How can clinicians provide guidance about medical cannabis to patients with cancer?

Summary
This conversation explores the topic of cannabis and cancer, focusing on its potential benefits and risks in managing cancer treatment side effects and improving patient quality of life. The guest, Greg Garber, is the director of Oncology Support Services at the Sidney Kimmel Cancer Center and part of a program that educates patients on the therapeutic claims of cannabis. 

Takeaways

• Cannabis has shifted from being perceived as a gateway drug to being recognized for its potential medical benefits, particularly in managing cancer treatment side effects and improving patient quality of life.
• There is a lack of education and understanding about cannabis among healthcare professionals, which creates challenges in providing sound guidance and instruction to patients.
• The registration process for medical cannabis can be complex, and patients may face barriers such as lack of digital literacy and financial resources. 
• Normalizing conversations about cannabis and de-stigmatizing its use are important in providing comprehensive care and addressing the needs of patients.
• Building trust and open communication between healthcare providers and patients is crucial when discussing medical cannabis as a treatment option.

Chapters
00:00 Introduction: Cannabis and Cancer
08:29 Challenges Faced by Clinicians
14:38 Normalization and Destigmatization
24:10 Obtaining a Medical Cannabis Card
27:26 Personalized Care Plans for Cannabis Use
29:02 Building Trust and Open Communication
30:40 The Role of Trust in Patient Experience
32:11 Considering the Whole Person in Treatment
36:11 Resources for Clinician Education
44:36 Expanding Evidence Base and Potential Benefits
48:50 Empowering Patients and Caregivers to Initiate Conversations
52:06 Enhancing Quality of Life and Health-Related Outcomes

Resources
-Cannabis and Cannabinoids in Adults With Cancer: ASCO Guideline
-A Mapping Literature Review of Medical Cannabis Clinical Outcomes and Quality of Evidence in Approved Conditions in the USA from 2016 to 2019
-MS in Medical Cannabis Science & Business Jefferson allows providers to audit any course for free 

Check out the book: "Healing and Cancer: A Guide to Whole Person Care"
Visit https://www.healingandcancerbook.com/ for more information.

Connect:
Twitter: @DrWayneJonas
Facebook: Dr. Wayne Jonas
Instagram: @drwaynejonas
LinkedIn: Dr. Wayne Jonas
LinkedIn: Alyssa McManamon

Visit Healing Works Foundation www.healingworksfoundation.org for more information.

Dr. Wayne Jonas is a board-certified physician and Dr. Alyssa McManamon is a triple-board certified hematologist/oncologist. The opinions expressed on this show are those of the hosts and guests and do not necessarily represent the views and opinions of their places of employment, the Department of Veterans Affairs, or the United States government. The opinions expressed on this podcast are meant for entertainment and education and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Wayne Jonas and Dr. Alyssa McManamon have no relevant financial disclosures.

Transcript

Please note that this transcript is produced electronically and may not be an accurate representation of what was said. It may not be reproduced, edited, altered or modified in any way without prior written permission. Any use of quotes or excerpts from this interview requires explicit permission from Healing Works Foundation. Please contact us at healing@healingworksfoundation.org if you would like to use any part of this transcript for quotes or other purposes.

“How Healing Works with Dr. Wayne Jonas & Dr. Alyssa McManamon”

How can clinicians provide guidance about medical cannabis to patients with cancer?

Alyssa McManamon (00:01.661)

Welcome to How Healing Works. I'm Dr. Alyssa McManamon, and today we're going to cover the topic of cannabis and cancer. Once perceived as a gateway drug, and since 1970 regulated to schedule I by the DEA, by the US government, now the stigma connected to cannabis has shifted to one more of medical use and potential benefit, and specifically in regards to the management of cancer treatment side effects, like refractory chemo-induced nausea and vomiting, and patient quality of life.

Our guest today is Greg Garber, and Gregory is the Director of Oncology Support Services at the Sidney Kimmel Cancer Center at Thomas Jefferson University Hospital. He's also part of a program at Jefferson which helps guide patients through the medical cannabis registration process and helps to educate people on the benefits and risks of cannabis and the evidence behind those therapeutic claims. Greg, thanks for joining me today. We'd love to hear more about your background and the path that you've took to get where you are today and tell us more about yourself if you would.

Greg Garber (01:01.986)

Great, thanks, Alyssa, so much for having me today. This is a topic that I find myself talking more and more on, and I think it's kind of interesting and timely. Back in 2017, when Pennsylvania's legislation for medical cannabis was passed and dispensaries were starting to open, my colleague, Dr. Brooke Worster, and I sat down and had a conversation and decided that we didn't want...

this to be another healthcare disparity in the making. We realized that there was a tremendous deficit in education about this. We didn't fully understand how to access it. So we took on educating ourselves and building a medical cannabis certification and now research program to help our patients and to better understand how we can guide them and what is helpful and what is not and what's the right way to do this.

You know, it's a constantly evolving subject and data is coming out every day. It's, as you know, a hodgepodge of different state regulations and laws. And so kind of staying on top of it has been tricky. But to date, we have, Dr. Worster and I have certified about 4,600 of our cancer patients and have followed them longitudinally for quite some time. We've had two, we...

one R01 and one U01 grant one looking at cannabis and pain and one looking at cannabis and its potential impact on immunotherapy. And so we are wanting to try and understand this better and wanting to have our patients feeling as informed as they can, kind of recognizing that there are varying levels of health literacy and comfort having conversations about this, you know, once highly stigmatized, hopefully less stigmatized subject.

Alyssa McManamon (02:56.953)

I just want to commend you and Dr. Worster on kind of the leadership that it took to step outside of your own boxes, you know, and see that other people could be put in boxes and you didn't want to see that happen. And to do that, you really had to step out of your own box, you know, as a social worker potentially and for her, I think as a palliative medicine physician to really, you know, add to the literature, I think, and really help people as you do so. So that's impressive. I just want to really call that out. 

Alyssa McManamon (03:32.925)

So, you know, in all of that, Greg, really you may or may not feel like an expert at this point, but we are interviewing you as someone with expertise. And I would love it if you could in a general way sort of provide an overview of the cannabis plant, as we know has so many compounds within it, and also a larger question as to the medical use benefits and the risks for people, particularly with cancer.

Greg Garber (04:29.007)

Certainly, certainly. And it's a great question. So the cannabis plant is this kind of fascinating plant that's been around for thousands of years. People have been using cannabis in most of documented history for a variety of things, be it medical kind of ceremonial ritual things, religious things, recreational things, it's been around. This is not a new subject. It has unfortunately gotten a tremendous amount of

uh, you know, political attention going from legal to illegal, you know, there's a hodgepodge of kind of international laws about this. Some countries are very, um, progressive, others, you know, much, much less. So, but the cannabis plant is this, this plant that has, you know, grows fairly easily in a, in a lot of parts of the world and has, um, a lot of compounds in it, it's, um, we use the female plant because that is the one that produces the buds that are used to

produce the product. Most cannabis grows in this country are done inside. That's a result of state legislation, although there are some outdoor grows. But it's become a very highly scientific, precise process with the right amounts of light and moisture, trying to kind of optimize yield. There are hundreds of compounds in the cannabis plant.

We are just beginning to understand what some of them may do. There's so little research on so many of them and so many kind of marketing claims and things that are not backed up to make recommendations like this is better for sleep or this is better for nausea or this will kind of create, you know, reduce inflammation. And, you know, truthfully, we really don't know that much. What we do know a fair amount about the two main compounds in the cannabis plant, the cannabis sativa plant it's called. And one being THC, which people are familiar with it is the intoxicating compound in the plant and the other being CBD, which is the non intoxicating compound, which is thought to be helpful with things like inflammation and whatnot. So we really stay focused in our work with our patients on those two compounds. We really don't know an awful lot about

Greg Garber (06:46.334)

um, many of the other cannabinoids, so there are over a hundred cannabinoids. There are terpenes, which give things kind of, uh, their smell and taste profile. And there is, you know, some evidence that some of those can be particularly helpful with certain conditions, but again, it's, it's a, it's a nascent field. And so we're, we're learning as we go. Um, and, and a lot of the information that we have is, is kind of first hand patient experience. If you hear patients that you've spoken to saying, I've used this and it's been with sleep. Sometimes that's compelling enough to kind of go with that. 

Alyssa McManamon (07:24.121)

Yeah, I think as we get into maybe later talking about what the evidence base is, because it's been a schedule I agent, it's been very difficult for anyone to do research on it. And so you oftentimes are left with people's lived experience, which we don't want to discount because like you said, if you have 20 people in a row saying the same thing, they don't know each other, they're probably not making it up. And this comes back to kind of listening to people and learning from them as patients as well.

Alyssa McManamon (07:53.325)

It's, you know, as I listen, if you, you know, the depth of the complexity is quite apparent right away, both for the clinicians and for the nascent user, if that is a person with cancer who's exploring the use of cannabis or cannabinoids. But what particularly do you see as challenges for clinicians that they face in helping patients who express, say, an interest in trying cannabis to alleviate symptoms in the cancer clinic and really...

what are you and your team doing specifically outside of the registration process for the medical marijuana use card? What are you doing in the clinic?

Greg Garber (08:29.646)

Sure. No, that's a fantastic question. And that really is, that's kind of what we grapple with day to day. How to provide sound guidance and instruction in an environment with which most people are not familiar. This is not, and one of the things that our patients realize very quickly, this is not a pharmacy like experience. Even though pictures of dispensaries are often kind of very beautiful places that look like

you know, boutiques or cosmetic counters that are kind of, you know, highly designed and are meant to be welcoming, which is great, that's terrific. But once you get certified, at least in Pennsylvania and in many other states, you can go into a medical cannabis dispensary and you can buy any one of thousands of products. As certification essentially in most states just enables you to go and buy products. It doesn't give you a prescription per se to go in and get

this particular product. You can make some recommendations in at least Pennsylvania State Portal, but whether those are looked at or followed or always remains questionable. So our approach has been to start where the patient is. We wanna understand how patients, if they've used cannabis, what their experience has been, what negative experiences they've had, what they are looking to

get some help with what symptoms they are looking to treat. We'll listen carefully, we'll dispel myths, we'll provide corrections. We never tout cannabis as something that can treat cancer. We say to people, we hope, you know, maybe at some point we'll learn more about that, but there's really no good clinical research that says that cannabis is going to be helpful with cancer. There's some in the, you know,

Greg Garber (10:24.198)

one GBM study where you, like massive amounts of locally placed cannabis, you know, had the same outcome as, you know, standard of care. So it was.

Alyssa McManamon (10:33.605)

Yeah, yeah, the data for treating of cancer, you know, as a replacement for cancer treatment, we agree with the guidelines which say that data does not exist. And so I hear you there, but part of what you're saying is the education piece, you know, really like hearing what they already know. And I think taking that kind of use history, you know, is part of what you're saying too, which is really in line with the ASCO guideline that just came out about use of cannabis in the medical, you know.

oncology space. And so I think, you know, taking that use history is what I hear you saying and then really building from there, but acknowledging that it's different than we're going to be talking about a prescription, yeah, per se.

Greg Garber (11:14.994)

I mean, I remember when Dr. Worster and I sat down in the beginning of this, and we just we decided it was going to happen. And so it happened. And we met with the Epic folks to build a templated note. And we kind of structured our clinic. And then we got everybody on board and we're like, OK, so what do we want to ask? What do we need to know? And there really were no kind of guidelines for that. And like, OK, so what should we know? We should probably know what people's experiences were. One of the one of the challenges is that

Greg Garber (11:44.142)

products with, and this is changing a little bit, but the most appealing products for growers and dispensaries to grow are things that are very high in THC. And so for novice users, you can create some problem there. Somebody is willing to try this, is interested, and then they get a product that is way too potent and they lose a couple of days and they're on their couch and they're really uncomfortable and they're maybe paranoid and anxious. And that's not our goal. We don't want that to happen.

Greg Garber (12:13.33)

So we start very basically, we really only focus on THC and CBD and the ratios or the percentages of those two products. We listen to what they are looking to treat. There is some evidence, there's decent evidence that shows there is some relationship between psychosis and cannabis in younger patients. And so we get a mental health history. We ask, you know, does our patient have any history of

Greg Garber (12:40.822)

of a serious mental illness, typically for which they've been hospitalized and want to know about that. It doesn't mean that we won't kind of help people who have that. If they have a stabilized serious psychiatric illness and they've used cannabis before, okay, we'll work with them on that. But if somebody has an unstabilized psychiatric illness, we are kind of really careful. We have good treatments for that. We don't want people, there's really no evidence to treat depression with cannabis. We have great...

Greg Garber (13:08.962)

treatments for depression, we kind of bring our medical knowledge to this. This isn't by any means a cure-all. And so if somebody is morbidly depressed, we treat their depression. And hopefully that resolves to some extent. And then we can talk about, okay, so you're nauseated from your chemotherapy, your appetite, or your... And so I think it's important to think about...

Greg Garber (13:36.282)

that as well. You know, patients who have histories of substance use disorder, that it's not an exclusionary criteria. We just wanna know about that. You know, adding another drug to the mix may or may not be a good idea. It's not, it doesn't suppress respiration like opioids do. So we're likely to create much peril, but you know, we are thoughtful about that.

Alyssa McManamon (14:00.429)

Yeah, yeah, because like, you know, the drug-drug interactions and things like that, even with the things that we are using to treat all the myriad symptoms that come from treatment as terms of side effects, we do have to be mindful of that. I think what I hear you saying is, you know, it's a risk-benefit conversation on an individual basis and again, just taking everything into account and not also the fact that you guys sat down and said, we're going to make a template for if it's Epic or whatever, EHR you’re using.

Alyssa McManamon (14:28.841)

That is the normalization and the destigmatization of having conversations occur. And that really is an aspect of how this connects to whole person care, is how do we normalize the conversation so it doesn't matter who you look like or who you are in terms of the way I am perceiving you, I'm gonna ask you these same questions because this is what we do here to kind of just get a handle on everything about you and what could be useful to you or not in this space. So I think that that's...

Alyssa McManamon (14:58.045)

Just the generalization of the knowledge that you're imparting for interested parties and also just learning about them as people, I think it makes a difference.

Greg Garber (15:05.97)

It's been really important to us. And I know the, I just read the ASCO guidelines last week, which are great. They're really thoughtful. You know, it's a good discussion. There's a lot of attention to health literacy and health equity and how to have these conversations and where to start. I think it's an impressive effort that will become a living document, which is really exciting because there isn't this lovely chart that tells you

Greg Garber (15:33.578)

what do you use for what? We want that, but it is really hard. Like you're looking at, you know, mostly retrospective or observational studies that have often small numbers of subjects or these huge population-based studies, which tell you something directionally, but it doesn't tell you a lot about individual users. And so we're trying to glean what we can from that. And we wanna make it manageable. And so-

Greg Garber (16:01.318)

It's funny, like every time Dr. Worster and I sit down, or most times when we sit down with a patient, we're like, tell us about your experience with cannabis. And patients will often go, well, they'll get bashful. And we're like, no, we really wanna know. Like this will help us help you. And that just opens the door. Then we get the, you know, I'm getting it from my neighbor. I used it as a teenager. I used it in college. I used it here and there. I had this bad experience or it's helpful with this. And then we can build

Greg Garber (16:31.282)

you know, a base on which to, you know, create a care plan for patients.

Alyssa McManamon (16:35.993)

Yeah, and I think it's really that I mean, so kudos to the ASCO working group who did, you know, create the guidelines because I think that table one that you're kind of talking about that you didn't have when you and Brooke Worster, you know, was there sat down to try and start this template, there wasn't a history taking, you know, kind of guide and they provide that in table one of that document in, you know, ASCO. So it's helpful to see that that's out there. I think.

Greg Garber (16:45.57)

Yes. Right.

Alyssa McManamon (17:02.053)

you know, again, just like we're moving the field forward, you know, in these steps. And hopefully, as you said, it's a living document and some of the research that you and others are doing can help them inform the next iteration because some of the questions that you're posing are important to have answers to for sure.

Greg Garber (17:17.174)

And we don't wanna send people down the wrong path. There are a couple of interesting studies that show some impact on immunotherapy with cannabis. And we've come so far in oncology care that we don't wanna lose that. We wanna be kind of cognizant of that. And this is, we see this as an adjunct. It's wonderful when somebody can reduce opioid use because they have found...

Greg Garber (17:45.902)

by adding cannabis to their regimen that they have less, they've reduced their needs for opioids. We see that many, many times, not uncommon at all. There's no real guidance for that, but patients are resourceful and we'll kind of play around with that. And many, despite the opioid epidemic, many patients don't just don't wanna be on opioids and find that. And so, that's been really interesting to watch. 

Alyssa McManamon (18:13.071)

Yeah, that's part of maybe what's not there in the guidelines yet, but if you're seeing it in practice, it can be informative and kind of inspirational too, because you're really helping people to a goal in that case, which is to decrease opiate use, if that's what's true for them and that is what you've seen. So it makes a ton of sense. I think with the immunotherapy, hypothesis generating very concerning initial data sets that we saw.

So right now recommendations are to not use cannabis products at the same time as immunotherapy because of decreased efficacy that may be has been seen with immunotherapy in those cases. So just to be kind of clear about that for the listening audience, that's where the data is.

Greg Garber (18:52.054)

Yep. Yes. At least high CBD products, which have more of an immunomodulating effect. So we always have that conversation. Yes.

Alyssa McManamon (18:58.201)

Okay, clarification. Thank you. So as we were getting back to at Jefferson, patients can apply for the medical cannabis card and I might have said medical marijuana, but medical cannabis is kind of the terminology. And then they're registered with the state of Pennsylvania, as you said, if that's where they live. And so they can kind of do all of that at the local dispensary.

So how does Jefferson actually assist the patients who are interested in obtaining cannabis for medical use? Like, is it just, is it a one-stop shop where they come in and you help them with paperwork, or is this a long process? How does this actually work?

Greg Garber (19:34.154)

Yeah, so another really good question. And this has been iterative. We've learned as we've gone along. And Pennsylvania has been wonderful. Pennsylvania has created these opportunities for institutions to work with the state and growers, producers, sellers in the state as well, to generate research. So we're allowed to partner with a local dispensary to do research within. It's observational, and they dispense the products, but we can do

research with one of the dispensaries near us, which has been really cool and has made it a little bit easier for our patients. But essentially we learned that we, for our patients, we needed to give them a fair amount of help just registering. A lot of this is done online and we, in this process, and we've done research on digital literacy and other things.

We realize that 20% of our patients probably don't have an email address to which they have access or don't have one at all. And you need an email address. So like on my laptop that I'm doing this from right now, I have probably 80 Gmail accounts logged on that we have created.

Alyssa McManamon (20:42.781)

Gosh, I don't know if we should edit this out. Are you allowed to do that, Greg?

Greg Garber (20:48.998)

It's with a patient's permission, we have helped. And the email is not, there's no HIPAA that is being shared through that. A patient is sitting in the room while we do that. And in order to register that they need it, we first try to help them. If there's a family member with them, we'll use theirs. But that's a rate-limiting factor. Now there are states have gotten, kind of made progress on that.

Greg Garber (21:12.15)

Like I was just looking at Virginia's program and Virginia has a very humane program where they don't have a lot of dispensaries, but each state seems to get something really well. And Virginia makes it easy to get patients certified. They need essentially a doctor's note to go to a dispensary. They get entered into the system that way. So they don't have to go through an arduous online process. But so we learned also patients are, for patients who are, these are like real social determinants health issues

Greg Garber (21:42.074)

who are unbanked, who don't have bank accounts or don't have a credit card, it only takes a credit card to pay for the card for Pennsylvania, not for the product. Let's be clear about that. Pennsylvania used to charge $50 for the card. Now, if you're on medical assistance, they don't charge you or a number of other public benefit programs. But that was an issue. And so we, so we had some

Alyssa McManamon (22:04.526)

That was a barrier. It was a straight-up barrier.

Greg Garber (22:09.846)

We have some discretionary funds, philanthropic funds that we could use to help patients out with that and could use a card that we had within our control to help them do that. So, but these are like real barriers and I would probably not edit this out because this has been a discovery. I know, I get it. Yeah, yeah. I mean, we have to be thinking about social determinants of health. We did a paper at...

Alyssa McManamon (22:27.829)

It wasn't, but now I agree with you. Yeah, I just wanted to make sure you can read emails on your computer.

Greg Garber (22:35.106)

American Psychosocial Oncology Society last year, where we looked at all the patients certified within Jefferson actually, to see the percentage of patients that we've certified who are on medical assistance or who are persons of color. And we had a disproportionately high number of patients of color and those on medical assistance, which was kind of fascinating to us. I mean, I think the takeaway was that we've kind of worked hard to

make this accessible and to create pathways into this. The one challenge is that cannabis is still a cash-based process. And so once you go into the dispensary, you need to pay cash for your products. 

Alyssa McManamon (23:20.037)

Oh, that is fascinating. So you cannot use a credit card to pay in a dispensary.

Greg Garber (23:23.85)

You can use a debit card, but they charge you to do that. So it's handled as like a debit transaction for some people, but they charge you an extra three or $4. And it's, but you can't use credit cards at all, really anywhere. And, and, and rescheduling will hopefully change, it should change the banking laws about this. It's, it's, they're all, you know, myriad policy issues on this one. 

Alyssa McManamon (23:47.733)

Yeah, this is fascinating. I mean, just some of the nuts and bolts, because this is, if a place, you know, a cancer center or other wants to kind of consider starting a program similar to yours, these are the real deal. So literally though, if we take a patient who doesn't have an email address, they get to you, they get an email address, and they get online registered, and they have enough cash to go and do a transaction in a dispensary.

From time of sitting down with you and creating the Gmail account to when is that possible? How quickly is it possible to be approved?

Greg Garber (24:17.166)

Once you've kind of initiated the sign up on the patient side and on the provider side, those things come together. If you owe a payment for the card, you pay that. If not, the card comes in about a week. Pennsylvania has a fabulous program. The operations are really, really good. And so a patient could get a card within a week and they can go to a dispensary. And we will give patients some recommendations and give some places to start.

We make ourselves infinitely available. So patients can call us, they can email, they can portal message us. If you're going to have a successful experience, you need to think about kind of avoiding some of the pitfalls, like getting a product that's too high in THC or getting something way too expensive. And so we try to get around that. And then we follow up with patients,

Greg Garber (25:16.326)

in six weeks. And we try and make that humane. They don't necessarily have to come in. We can do that as a telehealth visit. They can reach out to us ahead of time if they run into any roadblocks.

Alyssa McManamon (25:25.649)

Yeah, and these are obviously billable. Billable. When you say telehealth, you're saying you're having a medical appointment, you know, with Dr. Worster, whoever.

Greg Garber (25:28.866)

Right, and I should mention that, it's a good point. When we built this clinic at that time, there were a lot of community providers who were charging cash to certify patients. So they weren't billing, it is an office visit, it was a separate visit, it could be $200, $300 to get the certification. At the time, you could do shorter than a one-year certification, you may still be able to do that. So some providers were

certifying patients for three months, making them come back pay more. That's largely gone away. There are many, many good physicians out there who are doing certifications in Pennsylvania who make it as easy and inexpensive as possible, who really are kind of doing the right thing, who don't charge veterans, who charge people who need recertifications, $50. We're thinking also of a patient population out there who is not just oncology. They're folks who have disabling conditions and are not able to work.

Greg Garber (26:28.194)

And so when you talk about the financial piece of this, it becomes a real issue. And there is, while we're working towards third party reimbursement for that, I think we're a ways away from that. The other thing that's been very interesting is we've been working with a company up in Boston that is building a platform that has built a platform that gathers information from a patient

about their symptoms they're looking to treat, when they can tolerate taking THC or CBD, what their work schedule, sleep schedule looks like. And it generates a care plan localized to a dispensary near them. And it uses this combination of AI and machine learning, gathers PROs, so it elicits feedback from patients on what they're taking. 

Alyssa McManamon (27:20.317)

Right, PROs are patient reported outcomes for those of you who don't know.

Greg Garber (27:26.678)

Correct, patient-reported outcomes, excuse me. We're building this that, you know, hopefully the patient experience can also drive some of, you know, how we're making recommendations to patients. And it creates a care plan that looks much more like a pharmaceutical care plan. Like at 9 a.m., you take this. At noon, you take this. At one, you take this. This you can take on a as needed basis, like if you need more, which is kind of wonderful because you're not wandering around trying to figure it out.

Greg Garber (27:57.21)

All kinds of challenges. There are many of the products that you buy, the box itself is labeled, but the cartridge or the whatever's inside of it isn't labeled. 

Alyssa McManamon (28:17.645)

Yeah, I mean, I think that's the, you know, the side, if you're using it for medical use, to have it as clear as possible, to have, you know, like you said, the patient experience, not only informing the, you know, the machine learning and the AI and everything, but also giving them a good experience. When you said patient experience, I don't just mean them reporting outcomes. I also think you mean, you know, their actual experience of how to do this, how to do it safely. I mean, I'm not interested in having a bunch of people on THC driving a car, you know, we need to tell them.

Alyssa McManamon (28:47.005)

Here's the last time you can use this before you can get in a vehicle and safely operate, and take it into account if you live alone, because I have so many patients who live alone. And so all those kind of little things that aren't little, but really are part of the prescribing in a safe way that really guides people.

Greg Garber (29:02.91)

Or if you're frail, like we don't want people falling, we don't wanna make things worse. And so those are like real things to consider, kind of our older adult population, we do not want somebody getting dizzy, we wanna be thoughtful about that. And so, and educating caregivers as well is just kind of critical in this. And it's been a really interesting process. I think once you get past the initial kind of conversations, our patients are really willing to kind of

Greg Garber (29:33.154)

have these conversations and share, we're as interested in their experience with this as they are in our guidance, which is great. Like we always start with kind of, how's it going? What did you buy? What are you using? How are you using it? Tell us about, tell us more about that. Because the other issue with this is it's not like you can log on to your EHR and see what they filled at a dispensary.

Greg Garber (29:55.914)

You're relying on a patient reporting that to you. Now, since we are in this research program in Pennsylvania, there is a database that we can kind of look in, but that's onerous. It's not easy or quick.

Alyssa McManamon (30:11.841)

Yeah, this is so much about trust. It's about building a trusting relationship between you, you know, the provider, the patient. I mean, this really is a conversation that has to be built on trust that happens over time is what I'm hearing. I mean, you know, in the Integrative Oncology Scholars Program at University of Michigan, you know, for the section on cannabis, medical use, and whatnot, I mean, it really was, you know, start low and go slow kind of thing. So I think the safety things, we all are getting more aware of that.

But the actual part of having this open discussion and then building the trust between a provider and a patient, that is what this is about. And I'm fascinated just thinking about, you know, how that changes their whole experience of, you know, treating their cancer as well. Because if this is in the sphere of oncology, it really is, you know, we need that trust to be built on both sides for all the reasons. And so they can tell us if they're having, you know, unexpected side effects, say from, you know, another part of the treatment for the cancer itself. So,

Alyssa McManamon (31:09.529)

If in the future you ever can study that part in terms of either compliance with oral chemotherapy, which is a tricky one, or some of the places where we know we have what they call pain points in oncology as far as really getting the drug delivered to the person outside the financial toxicity, but just the actual drug delivery. I think that'd be really interesting information because it's really this aspect of everybody as a whole person. How does that all fit together? 

Greg Garber (31:35.89)

And even within the system, like, so we work in a large academic cancer center, and we have, I don't know, 50 or some oncologists and stuff. So we have spent a lot of time educating the oncologists and the nurses and the NPs and others, PAs, who are working within this, in our ecosystem here, and helping to relieve their anxiety. Interestingly enough, there's kind of widespread acceptance here. We abide by their rules.

Greg Garber (32:05.31)

They ask us questions. They're, they want to, our patients want to know that their oncologist is okay with them, with this, with them doing this. And often the oncologists are the ones who are, say, go talk to Brooke and Greg, they know about this. And so there's that as well. They're not putting, there's no kind of burdening a patient with the feeling that they're putting something over on, you know, or holding something back from their care team. Like we're all in the same, notes go in the chart. These are documented. It's like we will, we'll

Greg Garber (32:33.558)

provide as much education and support as needed.

Alyssa McManamon (32:35.513)

Yeah, and that's that part of like team. You know, you have an expanded team because you've made this, you guys have championed this so that it's not a burden on the oncologists who maybe have less interest in personally educating, even though patients want us to all be educated on everything, some people are gonna have more or less education in this area or choose more or less to be involved. And the fact that you have a dedicated team to turn to, it's really priceless. I mean, to me, there's a corollary here between..

Oh, you know, what should I eat? I'm on treatment and nothing tastes good. Well, just eat whatever you can eat, you know, with no nutritional value discussion at all, right? This is kind of like, oh, well, what products should I use if I want to treat X, Y, or Z potential side effect? And it's like, just blank stare, nothing, you know, I don't know, but at least here, there's a place to go and say, oh, well, you can speak to this team that's part of my larger team.

Greg Garber (33:27.51)

For sure, for sure. And we actually, we did a survey within Pennsylvania a few years ago, which we published. Really no medical professionals have any significant amount of education, if any, in their training. And so only 10% of patients are getting guidance from an actual trained medical provider. The rest were getting it from...

Greg Garber (33:53.422)

dispensary employees and friends and Reddit. And I mean, we have a wonderful graph kind of showing this, which is fascinating. Like where else would you get medical advice from nothing against bud tenders. They're often very lovely, bud tenders and the folks who do customer service in it. It's great.

Alyssa McManamon (34:08.489)

They may be, what, 18. Can they be 18? I mean, I've seen some young ones, yeah. I don't know what the life experience is always there, yeah.

Greg Garber (34:15.859)

And I love this product and it's great and they're really nice, but like that's not, that's not a good way to do medical advice.

Alyssa McManamon (34:25.273)

Yeah, yeah. No, I think that the venture you're talking about out of Boston and kind of the gaps that you're identifying, I think that we all are aware of them to more or less degree. But for the actual person with the lived experience of having cancer and trying to seek medical cannabis as part of the therapy for symptoms, side effects, that sort of thing, I think that there are a ton of gaps that are being identified.

I think this is helpful just to talk about them at this stage to get kind of to what's next. And you made quick reference to some of the things that you've seen people get benefit from. And then for clinicians listening to the podcast, like you just said, many have not learned in medical or nursing school anything about the medical use of cannabis and are unsure of what guidance to give patients. So if you, outside of Jefferson where you have this wonderful team, if you were just trying to give guidance

on favorite sources for clinician learning and patient education both on this topic. Can you share anything that you'd point people to or that you would point people to start getting educated as clinicians, let's say first?

Greg Garber (35:31.934)

So certainly there's a lot of very decent material out there like cannabinoid overviews, the NIH and others and ACS and cancer support community. We've been working with a lot of organizations to kind of get really good kind of patient and provider facing education out there. You know, very, very basically it is, you know, start low and go slow. It is, you know, thinking

Greg Garber (36:01.47)

about THC and CBD, you know, not going down all these rabbit holes of the other cannabinoids that we do not know an awful lot about.

Alyssa McManamon (36:11.221)

I'm just thinking like straight up resources like MASCC (Multinational Association of Supportive Care in Cancer) their guideline. I don't know if they're kind of a symptom management sort of guideline. 

Greg Garber (36:22.73)

Yeah, no, MASCC is good. But most of the stuff out there is kind of fairly basic on guiding patients and certainly can send some resources that you can add to, you can tag on. 

Alyssa McManamon (36:43.473)

Yeah, to the show notes, you know, just like I think there's a 2017 National Academy of Medicine sort of report on cannabis, you know, these kind of foundational documents that just show the state of kind of the knowledge base in the last five years, you know, last seven years. And so I think, but as things develop, have you seen any CME that's been useful? And I know we're getting a little off script, but I'm just, we can put these things in the show notes if you do find anything.

Greg Garber (37:08.682)

Yeah, there are certainly CMEs out there that are useful. I know Jefferson does a couple of them in their other organizations nationally that do them. Again, happy to share those with you. There are more and more presentations showing up at conferences. One of the ways that I have found helpful to gather information is to look for review articles. Like, you know, there are a number of good ones on pain and on nausea, and I'm talking about the oncology space, but there are...

Greg Garber (37:38.054)

on spasticity, on PTSD, and they're, because most of these studies that have been done are very small and they're observational. So when somebody does a review article and kind of pulls all of that data together, there's a good one in the supportive care journals doing a kind of a retrospective review of all the different oncologic type symptoms and where we stand with evidence regarding those.

Greg Garber (38:07.846)

And I would also caution, as you saw in the ASCO guidelines, like chemotherapy-induced nausea and vomiting has some evidence, pain has some evidence, but really nothing else. 

Alyssa McManamon (38:25.021)

Out of that guideline, really, the one thing is like, you know, you've used guideline-based anti-emesis therapy for moderate to highly immunogenic chemotherapy and it hasn't worked. And so then you can consider adding, you know, cannabis and or you can consider adding also something that's a drug, you know. So it really, there wasn't a lot.

Alyssa McManamon (38:53.617)

to take from that except for that we're still missing so much of the potential benefit because we don't have the studies yet. But I think that things are going to change as you mentioned with more information.

Greg Garber (39:04.178)

And these other kind of more nebulous things, which are not necessarily less significant, is there isn't evidence that says that if you use cannabis, that you're gonna gain weight or have more of an appetite. Although many people who have used cannabis certainly would attest to being hungry. However, it improves the enjoyment of food for a lot of people. And that is a real loss in cancer care. So that's not being looked at.

Greg Garber (39:29.762)

But it certainly does. So, you know, people have, as you know, as an oncologist, terrible taste in their mouth and loss of appetite. There is something kind of good about that, that we hear that over and over and over again. Neuropathic pain, patients are getting benefit from neuropathy. There's like not a lot of good treatment out there for neuropathy, right? And so there are topical formulations seem to be helpful for a number of patients. Like it is interesting to see that. So like...

Greg Garber (39:56.902)

Even though this is anecdotal and wouldn't meet the, you know, the RCT gold standard, it's, it's something. It is a quality of life enhancer. And when you're talking about whole person wellness and you're talking about helping people feel kind of whole again, this, this can help. And it's too much to ignore. We've seen so many patients. And as we kind of anecdotally collect this information, these are the things that people are telling us about. And

Greg Garber (40:25.887)

and health-related quality of life. 

Alyssa McManamon (40:32.497)

I think it's going to be risk-benefit, you know, like if it's if it's something that's medically acceptable for use in terms of, you know, there's a risk and benefit of anything that we prescribe, it may or may not work for, you know, even the things that have been studied may or may not work for you. You could be in the 70 percent of people for which this drug doesn't work for even your cancer. So, you know, meaning not medical marijuana, but whatever the prescribed treatment for the cancer.

Alyssa McManamon (41:00.637)

So, we're always in that kind of, you know, even if we have data, you still might fall into the group of people for which this may not benefit. Does that mean you don't try it? I mean, I think there's a question there of how to approach things based on people's risk tolerance and, you know, all the things that we've already talked about in terms of safety and drug interactions and all the things that we need to think about when we prescribe anything. So I just...

appreciate that the lived experience that you're having there and that you're seeing your patients have is important and we don't want to discount it because this is an imperfect space that we live in. It's life here.

Greg Garber (41:34.634)

A couple of challenges to think about. We have certainly seen a fair number of patients for whom cannabis has been a very powerful anti-medic, where they have not done well, or as well, on infusion anti-medics and oral anti-medics. Very few places in this country have an inpatient use policy.

And so you may find a wonderful cannabinoid regimen to manage nausea and vomiting. And somebody gets admitted to the hospital with a neutropenic fever, or they're having a transplant, or they need inpatient chemotherapy for whatever it is they're having treated. And they're in a situation where they are kind of this, this adjunct that has been very helpful, it's not available to them.

Greg Garber (42:25.774)

I suspect that will change. It's too compelling. Like we've kind of seen a fair number of patients now who have had repeated ED visits for pain or nausea and vomiting and they have kind of started cannabis and nothing really else has changed. And that has made really big difference. And we know the payers and healthcare institutions love when we're

kind of keeping folks out of the ER unnecessarily. And the patients love that too. We need to pay attention to those things because we have a lot of people kind of going and getting symptom management in emergency rooms.

Alyssa McManamon (43:15.23)

Yeah, the other side of that though that you're bringing up is that they're right now because of the laws and whatnot, there's an ethical quandary that may occur there or the guidelines or rules or whatever you want to call them within an institution about inpatient use. That's very fascinating that somebody could get admitted for another reason and then have to come off the regimen that's keeping their symptomatology at bay in terms of, say, for nausea, vomiting because there's different side effects from our anti-omedics that are all approved by the FDA.

Alyssa McManamon (43:42.533)

Yeah, we know why sometimes people might want to avoid one of those, just you know, but everybody is different.

Greg Garber (43:49.278)

Good discussions with like our head of pharmacy and like, people are thoughtful about this. It's, it's not trying to be difficult about it, but just as an example, our EHR, you can, you can put on the med list that somebody is using medical cannabis, but it doesn't have any other specifiers. It's just medical cannabis on the med list. It's not, you know, 10 milligrams of this or five mil. 

Alyssa McManamon (44:13.969)

It's a black box. It's the big black box problem. Yeah, yeah, for sure. You know, you've mentioned spasticity and some other symptoms from other disorders, not cancer related. I think, you know, we're aware of that. You mentioned some of the, you know, the reviews that talk about medical cannabis use and other sort of PTSD and other things. I think we don't need to get deeply into that. But just

to know that the evidence base is growing kind of not just, you know, in this space, but outside of this space, maybe even more so, and to be aware of that if you're trying to educate yourself. 

Greg Garber (44:43.154)

And seizures as well. I mean, we have very good evidence on CBD and seizures. Like that is certainly compelling. Some of the autoimmune GI conditions, we have seen improvements in that. Scan evidence in other places. Certainly pain, we have seen. Spasticity, PTSD.

Um, not depression, um, anxiety, interestingly enough, seems to an insomnia or, um, CBD seems to be, you know, higher amounts of CBD seem to be helpful with those, um, THC, um, some of the things that you kind of thought like, okay, you, you get high, you take smoke, something or ingest something with THC and you sleep well. Actually, the CBD shows more evidence that is helping with sleep. So I mean, we

Greg Garber (45:39.462)

and need to pay attention and follow the evidence on stuff like that, it'd be wonderful to stop using benzodiazepines or non-hypnotics for sleep and reducing polypharmacy for patients.

Alyssa McManamon (45:53.649)

No, I think kind of taking everything into account. You're having to take everything into account and thinking about how does this, yeah, how does this change what other things the person's having to deal with in terms of other medications that maybe, you know.

Polypharmacy is a big issue. It still is a substitution of one for maybe two. So if you can get rid of two and beyond one, it's already a decrease of polypharmacy, I think is what you're saying as far as, there is some hope for people who feel like they're just like on too much with too many side effects for treating side effects of other things. So yeah, yeah. I just, if a patient is experiencing side effects and in this scenario, maybe from cancer treatment itself or from,

Alyssa McManamon (46:38.013)

the cancer itself, many patients, especially we've heard from patients of color who might feel uncomfortable asking about cannabis because of the perceived stereotyping of users of cannabis. And so if we're not at a place that has a center like your, or a program like yours, so specifically inviting the conversation, how do you suggest to maybe somebody, either a caregiver or to somebody dealing with cancer themselves, that they would broach the subject with their care team?

Greg Garber (47:07.79)

I think really the onus is on care teams and whether they have a palliative care program or not on just really keeping an open mind because the incidence of cannabis use in cancer patients has been estimated to be around 40%. It's big. So if we're not asking about this, we're not finding this out. And I would encourage patients and caregivers to ask, to share this with

a trusted provider, whether it's a PCP or an oncologist or somebody else. It's, it's the, the untoward reactions are usually more related to just providers, not knowing rather than having a knee jerk judgmental reaction to that. And so I, it's important to, you know, this is part of, you know, medical care and many people are using cannabis. And if that is something that you're using.

Greg Garber (48:02.482)

you're taking a little bit of a risk, but if there's somebody with whom you have a trusted relationship, that is where I would start the conversation. So, right, and maybe an oncologist, it might be somebody else, but we have longitudinal relationships with patients. In this day and age, nobody should be that shocked.

Alyssa McManamon (48:20.366)

Yeah, in your answer I hear, you know, it really, I hate to put any onus on the patient and the caregiver, you know, because I just have an open and trusting place for conversation. But activating, you know, or being empowered yourself as a patient or caregiver and knowing the laws in your state, knowing if you're one of the 38 states that has medical cannabis, those things can be looked up on the internet and then you can go to a provider and say, this is my understanding, I just would like more information. And if they don't know, then...

I would actually recommend just thinking about it after listening to your answer. Maybe say, can I have a palliative care consult? You know, because I just, I wanna have a bigger conversation than we can have here today, it sounds like. And so my next question is the caregiver say would be, can we get a palliative care consult for my X, Y, or Z family member, because we just need another conversation to occur on this.

Greg Garber (49:11.47)

Absolutely, and certainly inform yourself. But even if you live in a state where there is no cannabis program or a low THC program, these are still worthwhile questions. Like CBD is now abundantly available. There is obviously some quality issues you need to kind of think about where you're procuring that. And they are kind of increasing the amounts of...

It's long complicated, but increasing the amounts of delta 9 THC, which is the compound in cannabis that makes you high in CBD products. So hemp derived CBD, they're able to extract more THC from that and it stays within the law. So this is available, like even in states that have no interest in ever having cannabis, like it's available. So it is a reasonable question to ask.

Greg Garber (50:05.718)

The other thing is look at national organizations, patient support type organizations that are really paying attention now. American Cancer Society, cancer support communities, the things that people know are doing educational programming at chapters and nationally that, and are going to be more able and willing to have those conversations as the legal terrain changes. So that's gonna be a direction that certainly patients can look at. I know here we do,

Greg Garber (50:35.498)

a lot of cannabis education patient-facing. And so helping patients have those conversations in a non-judgmental way, our programs are open to anyone nationally. So, you know, certainly people could, these are a resource that we offer, you know, around, but there are other big organizations are really paying attention. And I think that we're gonna see that coming out more and more.

Alyssa McManamon (50:45.469)

Kind of stay tuned as things continue to evolve, yeah.

Greg Garber (51:04.414)

When things are rescheduled and hopefully that does happen, like people have to have the conversation, you know, it is, that is going to be, at that point it will be patient driven because we're, you know, now this is legal federally. How do we access this? What are, how do we have that conversation? 

Alyssa McManamon (51:20.429)

Yeah, when that occurs, it'll shift, it'll shift because the conversation will be happening, you know, more so everywhere. Well, I just really thank you for sharing so much information. And, you know, before we close, is there anything else you'd like to share with our listeners, you know, just as we summarize?

Greg Garber (51:37.038)

Yeah, it's been my pleasure, Alyssa. Thank you so much. It's interesting, I'm 57 years old and who would have thought I'd be doing, you know, kind of all of this, you know, have this kind of knowledge and interest in cannabis, but I think it really falls into kind of, you know, holistically caring for our patients and their caregivers. And if there are things that can improve one's quality of life and relieve some symptoms and really are minimally, if at all, harmful, although, you know, I know there's...

data on frequent use and heart disease and all of that, but like largely the patient's lives are often improved by this and health related quality of life. We've seen this, these measures are out there. It's also nice to be able to have these conversations with patients and not have them feel like they're doing something kind of secretive or that is stigmatized. I think part of enhancing

Greg Garber (52:37.598)

a patient's experience through difficult medical treatment needs to involve like all of these things like how do we how do we care for the whole person. 

Alyssa McManamon (52:43.845)

Yeah. Yeah, I just, I mean, Greg, just again, like you coming, you and Dr. Worster coming out of a box lets people come out of their boxes. You know, everybody gets to be whole and have the real experience, talk about what's really happening and try and make it better. And I think that freedom of, you know, really again, that space, that trust that you create and even having this conversation with me today.

Alyssa McManamon (53:12.345)

I really, really so appreciate all your work in this space.

Greg Garber (53:15.214)

It's my pleasure. And if you want to think about it this way, much better to have a patient coming to you who has been buying a bag of weed from their neighbor and burning it and smoking it, who has just had a transplant or is on some other immunosuppressive drug and is at risk of aspergillant. It's much better. There are things you can ingest. There are things that are much, much safer. And we have this, there are all kinds of angles to this.

Greg Garber (53:42.75)

I think we educate ourselves and we open ourselves to conversations with our patients as we would with anything else that can enhance the quality of their lives.

Alyssa McManamon (53:50.965)

Well, that's just a great place to end. And thanks to everyone for listening to How Healing Works. Please stay tuned for our next episode.