, they get their vapor out of CBD and they just take a few puffs, calms them down, 10, 15 minutes, they go up on stage and they start sort of reciting whatever speech they have. So it can be used for a variety of different things. Or, you know, you're going to a big party, you're all dressed up, you know, just before you get there, you get a bit of kind of anxiety where we all do, I'm sure we do. Take a couple of vaporize a couple of sort of inhalations via the vaporizer, suddenly they feel much more relaxed and calm and they do what they ever they need to. So it's each to their own and I think the the the method by which we deliver it is is important. And now we're starting to get the creams and stuff. I think I think there's CBD infused face creams and things like that. So all these different things are there and they need to be further investigated. And I think that's the point is that we're still very, you know, early on in this country with regards to it. So I think there's a lot more work to be done.
Dr Rupy: Yeah, that's a really interesting application because I think with the oil, I see why that might be useful for someone with chronic pain on a daily basis that's easily titratable. But if someone has acute pain, maybe even in the emergency department, who knows, where instead of us delivering Entonox or an opioid-based medication that we inject, perhaps there is a there is some utility from some elements of the plant that can be used in more acute settings.
Dr Attam Singh: I I I completely agree. You know, with its with its multitude of effects of being an analgesic, anti sort of like a muscle like a muscle relaxant and a feeling of, you know, a degree of, you know, well-being, I think it'd be perfect for things, I don't know, like dislocations and possibly things like that. Yeah, there's a little bit of a slightly quicker onset that that we need, but yes, I mean, we already use Entonox, but clearly it's it might have a, you know, an applicability in that environment.
Dr Rupy: Super interesting. I'm just wondering, and whatever you say next will not be construed as medical advice. So I'm going to add that before you.
Dr Attam Singh: Oh yeah, I just like to say these are my own personal thoughts. This is not what everybody else thinks.
Dr Rupy: Yeah, yeah. So if someone is listening to this and perhaps they work in a stressful environment, they don't have any medical conditions, they struggle with sleep a bit at night, you know, they've tried a bit of um maybe talking therapy and, you know, they don't feel unwell enough to speak to their GP. Is taking a CBD infused oil something that you think either now or in the future could become something that you could just do in the same way you might do, I don't know, a meditation course or change your diet somewhat. Or do you think we're not at that level yet where the consumer products that are currently available are of a high enough standard where I can experiment for 30 days with a couple of drops of CBD under the tongue before I go to bed?
Dr Attam Singh: So, I I I think it depends. I think I say that a lot when answering questions. It depends. I think as a medic, you always get that kind of, you know, thought process. There's two sides to the argument. I I always think of sort of like CBD products that are available over the counter as as like choosing a car, unfortunately. You get, you know, and and we're including second-hand cars, you know, and I and I and I don't want to, you know, say that there are some, you know, there are some reputable sort of organizations out there who are making very, very good CBD infused products or oils and stuff like that. But clearly there may well be other companies that aren't. And it's about choosing the right product. And it's how happy you feel about the product that you're getting actually says what it does say on does contains what it says on the tin. So when we do go out to sort of purchase this product, I think you should be careful about everything. You know, you don't buy, you know, as we have today, some, you know, you don't buy poorly formed, you know, lentils or you get a really quite good good deal, the type of mushrooms that you use are important. So when using your CBD product, buying over the counter, you just have to be careful about where you buy it from. And there are a lot of products out there. And I and I don't know, I don't know half of them, but it's about choosing the right product. However, if you have been able to find the right product and you find that it is a reputable sort of and it says what it is, then it it is something that I can foresee that actually with with the kind of if you look at the science behind it and you look at the way that it works, I can see its effect to be to be beneficial and to be taken in a manner that one would say, for example, take a glass of wine. I can see it being used in that manner. And I know of people who do do that without the influence of too much of the way of medical environments or, you know, getting a prescription and all the technical involvement that goes with medicines as such. I I I do see that it can be used in that way. And the fact of the matter is the proof is in the pudding. When I speak to patients who have tried it and I speak to a number of, you know, just random people through the work that I do, they say it's great. And and particularly for those things where you are sort of have such a busy lifestyle, you are quite stressed and you have, you know, a multitude of other things going on through your brain. And you are possibly having problems sleeping. The suggestion is out there at the moment that actually it is okay just to use it, to take a lot of, to take some of it and to see how it goes and to gain the benefits of it without thinking too much of the side effects. Well, the side effects of CBD will clearly be there and you can probably, you know, for example, some of my patients do say that they have, you know, it's noticeable that it doesn't taste great. It's, you know, sometimes that's why, yeah, it's a grassy taste and sometimes it's necessary to sort of be infused with sort of sweets and gummy bears and whatever they might have out there. But they're happy with that because it does give them the things that they're looking at. I think when we go back and I'm going right way back to something I said earlier, the the safety profile is probably key and the long-term effects of this drug needs to be sort of really born out. And I think we're we're on the way to working out the long-term effects of CBD and THC together and the effects of it. And I think that will be the real decider as to whether or not it is something that we are sort of going forward with. But let me say one thing and I think this is quite important is that if you were to re-advertise, for example, aspirin today and sort of say, oh, this is a new drug, it's an analgesic, it's an antipyretic, it's an anti-inflammatory, what do you think? If that drug was to go through the same sort of routines and regulations that possibly all drugs are required to go through now, I am sure that aspirin would not be allowed on the market. And that's the thing is that the complications that occur with aspirin, including the gastrointestinal system, if you talk about the effects it has on the lungs and as well as on the kidneys, I doubt very much that would be able to be allowed back on the market. So we're talking about a drug which is doesn't any of that, but still because of what's happened in the past and the kind of popular ideas of it is that people are reluctant to use it. I think let's see, like with everything, alcohol, smoking, clearly we can see the problems with that. This is much less than that.
Dr Rupy: With that to that point actually, there's definitely an incentive for pharmacists to become a lot more clued up on it, particularly as it's an OTC drug, or the the non-prescription um formulations of it. So for them, it's a great opportunity to to increase their own sales. So yeah, it's definitely something that they should.
Dr Attam Singh: Yeah, they they're definitely sort of getting on board and you know, and like yourself, I mean, you're seeing it at the front line, patients coming in, what about CBD? I'm sure you're getting it a lot. And I'm sure that the primary practice will be much more involved with it over the coming over the coming sort of years. The only thing I would suggest at the moment that seems to be the major sort of confounding factor to starting the medicinal cannabis, and I mean medicinal cannabis from a from a point of view from a prescription is at the moment it's quite pricey.
Dr Rupy: Oh wow. Wow, very pricey.
Dr Attam Singh: Yeah, so it depends.
Dr Rupy: Do we produce it in the UK or is this?
Dr Attam Singh: So there are, there there are, there is a company that actually and there are more and more companies coming out who are licensed producer who produce it in this country. Yeah, there is. So, um, it's starting to develop and and and and the price of it is comes from the distillation or the kind of extraction process and the fact that they have to grow it and it's a plant and it's quite heavy kind of intensity type product. And then it's got to go through a number of regulations to to match what we want it to be in it that we say that it is and that all that that just costs money. But um that has definitely come down from what we saw in 2018 where it was approximately about 1,000 quid. And I say um for a month's worth from when in 2018 towards the early on in 2018 and supply issues to something now that is 200, 300 quid and supply issues are minimal. There are still some supply issues. We still have to do it on a named patient basis, but it's much better than it was. So we're looking, we're, you know, it's improving.
Dr Rupy: There's definitely space to watch. Yeah.
Dr Attam Singh: Yeah.
Dr Rupy: I really hope you enjoyed that podcast episode with Dr Attam Singh. He's honestly a breath of fresh air. I love the open-minded attitude he has and the holistic nature in which he treats chronic pain patients. I'm sure this won't be the last time we hear from Dr Singh. We'll be doing some more stuff on CBD as an ingredient and I hope to catch you on later episodes of the podcast. Speak to you soon.
