Cannabis and Cancer Care Continued with Gabriela Montes

Dr Vaughn: Welcome to Cancer Shop Talk, Behind the Diagnosis. Today, we are speaking with a certified cannabis nurse. I am excited to introduce Gabriela Montez, who is a member of the Cannabis Nurses Association and Cannabis Nurses Network.

Dr. Vaughn: I just wanted to welcome everyone to another podcast. We are continuing our focus on medical cannabis and how it’s really sort of changing the landscape of medical oncology and really how we can treat pain, treat anxiety, treat insomnia, a lot of these supportive things that we need to continue to focus on their patients as they go through treatments for their cancer care. And I’m so excited. This is going to be such an interesting podcast. I’m speaking to Gaby who resides in Alexandria and she is a nurse who is a part of the American Cannabis Nurses Association. And I just wanted to offer Gaby a little time to talk about kind of herself, her nurse experience and what broader into kind of medical cannabis and this kind of association of nurses. So the floor is yours, Gaby.

Gabriela: Thank you. Thank you so much, Dr. Vaughn. So my name is Gabriela Montez. I am a nurse for five years now and I have been practicing in the area of oncology. I love oncology because it’s a very broad and complex part of the medical field. So that brought me to many changes to see how the patients are asking, “What else can I do to make myself feel better?” Also the anxiety, “What comes after I’m done with treatment as well, but I’m continuing to have side effects, anxiety. So what can I do? What can I look for?” So those questions are starting to come with patients.

Gabriela: And that’s how I got into looking into studying cannabis, how it works in the body, how we can help patients. And I found more nurses alike, where can I find these nurses that are thinking like me? And I found the Cannabis Nurses Network and the Cannabis Nurses Association. So these two entities are amazing because they help nurses to continue their education with the endo cannabinoid system, because this is not thought in nursing school. And it’s not in any medical books, as well, as you know it. This was not thought in medical school I guess for you as well.

Dr. Vaughn: No, we’re learning it as we go. You’re right.

Gabriela: Yes. So I decided to found a… I decided to study it, where can I find a certification? So I found Pacific College actually has a nice and very extensive six months of as a specialty in the endo cannabinoid system and how it works, cannabis medicines, and how interacts with the body. So I completed my six months of extensive training, I will say, in that subject. And finally, I presented this idea to where I’m working and they love it. And the palliative team actually it’s on board of it. So this is something that we’re going to start seeing more and more in oncology.

Dr. Vaughn: Yeah. That is fascinating. So you took the course for six months, got a certificate and you brought it back to your oncology clinic.

Gabriela: Correct. And I presented this idea and I said, “Look, let’s do this.” Patients are asking, this has been going on, we’re hearing about cannabis for many, many years. We know it works with the endocannabinoid system, but there is a big… I thought they were going to say no, but I was surprised. And because a palliative care team is also seeing these changes. And I think there was recently a research post from the palliative care website. They’re trying to push more into cannabis as a adjunctive. It’s there, don’t say no to it because it does work with the endocannabinoid system. So therefore, it has an effect on the body and how are we educating our patients about it?

Dr. Vaughn: Well, I’m so fascinated. So I guess just as I’m a practicing oncologist here in Fredericksburg, and we do have… We have our own palliative care clinic, actually, a nurse practitioner kind of runs it. And so how is the structure in your office as a nurse who now has this certificate? And I guess more of an expert, I guess, in this new genre of medical cannabis, do you go in with the palliative care physician or is it a separate visit with you or is it a team approach going in the room and talking about maybe narcotic medicine and then cannabis, how to adjust, how to dose both or? I’m just so in intrigued by how it operates.

Gabriela: That’s a million dollar question right now. So what the cannabis nurses network is helping me to build, and this is actually one of my good friends was going to be with us today, Nique, she’s also part of the Cannabis Nurses Association. She started the idea of the cannabis nurse navigator. We have the oncology navigator, the palliative navigator. Now we want to have a cannabis nurse navigator on board.

Dr. Vaughn: I got you.

Gabriela: So how is it going to be? The patient is going to see the palliative nurse, the nurse can actually… Or in our case our palliative doctor does a recommendation, okay?

Dr. Vaughn: Mm-hmm (affirmative).

Gabriela: We check already in the medical system and the records that the medications already. Let’s see. You prescribe Marinol, right?

Dr. Vaughn: Mm-hmm (affirmative).

Gabriela: That has synthetically THC. If that is a side effect with it, it will flag in the medical record already. So that’s a great idea to find and see… To play with certain medications and see maybe as an example, just to check if it’s going to have a side effect with something. That’s an idea that I’m putting on right now with my group. So we check that there is no side effects. Let’s do a good assessment. And now the patient you give the recommendation, okay. Now let the patient meet with me. I’m going to go over how to apply for the card. What do we know about your experience with cannabis? Let’s do a through assessment with the patient, and that’s what we want to do.

Dr. Vaughn: I got you.

Gabriela: And how is the patient going to utilize cannabis medicines as well? There is two months or three months of wait once you apply for your medical card in Virginia.

Dr. Vaughn: So Gaby, so again, it sounds like, a patient will walk in and meet with a palliative team, the physician or nurse practitioner, and then they’re going, “Okay. This patient would probably benefit from medical cannabis.” And then during that visit, do they, do they meet you in kind of a separate visit or is it another day? But it sounds like you have your own visit with them. They go through the process, which is as a physician, it’s still new understanding the process of how patients get the cannabis, get the certificate and all the sort of logistics that are involved.

Gabriela: So what it’s happening right now, it’s the patients actually, they’re saying… Many of them doesn’t even know that the palliative care doctor is actually providing the certifications. And some patients actually doesn’t even tell the doctors and how patients have talked to me is because I treat patients, I’m an infusion nurse, so, “Hey, Gaby, what are you doing? What do you do this weekend?” I’m like, “Oh, I’m studying to be a medical cannabis nurse.” And they’re like, huh? So everybody’s like, “Oh, okay. Tell me more about that. So other patients are hearing and they are coming out of the closet. “Oh, I use it. Oh, I have this CBD. Oh, can I bring this? Do you know what is this for?”

Gabriela: So I started talking to the doctors as well and saying, “FYI, this is happening. And do you allow for me to talk about this or educate the patients or for them to bring me a picture of what they’re taking or what they’re using, so it’s safe for me to check if that is a legitimate product?” These patients can be neutropenic. These patients can have gastrointestinal problems. So let me check if this is a legitimate product. So that’s what I’m helping them right now to give me the, okay. But it’s not something that I’m going to meet with them right now. That’s what we’re planning. This is something that is up in the air.

Dr. Vaughn: You’re still kind of working on your own sort of algorithm here for this. I got you.

Gabriela: Oh, yes.

Dr. Vaughn: Okay.

Gabriela: Yes. Yes. This is-

Dr. Vaughn: But it sounds great, almost like a nursing consultation, just to sit down for 30 minutes, and really spend some time to educate, review the, again, logistics of getting a card. And this is what I even need help with understanding kind of, and maybe you can kind of go into this a little bit, but how do you dose cannabis? Morning, night, evening? Do you ever utilize THC with it? These kind of questions as a physician, I don’t have the answers to, so it’s great to have an expert kind of run that.

Gabriela: Yeah, thank you. Definitely. So for example, I have a patient that she is on oxycodone. She is taking blood pressure medication, thyroid medication, omeprazole, something for hypertension. So it’s a polypharmacy event, right? She comes and she says, “I have pain and I will… My granddaughter, just gave me this CBD.” And I’m like, “Okay, let me check.” And is a 3,000 milligrams of CBD that has different cannabinoids. It has CVG, CBD, like I said, and THC Delta 8. So it’s different types of cannabinoids, and it has different milligrams. When you have more CBD, CBG in there, it actually helps not to feel the effects of the THC. If you have more of CBD and CVG in there. So those cannabinoids does not make you high and THC, actually, it helps you to make everything work better. It’s every cannabinoid has a effect, has a magic effect. So how to dose it depends on the product. So if a product, the whole bottle is 3,000 milligrams and a full dropper is 50 of CBD, 54 of CVG and five milligrams of Delta 8, for example, that’s a great combination because the patient will not get high.

Dr. Vaughn: Okay. And you’re saying these products are different in the, like you said, I guess the concentration, the Delta THC could be higher in some products?

Gabriela: Correct. So it’s about knowing what hypo cannabinoid is in that product. How many milligrams is the total and how are we going to dose it? Now, this patient is taking different medications, mostly Levothyroxine, correct? So I’m going to tell the patient, “This is what you take first, then you’re going to take, you wait an hour.” And then I even annotate them in the list of medications when they’re going to take, when it’s okay to take their tinctures, their gummies, would you like to vape it? I’m not sure. Depends on the patient. What is their preference? But those are the little things that is the education about.

Dr. Vaughn: Most of the time, is it frequency? Is it twice a day just based on the symptoms, I guess control?

Gabriela: Correct.

Dr. Vaughn: Okay.

Gabriela: Correct. So think about the beauty of cannabis medicines is trial and error, and you always start with low dosages. That’s your rule of thumb, and you will hear this with everyone. You start low, stay low if you can, and you go up in titrating. If you find that sweet spot that they call, stay there and annotate it. And if you find product that works for you, because it’s all trial and error, and I really recommend patients to write things down, to use a journal. And that’s something that, as a practice, we can develop with patients to provide pamphlets, infographics. And those are the things that I want to do as a cannabis educator. And that’s the other thing about this new world of the endo cannabinoid system is here to stay, and we need to continue to educate patients, providers, even the cannabis industry, patients are going to go to these dispensaries with no education. And the dispenser is done. They cannot give medical recommendations and say, “Take this milligrams three times a day.” That’s a medical recommendation right there.

Dr. Vaughn: When you educate them, do you, do you provide… Because I know when all I’ve done is sign… I’ve been a physician to sign for to get their medical certificate.

Gabriela: Well, that’s fantastic.

Dr. Vaughn: Not knowing the kind of dosing parameters and the makeup of each product. Do you suggest patients to go to the dispensary with this percentage of CBD or CBG and then THC or you can kind of give them that recipe to look for, for a product at the dispensary, or are you able to call the dispensary ahead of time? I’m just curious how it works.

Gabriela: Oh, I would love to. So Virginia has I think seven dispensaries, if I’m not mistaken. By now it’s seven dispensaries and the closest one is in Manassas from where I live in Alexandria. So that’s 40 minutes away driving. You cannot call ahead, or you might be able to call ahead. However, the products of the dispensaries, I have seen it and there’s not too much priority of it. And there is candies, there is more flower, there is more vaping. So patients don’t have that much understanding of what they were look for in a dispensary. So my homework actually, I decided to get a medical card, which I got. And I just got it in the mail. I waited from November until February, and I just got it last week. So finally, I’m going to go actually with one of my patients, because I adore her and we have been good close for many, many years.

Gabriela: And I said, “As your birthday, we will go,” and her daughter is aware of this. And we will go and I want to experience that as a patient, but I’m not going to say that I’m a nurse. I want to see how everything goes. And that’s an example of, “Let’s see how this things work, because it’s new for everyone.” And I want to have that experience. This is something that we’re going to see eventually. So how about create the experience from oneself and have it also with another patient and see how is she treated? The information that the dispensary is going to give. So I think we’re going to do a trip to Beyond Hello, that’s the one that is closest to us at Manasas. But you don’t know exactly what that product is going to be. So based on that, you can give a little bit of a recommendation of when to take it, how many milligrams and have to break if it’s a candy bar, if it’s a gummy. What is the package? Can the patient read the package label? That’s another one.

Dr. Vaughn: I could just imagine you doing some investigative journalism and posting it and provide it on social media. So as physicians, we understand what happens behind the walls, but that would be really cool to get your insight and kind of just to blog about it, or just to experience it so we know how to help. I guess, direct patients, what questions to ask when they’re at these dispensaries because-

Gabriela: Absolutely.

Dr. Vaughn: … I had an amazing podcast prior to this one with Dr. Katia Tonkin and she’s actually up in Vancouver. And it was fascinating hearing her talk about how, and you’re probably starting to see this too, how she would be able to really tell how medical cannabis was helping the patients as she was titrating up slowly as you’re mentioning kind of going slow. But when you get to that kind of perfect peak, you could then start to taper down some of their narcotic medicine and it was just… She was just thrilled when she was able to really kind of lower short acting pain medicines, even come down to long acting ones and really kind of balance out where you’re not having some of these systemic side effects from long acting narcotics so-

Gabriela: Oh, yeah. Absolutely.

Dr. Vaughn: It was really rewarding. Have you found not only treating pain, but what is your experience with also being an oncologist, there’s so much as far as anxiety and insomnia and these other symptoms that patients experience, how can you treat those with medical cannabis? Is it a different timing or dosing at night or a different, like you said, changes maybe in the percentages?

Gabriela: Oh, absolutely.

Dr. Vaughn: How do you treat those things outside of pain.

Gabriela: So for example, a good cannabinoid, let’s say insomnia is a big one. Patients that have a lot, lot of anxiety at night, you can do a combination of CBD, CBG. So I have found different products because I have done the homework. I attended two different conferences last year, because I wanted to continue my education on this, and I wanted to know more. So I went to a Cannabis Science Conference in Baltimore and I met amazing, amazing people over there who have worked on excellent products that have certificate of analysis. You can trust them, they provide some samples for the patients. And that’s another thing, are we as a practice, we take samples from medical laps, are we going to take cannabis samples? I think we should. Why? And this is a big why. Number one and this is funny because it’s… These samples, good thing about it is once the patients start using them, you can tell, “Okay, this works for me, does not work for me.” Because a cannabis medicine can cost from $45 up to $100 for a tincture or gummies – it’s costly.

Gabriela: The price is not cheap, and it’s not covered by insurance as we know. So patients can try trial and error and it will be really nice that you can have some samples to provide and they can get back to you and say, “Oh, this one work.” And how about if we have communication with this other brand or company or CBD because there is 3,000 out there of brands that if I can imagine, they’re so vast that you want to have different types that you can go and say, “Okay, this is five types. And I think these brands or these CBDs can work for you. So definitely is a trial and error that also as doctors and nurses we’ll have to take the risk and say, let’s do this and try it before the patient. You know what? My next thing is to get my integrative nurse coach. It’s everything. Even as a providers, I will recommend for you to use your CBD at night. You’ll sleep like a king.

Dr. Vaughn: As I mentioned, and we’re talking about symptoms, because I really find, one of the more troubling symptoms patients… And it’s with any Adjuvant therapy, patients with more of a palliative treatment, but insomnia is one of the symptoms that is just so difficult for patients. They wake up tired, they’re not sleeping. So having something, you try the usual stuff like melatonin or Ambien prescription stuff. It still doesn’t seem to sometimes work. This is what, as what you were talking about, having another option like CBD would maybe be something we need to really kind of think of in the medical community.

Gabriela: And the other, the best one for actually insomnia is CBN is another cannabinoid that is a… When THC actually oxidizes, it converts to another cannabinoid and that cannabinoid it’s amazing for sleeping. So there is different types of oils, tinctures that have different combinations of cannabinoids. So you can use it at night. So it depends on what the product is. I always said, “What are you looking for?” And that’s the assessment of what the nurse navigator will come about. It’s all about assessment. Let’s diagnose, let’s plan, implement and evaluate.

Dr. Vaughn: And are patients waking up rested, a full night sleep, there’s no sort of kind of drug effect next morning?

Gabriela: No. For example, there is different patients that they’re using cannabis. I have seen in the past year mostly a lot of the patients have, like I said, they’re coming out of the closet, and they have been medicating themselves. And many with polypharmacy. And they said, “I’ve been using less medication. This helps me more than the Ambien. Oh, I love how my gummies make me feel because I use less oxycodone.” And I hear this, but we don’t have… As providers, we don’t have that log in or log data that this is happening because of this cannabinoid intake that the patient is taking less medications, but the provider continues to do the same assessment and prescribe, but we’re not doing that goal of, “Okay. What is the end point of the patient’s goal for a symptom?”

Dr. Vaughn: Do you think, just from your experience, are there any reasons you wouldn’t use cannabis? Are there certain oncology treatments where it may hurt the effects of the treatment? I guess my question is, are there any kind of negative impacts where it might hinder the outcomes of some of our oncologic treatments?

Gabriela: So for example, there is… On the contrary, so there is two medications. Tamoxifen is one. There was a study that showed one person having issues with their outcome of treatment. But that was an old study. I think it was at the end what… The recommendation was in my last conference, if I’m mistake was to space out the Tamoxifen intake, if you’re going to use CBD medicines, space them out, at least six hours apart from when you take the Tamoxifen. If the patient takes it at night, then you’re taking your CBD or your cannabinoid medications, which also helps with side effects as menopause, in those menopause that patients are experiencing, patients with breast cancer that are going through a lot of changes hormonally. So CBD is also another cannabinoid, CBD, CBG is great for those symptoms of menopause. The other medication was immunotherapy nivolumab.

Gabriela: It was the response of the therapy, but I don’t think… Again, the data is one of those things that, what is the research trying to say and what is the study? So it’s one of those things that are very tricky. And how much cannabinoids are we going to give this patient? So it’s one thing to give little and see how the patient reacts. And the risk outweighs the benefits sometimes. It depends on the stage of the patient, what happened. So it’s a lot going on with this cannabinoid medicines and this care of, “Am I doing something wrong with my patient? Am I going to affect the treatment?” But that’s something that we have to research ourselves and do it ourselves because the data is not there. And this is why it’s very important than anything that from now on we’re going to do this has to be in written. And if we’re policies or advocacy eventually, have we seen changes in the community about patients using cannabinoid medicines? And actually is working with their adjunctive therapy is another door.

Dr. Vaughn: Right, right. I know because I get asked that a lot about just not only cannabis, but other supplements patients always worried about how it’s going to… Of course they want to take everything they can to help-

Gabriela: Correct.

Dr. Vaughn: … kind of make them feel good on treatment. But they’re also very scared about interfering with a mechanism with the drug so it’s not working as well. So it’s always that balance and you’re right. It’s going to be hard to really use some medical data to kind of guide decision making on that right now. But that would be great in the future though. I think having sort of these small studies. Maybe more community based and maybe like you said, some of the cannabis companies may want to come out to some community practices and may do some just small studies and you have to just kind of put this information together. But you’re right. I think as a physician you have to balance how difficult the patient’s suffering from certain symptoms and just disclose it. Sometimes you just don’t know what the effects may be on the response.

Gabriela: And of course there is many data right now. Drug interactions, of course it happens. We know actually cannabinoid medicines depends on the ingestion. It’s metabolized by our liver and or CPY enzymes are working arduously. So now what it’s going to happen is, patients also on warfarin, if they’re using THC or CBD medicines, those INR checkups have to be monitored more frequently. Well, if they’re going to use it. It’s not that they cannot, but if they have to, or it’s something that is helping then, okay, now it’s going to be a frequent checkup on your INR how your levels are and how your cannabinoids are affecting it.

Dr. Vaughn: Exactly. And we have some experience with some other medicine interactions with warfarin. And just another question, how do you feel the in Alexandria and just speaking of Northern Virginia, how is the buy-in from other physicians on cannabis? Are you seeing a change to kind of commit more to cannabis as a adjunct therapy?

Gabriela: The physicians right now, I see it mostly with the palliative team, mostly for that type of pain management and multi symptoms of related to treatment. Anxiety, insomnia, things like that. From the palliative thing mostly. The oncology side of it, they’re opening up a little bit more. I work with a big practice. So yes, I’m seeing the… Because patient are asking, and as a physician, and also as nurses, we’re like, “I’m hearing this a lot. Let’s take a look.” So it’s opening up and the changes are coming. And things at this rate it’s 2022, by 2024 I think we’ll have, the dispensaries is open in Northern Virginia. And I think there is some in Fredericksburg or Richmond.

Dr. Vaughn: Right. Yeah. Closest one we have is Richmond, but hopefully it’s going to be much more available. That’s the thing. It’s a lot for patients sometimes to travel at least for Fredericksburg, 50 minutes down to Richmond. I’m hopeful there’s something in everyone’s backyard to go to.

Gabriela: Absolutely.

Dr. Vaughn: Do you have any trouble navigating any issues with, with certificates or any difficulty is some of the Virginia laws or is it pretty seamless for you now?

Gabriela: Oh, absolutely. So right now, the cannabis is schedule one at a federal level. So I always tell patients, “If you’re going to your dispensary or if you’re going to cross the state lines, treat that cannabis like it’s a closed bottle of alcohol and put it in your trunk. And make sure that you carry your medical card and your certificate with you, if you’re traveling.” And also while they’re waiting, a lot of patients are having trouble to get their medical card. Like I said, it took two to three months also to get a response. Finally, it gets through your email. They’re not sending you the VML anymore. So once you get it, you have the freedom to go to your dispensary, either in DC or Virginia. In DC is reciprocate. So they accept Virginia medical card holders. So you can go to a dispensary DC. And that’s another trip that I will have to take.

Dr. Vaughn: Yeah. Right.

Gabriela: Yes, yes. So it’s a lot going on in this world of cannabis, but definitely, the more physicians knowing about the endocannabinoid system and cannabis medicines, that’s the main goal. Get to know that. Study that side, get curious about it. How is it working with people. And get to know the community. What are we looking for as a physician also and as a nurses? I think another thing is the national council of state boards of nursing in 2018 actually established their guidelines and posted their guidelines about medical marijuana and how nurses are actually, they need to know what endo cannabinoid system is, their regulations and their state, how to talk about cannabis medicines with their patients, how to obtain a medical card. So nurses need to be aware of this loss, and how to respond to patients as well without approaching of judgment.

Dr. Vaughn: If you’re starting to see it in the certification of nursing and licensure, you know where the landscape’s moving. So that’s very interesting. And it sounds like you’re seeing… I imagine you’re seeing an increase in the nurses joining the Cannabis Association.

Gabriela: Yes, definitely. This last year, this conference, I think it was almost 250 nurses.

Dr. Vaughn: Excellent.

Gabriela: Around the nation. I met nurse practitioners, midwives, everything from all around the nation. From Hawaii, they’re practicing. So it’s moving and all this laws that are happening and all this changes that we’re seeing with cannabis laws, it’s because of these pioneers of nurses, scientists, research, doctors behind the government.

Dr. Vaughn: And it sounds like you’re seeing it firsthand though, through experiences of your patients. You’re seeing them benefit.

Gabriela: Absolutely.

Dr. Vaughn: And how have you seen it? Just in their symptom control and just their affect? What have you kind of personally seen?

Gabriela: Remember that patient that I mentioned to you earlier about the levothyroxine and her granddaughter giving her that CBD oil combination?

Dr. Vaughn: Mm-hmm (affirmative).

Gabriela: She came with a lot of arm pain because her cancer has metastasized to the bone shoulder. So she couldn’t move her arm. And she is like, “Nothing works, nothing works. You don’t understand. I’m not sleeping, I’m not sleeping. And my granddaughter gave me this and I don’t know if I should use it and you know it.” And I’m like, “Okay, let me see.” And I explained to her how to break it down, where to use it. The following in week, she came moving her arm. I was impressed. And it’s not a miracle drug, but it’s something that I’m like, “excellent.” Patients with nausea and vomiting, for example, they have tried ondansetron. Composing with side effects of constipation. Nothing works. Then you add a little bit of CBD or a combination of cannabinoids. It works. CBDA is another raw cannabinoid. And it’s a sublingual. You can give it as a sublingual oil, and it does work with other medications. So it’s an adjunctive. So it makes your medications work better as well.

Dr. Vaughn: And that’s an anti-nausea sublingual. You can use it with compazine and other… Oh, that’s wonderful.

Gabriela: For example if patients taking Gabapentin sometimes for neuropathy or for pain or oxycodone, what happens is when you’re using cannabinoid medicines, it enhances or it helps those receptors in your body to work better because we… our body that endocannabinoid deficiency, our body’s not creating that healing process. So we are out of balance, not homeostatic, right? So you give that adjunctive medicine and you’re already taking those prescriptions. So that combination makes that work better. So I can see that in patients saying, “I feel less side effects and I’m taking less prescriptions for my side effects.”

Dr. Vaughn: I was going to say, as a physician doctor, our reflex is always just to kind of go up on the dose of the prescription medicine. But maybe if we could just add in… Somebody that’s adjunctive, you save that dosage and the side effects from doubling Gabapentin for instance, and the lethargy with that, or the constipation from pain medicines. That’s very interesting approach, and maybe something that would definitely change medical practices. If you could add something on top of the whatever prescription medicine is, you’re not constantly having to double or triple the dose for the effects you need.

Gabriela: Oh, absolutely. And that’s the trial and error that we were talking earlier. Don’t be afraid. Let’s remember, we’re talking about… We’re practicing medicine. This is chemotherapy. This is mixtures of medicines. And if you read the side effects, it’s lethal this and that, heart this, and it gives you so many scary side effects. If you read the side effects of cannabis, dry mouth, red eyes, hypertension, it can give you tachycardia. And we can actually discuss those side effects in detail with the patients, but it’s not… No one has died from an overdose of cannabis or using cannabis medicines. That’s not going to happen. And that’s one of the biggest scares. “Am I going to die from it? Am I going to get addicted to it?” And we talk about those more in depth with the patient. “Where are those questions coming from? Talk to me about, where is that fear?” So it’s more assessment towards seeing the benefit of the medicine awaiting the risk.

Dr. Vaughn: I’m glad you brought that up because I find that sometimes to be a barrier patient, especially some of our old patients there. And kind of the stigma around cannabis, and they’re so fearful of being addicted to cannabis. And I love your approach, how you just kind of sit and talk, go into what their fear is about that. And as you mentioned, kind of a slower approach, I love the journaling idea. That’s something that’s tremendous. And I think you just got to have buy in from the patient. I guess, once they start seeing the benefits, their angst will definitely settle down.

Gabriela: Absolutely. And they bring it up with their patient… With their doctor, they’re bringing it up with their doctor in their follow ups. And that’s one of the things. How eventually we can create this path to help patients. The cannabis nurse navigator can be something that is going to be used in practice, in oncology, in the palliative setting, in the pain setting, in the hospitals as well. There is a lot that just passed in California, Ryan’s Law that is allowing patients for them to use their cannabis medicines in the hospital or in their outpatient… sorry, inpatient facilities. And nurses actually are so… Their role is, “Okay. I need to know that my patient is taking their medications. And also, am I going to space these medicines that I’m going to apply?” So it’s very interesting. The laws are changing right now and are going… Virginia’s going to catch up soon.

Dr. Vaughn: Oh, I agree. I think it’s happening so fast and-

Gabriela: Yes,

Dr. Vaughn: … we have to educate ourselves and be comfortable with it. I think, well, it might be time to kind of wrap up, but I’m so thankful for you joining us. That was just so insightful and you’re kind of pioneering something up there, kind of creating this Cannabis Nurses Network. I hope it continues, and the success will even kind of work its way down here to middle Virginia.

Gabriela: Oh, absolutely, absolutely.

Dr. Vaughn: And we might need to give you a call to bring you down here to kind of set up, like I said, an algorithm for us to kind of have our own cannabis liaison.

Gabriela: Please. Absolutely.

Dr. Vaughn: For us, I think just incorporating this into that palliative care kind of therapy and how we can utilize cannabis in our palliative care outpatient clinic is something that I foresee is going to be that happening in the future in the next one to two years. Anything else you’d like to add?

Gabriela: Oh, yes, yes. So if you want to learn more, I’ll give you three good websites. Project CBD is really good if you want to know more about CBD dosages, endocannabinoid system, products that are trusted and are lab tested and has their certificate of analysis. So those are products that they’re legitimate and they are safe to be used. Project CBD, and then you have Society of Cannabis Clinicians, and also Doctors For Cannabis Regulation. That’s a great resource for loss.

Dr. Vaughn: Well, I guess two community networks and one website that we can go to as physicians who hopefully we do have some providers who listen to the podcast, hopefully this will enlighten them and they can, learn about it through these three offerings. So, well, thank you so much again, Gaby. I appreciate it. Like I said, we’re doing on this podcast, we’re kind of highlighting different themes and aspects of medical cannabis and how it’s beginning to evolve into oncology care. So I appreciate your time.

Gabriela: Absolutely. No, and I appreciate you and what you’re doing for the community, for your patients, and it’s great that physicians like you are open minded to say to their patients, “You know what? Yes, let’s try cannabis. Why not? If it’s something that can help you and they can make you feel better, and I’m here to help you, why not?” And that’s great to see that.