Cannabis - what is it good for?

While cannabis (marijuana) is still classified as a Schedule I drug at the federal level, meaning it has no legitimate medical use and a high potential for abuse, the same is not true at the state level. Forty states plus the District of Columbia allow licensed health professionals to prescribe cannabis products for medical use.

(24 states allow recreational use of cannabis – no prescription required.)

One consequence of the federal classification is that the NIH is not allowed to fund studies of medical marijuana use, and this has greatly limited good research on such use. Despite this, 27% of U.S. adults have tried marijuana at least once for medical purposes.

There are FDA-approved cannabis-like products (dronabinol, nabilone) which are approved for nausea and vomiting due to chemotherapy and for severe anorexia due to HIV/AIDS. Another, cannabidiol, is approved for rare pediatric seizure disorders. That, according to the FDA, is that.

Advocates, however, claim that cannabis can do wonders for just about every ailment. Are any of these claims valid?

Chronic pain is a common reason for cannabis use, and a recent study found that chronic pain patients using narcotics were able to reduce their narcotic use after using cannabis. Certainly marijuana is less dangerous than narcotics.

Most of the other reasons cannabis is used have limited or no good data supporting this use. Anxiety may improve but may get worse. Cannabis is used for insomnia, but the sleep it induces is often poor quality. Some PTSD sufferers report help.

Inhaled marijuana lowers eye pressure, but this effect wears off within a few hours, making it of minimal benefit for glaucoma.

Migraines, inflammatory bowel disease and fibromyalgia are often treated with cannabis, but again, there is little solid evidence of lasting benefit.

Why not “just give it a try”?

Cannabis is not harmless. Acute side effects include heart racing, drop in blood pressure, dizziness, impaired coordination and slowed reaction time. Driving after cannabis use is as bad as driving under the influence of alcohol.

With chronic use, particularly daily use, there is evidence that cannabis increases the risk of heart attacks and strokes. Use by adolescents and young adults is associated with cognitive defects and lower IQ scores in adulthood. Regular users can have a severe vomiting illness requiring emergency department visits. Susceptible individuals can develop psychosis and/or increased anxiety.

If you are considering using cannabis for a medical condition, discuss it with your doctor. If what you have been using is not working, there may be better options. Marijuana should be a last choice, not your first.


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Could I be having a heart attack?

Until the late 20th century, getting to the hospital quickly with a heart attack was not that critical. Very little was done for heart attack sufferers beyond letting them rest and treating some complications.

Around 1990, use of clot-dissolving drugs to dissolve the clot in the coronary artery that caused the heart attack became the standard of care. The earlier they were given, the better they worked, and the mantra became “time is muscle.” The drugs worked best when given within 6 hours of symptom onset.

In the early 2000’s, an even better treatment became standard: angioplasty - opening the blocked coronary artery by putting a catheter in the artery and opening the artery with a small inflatable balloon. Current best practice is to then put in a stent to keep the artery open.

What has happened in the past 35 years with these advances is that the early (30 day) death rate from an acute heart attack has fallen from over 20% to under 5%. To achieve these results, the earlier the better. Hospitals strive to get a patient from arrival at the emergency room to the cath lab in under 90 minutes. Most hospitals that provide emergency angioplasty have systems in place to achieve this goal.

The weakest link? The patient calling 911! To get the best contemporary care and to have the best odds of surviving a heart attack, it is key that someone experiencing a heart attack gets care ASAP.

How do you suspect you may be suffering a heart attack? The textbook description is crushing pain felt under the sternum (breastbone). The pain is often felt in the jaw and/or left arm as well. You may get sweaty, and you may feel nausea. The pain is not always excruciating – heart attacks are not as painful as childbirth or kidney stones – but there is something about it that tells you “this is serious.”

Unfortunately, your body has not always read the textbook.

Some people experience sudden shortness of breath rather than pain. Some become profoundly weak. Some feel abdominal rather than chest pain. In most situations, this is a new symptom, one you have not had before.

Women, particularly young women, much more than men, are likely to have non-textbook symptoms, and as such are more likely to delay seeking care and/or be treated less urgently than men who show up complaining of “something sitting on my chest.” Some 40% of younger (under 50) women with heart attacks do not complain of chest pain. (By the time women pass 65, they have similar symptoms as men.)

If you experience symptoms that may be a heart attack, call 911 and get an emergency ambulance. Do not drive yourself to the emergency room. In some communities, the advanced Emergency Medical Technicians who arrive may be able to initiate treatment even before you get to the hospital.

In virtually every situation, arriving by ambulance will get you seen and treated faster than presenting at the front desk.

If it is not a heart attack? Great – you will be allowed to go home and follow up with your doctor for any more testing needed. Never be “embarrassed” by a false alarm. Every emergency physician will tell you it is better to come in when you are not having a heart attack than to stay home and suffer the consequences when it is one.


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What you need to know about influenza

First, you should know that influenza is a serious illness, not a bad cold. If someone says they missed work yesterday because they had “a touch of flu,” it was not influenza. We get upper respiratory illnesses from a myriad of viruses, and most are annoying but not serious.

Influenza comes with a high fever, bad cough (including possible pneumonia), feeling too weak to do normal activities and the possibility of dying. In the U.S., depending on the influenza strain, between 20,000 and 60,000 adults die of influenza each year. Those at highest risk are the very old and the very young.

Experts are expecting this to be a bad season since it was bad in the southern hemisphere during their May to September flu season, and that usually predicts what we will experience in our November to March season.

Another troubling factor is that there is a new strain circulating, already causing the majority of influenza cases in Britain and Japan, which is not targeted in this year’s vaccines. The influenza virus constantly mutates, trying to evade our immune system.

Until we switch to the “just-in-time” production of flu vaccines using mRNA technology, we are going to be using educated guesswork to decide what to put in the vaccines. Some years the experts guess right and other years, like this one, the virus fools us.

So, what should you do?

Number 1: get vaccinated! Even if the vaccine is not perfect, it will reduce your chances of getting influenza and it will markedly reduce your likelihood of being sick enough to be hospitalized or die. If you are over 65, get the high-dose vaccine.

The national association of cardiologists recently emphasized that flu vaccines prevent hospitalizations and deaths in people with cardiovascular disease.

Number 2: wear a mask when you are indoors in crowded places like theatres or Black Friday stores. Masks are not a panacea but do reduce transmission of respiratory viruses by about 25%.

Number 3: if you are sick and coughing, stay home. Sharing your toys is good. Sharing your viruses is not.

Don’t spoil the holiday season by catching or giving influenza


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Using AI for health information

Health information has always been one of the top reasons people turn to the Internet. “Dr. Google” has helped answer many questions, though the fact that savvy programmers could ensure high placement and that sponsored sites got preferred placement meant that the results were sometimes suspect.

Facebook has also become where too many people get health information, even though misinformation about many subjects exceeds valid information. Just because someone says something loudly does not make it true.

Another terrible place to get health information is from “influencers” on TikTok or Instagram, most of whom are paid to push a product or service.

I have long advocated that seekers after valid health information turn to trusted sites maintained by non-profits or major health systems.

For information about vaccines, Google “Vaccine Information Center,” a site maintained by The Children’s Hospital of Philadelphia. For female health issues, go to ACOG.org and click on For Patients (this is the American College of Obstetrics and Gynecology). For children’s health, go to Healthychildren.org, a site maintained by the American Academy of Pediatrics. For general health questions, there is a wealth of good material at clevelandclinic.org under the Health Library tab.

The newest way to get help with health-related questions is to use one of the Large Language Model (LLM) “chatbots,” such as Gemini, Claude or ChatGPT, and use of these programs has exploded. Health questions are among the top inquiries they handle.

Before getting into specific suggestions, it is crucial to remind you that these programs do not think – they apply statistical methods to generate relevant text in response to queries. You can think of them as “autocorrect on steroids.” Just as your phone or email program usually anticipates what you are going to say and advance types it, LLMs generally give helpful responses. They also can be wildly off-base, having no “common sense” to check their replies.

If you are asking a chatbot for advice, be as specific as possible. The more detail you give them, the better their response. Don’t say “I have a cough. What could it be?” Say: “I am a healthy 32-year-old with 3 days of a dry cough, a mild sore throat and a fever of 99 to 100.”

Ask the bot what more it wants to know. A follow-up to its initial response should be “what else do you want to ask me to help answer my question?”

Remember that chatbots want to please. They will always give you an answer, even if they must invent something. So-called “hallucinations” are a very real phenomenon.

They will also appear confident in their responses when they should not be – if something appears odd, ask them for the source of their information – and check that source.

Do not rely solely on an LLM. They are best used as the start of a health information search, not the end. They can prime you for what to ask your doctor and can give you alternatives to consider.

Chatbots are great at retrieving information, but they are not health professionals and they do not know anything about you beyond what you tell them.

Unless you want your personal information to be public, use the "incognito" mode that most LLMs allow.


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Should you drink raw milk?

RFK Jr and his choice for the next U.S. Surgeon General, Casey Mean, are fervent advocates of drinking raw (unpasteurized) milk. Should you listen to them?

In 1862, Louis Pasteur invented a method of killing bacteria in wine and beer without affecting the taste. Beginning in 1920, Americans began to pasteurize milk using his method.

The process is simple: milk is rapidly heated to at least 161 degrees F (71.7 C) for at least 15 seconds and then rapidly cooled. This extends the shelf-life of milk and kills the harmful bacteria that can be transmitted in milk.

Today, about 3% of Americans consume raw milk and the MAHA movement wants to increase that number. Much of the rationale is simply “freedom to choose,” while touted benefits include more nutritional content and better taste. There have also been some observational studies that claimed that children who drank raw milk had fewer allergies.

The taste issue is false – it is impossible for most people to taste any difference. Pasteurization has minimal effect on the nutritional value of milk. A few vitamins may be decreased by pasteurization, but these are not in high content in milk in any form.

Since most children who currently drink raw milk live on farms, it is hard to say whether it is the milk or the farm environment that leads to fewer allergies. (We know that children who are allowed to play in the dirt have fewer allergies than those who are kept in pristine environments.)

What is clearly true is that drinking unpasteurized milk can lead to serious infections. Each year there are milk-associated outbreaks of infections with listeria, campylobacter, salmonella and toxin-producing E Coli. These are not trivial illnesses, and can be particularly dangerous to small children or those with immune deficiencies. Virtually every outbreak has been associated with drinking raw milk.

Can you follow Dr. Mean’s advice to “look the farmer in the eye and pat the cow” before drinking milk from that farm? No. Up to a third of all raw milk sampled contains harmful bacteria, and a healthy-appearing animal can be the source.

Protect yourself and protect your children – only consume dairy products that are pasteurized!


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The Basics of Medicare

Since we are in the Medicare “open enrollment” period, Oct 15-Dec 7, now is a good time for a quick review.

Medicare was enacted in 1965. It established parts A and B. Part A is free to all Americans 65 and older and to younger people with chronic kidney disease or who are chronically disabled. It pays 80% of hospital bills after a deductible. Part B, for which you pay, covers doctor fees and most outpatient services. Part B also has a deductible and covers 80% of the charges.

While Medicare B is voluntary, it would be playing Russian roulette to not take it, as you would have no coverage for doctor bills. Most people pay $185/month for Medicare Part B, though this goes up for those with higher incomes. It also goes up if you delay enrolling.

Medicare Part D became available in 2006. It is optional and helps pay for prescriptions. You must sign up and choose a plan annually. Typical premiums run about $50/month.

Because A and B only cover 80% of your medical bills, and these bills can mount up dramatically if you have a serious illness, most people pay for a supplemental policy to cover the 20%. These so-called “medigap” plans are offered by private insurers, not the government.

Part C, establishing what is now called Medicare Advantage, began in 1997. It gives private insurance companies a fixed amount per person per year to cover their medical expenses. The theory was that private health insurers would provide equal or better care and save the government money, a theory that has been proven wrong.

Medicare Advantage plans advertise heavily, and promise lower costs and extra benefits. At this time of year, you will be inundated with direct mail, phone calls and media blitzes trying to entice you to join an Advantage plan.

If you join such a plan, you must still pay your Part B premium, but typically will not have to pay for a medigap plan or Part D. Your monthly insurance premiums will usually thus be lower. There is, however, no free lunch. Under traditional Medicare A and B, you can be treated by almost every doctor and hospital in the country. This is not true for Advantage plans.

In return for the lower insurance cost, you will be restricted in the doctors and hospitals you can use and you will find that your doctors’ recommendations are subject to the whims of the insurance companies. Most hospital care and any expensive test or medication will only be covered if the insurance company approves it. I do not have space here to cover all the issues, and strongly recommend you Google “John Oliver Medicare Advantage” (the 31 minute one) for a biting and humorous look at the problem.

People who sign up for Medicare Advantage when they are healthy can be fine if they stay healthy. If they develop a serious illness they may regret their choice, as they find that the doctors and hospitals they would like to use for their care are not available.

Switching back to traditional Medicare would seem like an option, but there is a catch. When you first go on Medicare, you have free choice of medigap plans. They cannot refuse you because you are in poor health. If you try to sign up for one of these plans later, they can refuse to cover you at all or refuse to pay for pre-existing conditions. Just when you would need that 20% covered, it will not be, so you are locked into your Advantage plan.

My strong advice is that if you can afford the extra cost, start and stay with traditional Medicare and a good medigap plan. Otherwise, if you choose an Advantage plan, stay healthy!


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Time to say goodbye to Benadryl?

Diphenhydramine, commonly known by the brand name Benadryl, has been sold since 1946. It is an “antihistamine,” meaning it blocks the body’s receptors for the chemical histamine, which is released in response to allergens.

Diphenhydramine works very well to lessen allergy symptoms and is used not only as the sole ingredient in Benadryl but as all or part of the makeup of some 300 mostly over-the-counter medicines.

Diphenhydramine crosses into the brain and makes us drowsy. This “side effect” has caused it to become a widely used sleeping aid. Most OTC sleep aids have diphenhydramine (or doxylamine, a very similar product) as their active ingredient.

The problem with using these older antihistamines for allergy relief is that they are sedating and may make users too drowsy to safely drive or do other tasks requiring attention. They can be especially problematic for older adults and have been linked to falls and auto accidents. Regular use has also been linked to risk of dementia.

They can also be a problem with small children, causing extreme sedation and even coma. Also, oddly enough, in some children they have a paradoxical effect of causing agitation.

For allergy relief three newer antihistamines are available: loratadine (Claritin), cetirizine (Zyrtec) and fexofenadine (Allegra). These do not get into the brain and are much less likely to be sedating.

How about for sleep?

For very occasional use, diphenhydramine and other older antihistamines are probably OK. Like most sleeping pills, the sleep induced by antihistamines is not natural, with little REM sleep, and the sedation can linger well into the next day. It is not dissimilar to the sleep you get after drinking too much alcohol.

Better choices are melatonin or chamomile, which work immediately, or magnesium, which must be taken regularly and build up in your system. If you find yourself using an antihistamine to sleep more than 2-3 times a month, ask your doctor about alternatives.

So, yes, it is probably time to say adios to diphenhydramine, doxylamine and all the older antihistamines. Be sure to read the labels on OTC products before you buy them.


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