Arizona Center for Integrative Medicine

Transcript

Dr. Victoria Maizes
Yeah. Hi, Andy.

Dr. Andrew Weil
Hi Victoria.

Dr. Victoria Maizes
Today we will have Rebecca Abraham, who is a nurse who specializes in cannabis nursing.

Dr. Andrew Weil
I did not know there was such a thing as cannabis nursing, and I'm looking forward to hearing what she has to say.

Dr. Victoria Maizes
And I'm really looking forward to diving deep into ‘how do we figure out the best combination of CBD, THC, best way to offer it to the patients’ so let's get her on.

Dr. Andrew Weil
Okay.


Intro Music


Dr. Victoria Maizes
Rebecca Abraham is board certified in Critical Care nursing and certified in Cannabis Nursing through the American Association of Cannabis Nurses. She educates physicians, nurses, patients and the cannabis industry on the science, safety and potential therapeutic uses of cannabis. She is the president and founder of Acute on Chronic, which is the first cannabis nurse clinic in the Midwest.

In 2015, she was awarded the Illinois Nurses Association 40 under 40 Leaders in Nursing Award. Welcome, Rebecca.

Rebecca Abraham
Hi. Thank you so much for having me.

Dr. Victoria Maizes
It's a pleasure. It's interesting that as of 2023 37 states have legalized cannabis for medical purposes and there are 3.6 million users of medical cannabis in the U.S. But, and this is a big but, there's a lot of confusion about dosing cannabis and your business set out to remedy that problem. I would love if you could tell our listeners about the service that you offer.
Rebecca Abraham
Yes, I am happy to and thank you for having me. So as a critical care nurse I would have people and patients over the last decade, even prior to legalization, ask about medical cannabis. How can I use this? I heard this can help. Umm a lot of things in medicine, that are chronic …chronic pain, dementia, delirium, migraines, anything where we truly can't fix and that is ongoing we're not really great as an entire system of fixing that. So when people hit that wall in the current system we have, oftentimes that's where people start considering medical cannabis and recreational cannabis. So I had been getting questions my whole career. My husband's a physician, my friends are physicians, they were getting questions and they did not know what to tell people.


Rebecca Abraham
They didn't really want to talk about it because of what their employer could say as well as they didn't really feel comfortable sending folks just to dispensaries. Some doctors had told me that they had done that and they regretted it after because patients would come back with like horrible stories about how they were given 400 milligrams of THC and they were high for days, but their pain was not fixed.

So I had saw a problem. I was very interested in medical cannabis. I said, this seems like a problem nursing could easily solve in the ICU. I am the one who decides how much life support they get or not. So for those of you not in medicine, when you are in the ICU, typically the doctor says, “this person is very sick they need life support, nurse, it's up to you to choose which life support at the dose that they're getting. Just look at their vitals.” And so this is a skill. Cannabis is very similar and comparable to things like critical care nursing, as well as diabetes education nursing, and wound nursing. There are things that nurses do typically for treatment that are not based in pharmacology, that are more alternative, but definitely non pharmacological things are wheelhouse as well as medications that take a long time to titrate and figure out what the patient needs. And I thought, well, this seems very much the same as that. So I set out as an ICU nurse to hire other nurses, create a scalable model based in nursing methodology and nursing theory that helps the patients.

Rebecca Abraham
And so we had a couple of trial runs with this before we launch, just patients looking for advice to see if we could create something that worked. And it does. I'm always tracking our statistics. Nine out of ten of our patients, when they finish the program, will have mild to complete symptom resolution. I can at least promise some sort of change and some sort of range to the symptomology that they're experiencing. What we do is we interview the patient, we do a nursing assessment, we then do a complete lit review, and then we create our care plan based on nursing methodology. And then we see that patient a couple more times to increase or decrease their cannabis.

Rebecca Abraham
And we collaborate with their physician and their medical team to talk to them about what pharmaceuticals perhaps should be decreased or other signs and symptoms that we're seeing the patient experience through a therapeutic nursing relationship or side effects the maybe the patient may be having and how to mitigate those.

Dr. Victoria Maizes
So it's a lot we’re going unpack some of that. I think just let's start by saying there's so many different ways to ingest cannabis there are gummies, there are tinctures, there are brownies, you can smoke it, you can aerosolize it, lollipops. There's just so many different possibilities. How do you work with a client to figure out the best product, the best mode of consumption for them?

Rebecca Abraham
The nursing assessment tells us quite a bit. We ask the patient and client what they're comfortable with. We see what's available in their market. Hemp, so your CBD, which I think everybody has heard of, that is actually available in all 50 states. So if I find a really good modality, let's say you hate MCT oil, I can find a producer that has good lab reports, responsible farming, and I could recommend that product to the patient and say, I have this really great other manufacturer that cold presses the hemp oil. This is safe for you. A little bit of what the patient wants and then what the literature says that we should be doing. We are pulling from global literature and nurses do a lot of things on gut feelings.

Rebecca Abraham
It's really hard to describe, but a lot of our care is really driven by our gut. That is kind of the difference between a great nurse and a good nurse is the guts and the insight as well as now that we have more and more patients we can actually pull from our data and see, okay, we have an 80 year old female with chronic pain. What happened for that subgroup of patients? What worked best? And we take knowledge from the patient, from the literature review, and create this nursing care plan where we essentially act as their guide. What's really nice about this is there is a therapeutic relationship. The patient gets time to talk about their chronic illness or acute illness. A lot of things in health care, very kind of, you know, do as I say. And if you don't, you're going to be in chronic that you're going to have been cannabis nursing is not like that. We give the patient options, we give them dosing ranges, and we tell the patient, this is you are the driver of this bus.

Rebecca Abraham
What are you comfortable with? Are you somebody who is organized and you are meticulous and you're okay with taking something three times a day or are you forgetful? We meet them where they're at. And that, I think there's a multiple components of how we have success with cannabis and using cannabis more as a supplement that is a medication and why we have seen some success with cannabis but not, not the same success that my company is having when people just kind of sort of try this out on their own and wing it essentially.

Dr. Victoria Maizes
Andy as a botanist and someone who has studied cannabis for many years, what's your sense of the advantages and disadvantages of the different methods of consumption or ingestions.

Dr. Andrew Weil
Victoria, it's not just different methods of consumption, it's that cannabis has such a complex chemistry, and we really don't know the actions of all these different components separately or together. And there's so many different products out there with different composition. There are different strains of cannabis with different effects. And on top of that, there is a great individuality of response to cannabis.

Dr. Andrew Weil
There are people who can smoke pot before bedtime and they fall asleep easily and other people, if they do that, they can't get to sleep at all. So I think that makes it rather difficult to use as a medication. It's a unique product and I don't think we yet know all we need to know in order to tell patients how to select the particular type of cannabis, you know, let alone the method of ingestion. It's just it's complicated.

Dr. Victoria Maizes
And one of the reasons for this is it's schedule, because it hasn't been legal to study the therapeutic uses of cannabis.

Dr. Andrew Weil
Yeah, and let's remember it is in schedule one at the federal level, which mean is defined as substances with high abuse potential and no therapeutic potential. And I'm wondering, Rebecca, does that create any obstacles for you that federal prohibition?

Rebecca Abraham
Oh, yes, because when we look at what the schedules are, just to put it in perspective, fentanyl very popular in the market, a lot of wrong information happening in the world about fentanyl. Fentanyl morphine is schedule two. Benzodiazepines so for those out there, that's your Xanax, your Ativan, your Lorazepam is schedule four.

Dr. Andrew Weil
Highly addictive.

Rebecca Abraham
Fairly under.

Dr. Andrew Weil
Very dangerous and very dangerous.

Rebecca Abraham
Actually, when we look at the safety profile of cannabis and everything you said is true, it's complicated. And that is what the cannabis industry is really missing. They keep trying to pack it in this box and put a bow on it. And if you want science to take this seriously, if you want medicine to engage, it is not in a box.

Rebecca Abraham
It is quite complicated. And my prediction is it's probably going to be its own specialty. If not maybe housed in someplace like palliative care. So I wish cannabis would be descheduled to something much lower because if you look at the safety profile, it's there are side effects, there are downsides. But if you compare them to things like your ibuprofen your Xanax, it's safer.

00;13;30;16 - 00;13;51;08
Dr. Andrew Weil
I would go farther than that you can't kill people with cannabis. There are no reported deaths from cannabis and there's no drug that we use in medicine which does not have a lethal potential. So it's totally irrational that scheduling. And I hope a lot of people are working on getting it out of there. Can I ask you, what is the American Association of Cannabis Nurses, I'm unfamiliar.

00;13;51;26 - 00;14;17;09
Rebecca Abraham
So the American Cannabis Nurse Association is a group of nurses, first generation nurses who came together and said this should really be a specialty.

Rebecca Abraham
This is absolutely belongs in nursing. So what they did is they now are working to get recognized by the American Nurses Association, and we are job to that board and of course, we are working on a true board certification to be a certified cannabis nurse.

We will have a test, takes a long, long time to get. I think hospice nurses just got their test. So hospice nursing created in a very similar way. Doctors didn't want to touch it in the sixties. They said it was the family's job and a nurse from the UK said, no, this is this is absolutely nursing.

Dr. Victoria Maizes
You've mentioned nursing process a few times, and I know from our prior conversation, one of the things that you do is you work on a care plan and setting goals. Can you speak about that in terms of recommending cannabis products to a client?

Rebecca Abraham
So essentially a nursing care plan is how all nurses learn how to be nurses. It teaches us to think as nurses where I talked about guts, that's where that is. So cannabis is a very strange gray area. It's not prescribed. It's recommended. There's no standardized dosing. You can't die, and nobody's really taken responsibility.

Is it a food? Is it a supplement? Is it a medicine? This is where it gives a lot of room for nurses to touch this and do the education with it, because no doctor is writing a prescription for cannabis, not plant cannabis. Now there is Marinol, right? You know, Sativex, Epidiolex, those are prescribed pharmaceutical synthetics.

Rebecca Abraham
We're not recommending those. We're not prescribing those. So that's not nursing. But I was like, How do I do this work? Get accepted by physicians And the nursing care plan is that modality. Totally rooted in nursing science, goal setting, assessment, education, reassess.

What's even better about that is not only does this allow us to do our work, but patients love it because it gives them back that choice. I talked to people who have had chronic pain for 20 years and they're shocked like me, I have a choice.

Rebecca Abraham
I could choose any of these these five products you've listed, I could make my choice. Yes, you can make your own choice. They're shocked by that. And it really does build that therapeutic relationship that helps the patient do this in a safe way because you can't die. And we're working a little bit backwards

Rebecca Abraham
So everything we do is based on these very advanced trials, the randomized double blind control trial, right. There's reasons why we do that. Just like you said, many pharmaceuticals are have a lethal potential, even water. Cannabis if you overdid cannabis, you wouldn't die. If you overdid water, you would. So kind of a strange phenomenon there for sure. There's a safety mechanism built in when we're doing pharmaceuticals with cannabis, you can't die.
So how're my nurses? How are my physicians? How are we building science and cannabis? All nursing is done through practice-based evidence.

Dr. Victoria Maizes
I drive a drive around my community, which is Tucson, Arizona, and I see people waving signs that say, ‘CBD here’. And CBD, as you said, is legal in all 50 states, but it may not be the ideal product for most people. And in fact, the evidence suggests that you do need a combination of CBD and THC and maybe many other of the complex set of ingredients that are in the plant.
How do you decide what percent THC, whether you're using one form of cannabis or another? get us into some of the practicalities.

Rebecca Abraham
So the way we pick it really depends on the patient. It depends on what pharmaceuticals they're on, what supplements they're on. Is there an interaction? Are they immuno compromised? What do they want to use it for? What route of the administration are they comfortable with?
What route of administration is beneficial to them? Diet, age, tolerance. Some people lack an enzyme, some people hyper metabolize things. Sometimes they get clues through tramadol actually gives me a clue. This has not been studied, but this is a little bit of some nursing gut work when people hyper metabolize tramadol most of the time they will hyper metabolize cannabis too, just what I've noticed from working with patients.

I wish somebody would do this study to help understand it. 23 and Me, if they've done that and I see that their liver is noted to hyper metabolize, I know that they're going to click through something like an edible quite fast. Yeah, no patient is truly the same. So some things that make me avoid CBD actually is a big one.

A common misconception is people think THC is the most dangerous cannabinoid. No, it gives you the most side effects and has the potential for the most uncomfortable side effects. But CBD is actually the one I worry about and the one most physicians and patients don't worry about. And it's because the drug interaction is not completely understood. CBD seems to interact with more than THC does and a little bit a little bit in scary ways. I would love to see a study done, particularly on CBD and the interaction with Plavix.

Dr. Victoria Maizes
And Plavix for those who are listening is a blood thinner. And if you need a blood thinner to work for you to prevent, for example, a stroke. So you have you have atrial fibrillation, you don't want it to be metabolized too quickly and get out of your system.

Rebecca Abraham
Yeah, so when I started working with patients, physicians started sending as folks and when I looked up drug interactions, I used three databases that we commonly used in the hospital and an outpatient setting. And I did not see anything on Plavix for a long time, even though all of these things are metabolized in the liver.

Late July, I saw cannabis, particularly CBD, can decrease the circulating amount of Plavix, the thinning of the blood. That's not good because we want people to get the full dose of that medication and then a doctor that I work with called me in in August and said, “Did you see this study where people are having repeat heart attacks with cannabis?”

I immediately thought of the Plavix. So just to explain this to the audience, when you have a heart attack, you go to a place called Cath Lab most of the time. And what they do there is they put a stent in. So it is a metal sheet and they open it up. The metal sheath stays in the arteries. Blood flow is returned to prevent our body from clotting and attacking that stent. So the metal in our heart, we give people Plavix to keep the blood thin from platelets, keep it moving through. If you are a cannabis user and you just got that placed and you are decreasing that medicine, you are likely to have a heart attack again.
As legalization and CBD became mainstream, we saw an uptick of these cardiac and events strokes, heart attacks increasing. I would love to see if this is concurrent with people just on Plavix and Cuminum, another blood thinner that CBD effects.
Was this affected by the mass use and lack of understanding of CBD? What I have good the good news and bad news is with us working with physicians and more of us educating and being out there. These are manageable things currently we recommend if you've had a heart attack within the last year, you're going to need that Plavix therapy.

Call us after the year is done. We'll talk to your cardiologist, see if you want to go forward. As long as people know it's controllable with warfarin, another blood thinner, that CBD actually increases the amount of. As long as you're getting your labs checked and your going infrequently and you're seeing what your levels are you can use CBD. We just have to know.

So I don't think cannabis is necessarily a hard stop here with these interactions. I just think that we have to spread knowledge and there has to be informed folks involved and the patient has to have informed consent. Another interaction with CBD is birth control. Informed consent is very important there because sure, you should absolutely use CBD to control your anxiety if you are a woman of childbearing age, but you absolutely want to know if it's going to interact with your birth control.

Dr. Victoria Maizes
Yeah, those are some important interactions and I know that's one of the things that your company offers by doing the literature review and looking specifically at any cannabis medicine interactions that may occur. You know, it's such an interesting time Reuters suggest that 4% of baby boomers are using cannabis medicinally and those of us of a certain age will remember that film Reefer Madness that suggested if you use cannabis, you could get addicted and you could get yourself in trouble.

How common is addiction Andy is this something that people using medicinal cannabis have to worry about?

Dr. Andrew Weil
I don't think there's true addiction with cannabis, but there can certainly be dependance. You know, it can be an unproductive habit among many people. It really doesn't benefit you. And some people have difficulty separating themselves from it, but I would not call it true addiction in the way that alcohol and tobacco and opioids are addictive.

Dr. Victoria Maizes
It used to be called a gateway drug, which suggested once you began to use marijuana cannabis, you'd go on to more potent forms of mind-altering substances. I was really surprised in 2019, there was a large study out of Canada that showed that their registered cannabis users and they track it carefully in Canada at the federal level, actually reduce their use of opioids and benzodiazepines, suggesting that it's actually the reverse of a gateway medicine. It reverses the likelihood you're going to get yourself into trouble.

Dr. Andrew Weil
I don't think there's any quality of any drug that leads users to go to, you know, a different class of drugs. If there's anything that's a gateway drug in our society, it's alcohol. You know, that's that is the first psychoactive drug that most people, young people use.

Dr. Victoria Maizes
Where do you think, as an integrative medicine physician and educator that cannabis is most useful?

Dr. Andrew Weil
Well, let me say, I think it's great that the nursing profession has taken this up because I don't think physicians are going to do it yet. And the reason is that physicians would need to see a cannabis preparation that looks to them like a familiar pharmaceutical, and there aren't any out there. Rebecca mentioned Sativex, which is a made in the UK, and that is a whole cannabis extract.

I think it's a very good preparation and it looks like a medical drug and doctors would be comfortable, I think, using it but the FDA will not allow it in this country. I think that's just stupid. But if we had a preparation like that, I believe more doctors would feel comfortable recommending or prescribing cannabis. At the moment I think they're confused and don't feel comfortable recommending the things that are out there in dispensaries. But if nurses can do that, I think that's a great way to make it available to patients.

Rebecca Abraham
I agree with everything you said going all the way back to cannabis use disorder. Yeah, it doesn't really exist. The study done on it was in 2015 prior to legalization in most states, and we have to think about who is answering that question. There are already people who are open in an illegal time to disclosing cannabis use.

I could bet money that there were a ton more people in the population using cannabis, but they were like, “Oh, I'm not admitting that..”That study came out to about 10%. I bet if we redid that study today it would fall. And I agree, there's no chemical addiction that we've ever seen. The mortality. When you have a dispenser, each dispensary in each county in the United States, your mortality from opioid addiction falls by 12 to 16%.
So it's opposite of the gateway drug decreases polypharmacy in older folks. we actually see it. It antidrug which is really interesting after all we've seen in the last 80 years. And I completely agree that doctors do not want and probably will continue to not want much to do with cannabis. And the reason is is let's say that it falls off the scheduling.

It's completely legal. Everybody can do what they want now, hospital policies open it up. The problem is it's a time consuming and titratable supplement to get right. And doctors, particularly in the United States, in this model, they don't have time in that encounter to keep counseling people on cannabis care. That's why diabetics are sent to diabetes educator nurses.

They don't have the time in a 20-minute encounter. I keep seeing people in the cannabis space. Innovators keep coming up with apps for doctors to use, a website for doctors to use. And I laugh because doctors don't have time for that. They're just trying to get in just the basics of what they need for charting and assessing and diagnosing and prescribing so they will not have time to do these things.

So the absolutely. I think as this grows, nurses are the solution. And I compare it to therapy. You can't go to therapy in one day and get the results you want.

Therapy works for many, many things and you see that in the literature. But you know, you can't see one therapist one time and be solved of all of your trauma and everybody's different.

Dr. Victoria Maizes
So you sent me a couple of abstracts about case studies where people had remarkable outcomes. One was a woman with Alzheimer's who had agitation and maybe delirium, and you were able to put together several different cannabis products that dramatically improved her status. And the other was for someone who had uncontrollable restless legs, extreme difficulty sleeping, that was not solved by any of our conventional medicines.

That's exciting to see. It's always exciting to see when we can find solutions to difficult problems. Rebecca where else do you think cannabis is going to turn out to be a solution to some of our difficult medical problems?

Rebecca Abraham
So I was actually just talking to my hospitalist husband today. He was telling me the story of he knows a rheumatologist who was complaining about we don't understand fibromyalgia and how the heck did rheumatology get stuck treating fibromyalgia because nobody knows how treat it. And we were talking about how doctors, even some palliative doctors and rheumatologist do not like chronic pain neurologists don't either because you essentially diagnose people with bad news and say, I'm sorry, I can't fix it.

And for nurses and doctors we came here to help people and it could get frustrating, especially over years of not being able to treat something with anything we have available. And I said, I love treating pain, I love palliative.
And he said, “Yeah, you love it because you found something that makes people get better. So you're ahead of them.” Because if you saw people not getting better like you did in the ICU, you would absolutely hate it. And so I think chronic pain is where cannabis can truly make a difference in a safe way because you use ibuprofen end sends enough over the course of 20 years and you're going to have some real side effects from that. Opioids, we already know of their problems. Cannabis is a solution that can absolutely be a long-term idea. Dementia delirium is something that is very, very promising. I think next to chronic pain and could not only improve the quality of life of millions of people and their caregivers, but actually be quite the cost savings for the entire health care system as a whole.

Rebecca Abraham
The study you mentioned, the case study, we did was on a patient in their home. We actually can replicate that in facilities as well. So in our case series that we're doing, we've actually had two patients in facilities that also did quite well. So we have seen this both outpatient and in essentially. And just to think about the quality of life for everyone that improves currently delirium in the hospital our choices are horrible and awful for everyone, restraints, both physical and chemical. Continuous nursing is often required continuous family monitoring. That's really hard for families and even in facilities, even in the ICU, more than one patient, hard to watch. With the infusion of cannabis could these other modalities patients are much, calmer. They are sleeping, their circadian rhythm seems to regulate. They seem to be in less pain. Even our nonverbal patients that we've looked at, they are not yelping in pain anymore. They are much more happy, smiling, more, less moaning, moving more, more exercise is being done… so really cool stuff. So I think difficult to treat things chronic illness, chronic pain, dementia, delirium and anxiety I, I think are going to be the biggest uses.

Rebecca Abraham
I do think there's a future for adjunctive therapy in cannabis with oncology, so that's cancer. What does adjunctive mean? We see really cool results with cannabis when used for symptom control in patients with cancer who are getting chemotherapy and radiation.

Sometimes we also see in test tubes and animals. And some of these patients that we're looking at after, they're having a little bit of better outcomes. These results are very mixed. But I, I have a feeling with more research, if we include cannabis care with oncology care, I feel like we're going to see a lot of really interesting and cool things in the future.

Dr. Victoria Maizes
Thank you so much for sharing your expertise with us. We really appreciate it.

Rebecca Abraham
Great. Thank you so much. So, yeah, lots of really neat things out there. We are just in the beginning of this and I know some of my some of my guesses are going to be wrong in the future, but I think some of them are going to be very right and I'm really excited to see. But so far what we see looks great.
And it's I tell you, coming from the ICU where many, many people did not get better to coming to a place where they do when they never thought they were going to feel better again. It's I love it. So thank you so much.

Dr. Victoria Maizes
Thank you so much.