Grass Roots America Magazine - May - COPING with COVID-19 by Grass Roots America Magazine

COV I D -19 S PEC I A L

M AY 2 0 2 0

COPING with COVID-19

CANNABIS | TRENDS | SURVEYS

WHAT’S UP AT GRAM? GRAM has been learning how to live and function in the current world with the pandemic like everyone else. Mid March our April Issue was printed. Later that day, we heard from dispensaries in Nevada, Washington, and California not to ship. Within days, all distribution had been canceled until further notice. We quickly put the issue online and will continue to publish online until we can resume distribution. Some of our team have had difficulty accomplishing daily tasks, sleep disruptions, and appetite changes. Others have been busy helping others, and most of our team have experienced periods of both. Ellen Kauwana founded WeGotThisSeattle.co to support frontline and local businesses in Seattle. Jordan Person has held several webinars for her clientele at Primal Therapeutics. Both have been able to donate thousands of meals to Frontline Workers and Feeding America. GRAM participated in Nugtopia’s 420 Webinar on Facebook. Jordan Person represented GRAM with a live interview with Dr. Jackie Salm. Dr. Salm is an award-winning Cannabis Scientist for her research on cannabis terpenes. They spoke about cannabis, cannabis science, terpenes, and living in isolation, as Dr. Salm did research in Antarctica. You can view that interview on our website at Getgramnow.com. We decided to address COVID-19 and cannabis this issue and will present our planned May Natural Plant Medicine issue in the coming months. Dr. Aias-Theodoros Papastavrou provided us with “Cannabis and Covid 19.” He also contributed a second piece, “Trends in Endocrinology & Metabolism, the quest for a healthy endocannabinoid system with an emphasis on immunoregulation.” We begin the first of a four-part series on Cannabis Testing in this issue and have selected some previously published articles for your enjoyment and information. We dedicate this special issue to the scientists and frontline workers around the world. Stay Safe and Stay Healthy, Nancy

We Got This Seattle

Feeding the Frontline Healthcare Workers in Seattle

WeGotThisSeattle.co OUR DUAL MISSION:

TO SUPPORT OUR FRONTLINE AND LOCAL BUSINESSES DURING TIMES OF CRISIS, SUCH AS COVID-19. The group was founded in March 2020 by Ellen Kuwana, a Seattle science writer who worked alongside physicians and scientists for 20 years at University of Washington and Seattle Childrenâ&#x20AC;&#x2122;s Research Institute. As the COVID-19 pandemic worsened, Ellen became more and more concerned about her friends and family on the frontline. She decided to order and deliver pizza to 70 lab personnel at University of Washington Virology. When she described what she was doing and why, the owner donated the pizza. So she did another meal with that money. Several other restaurants she contacted responded with donated food, and she realized that lots of people wanted to help. Her effort snowballed from there, resulting in almost 5,000 frontline workers getting fed (and caffeinated) in the first month. We rely 100% on generous support from the community to fund our initiative and provide much-needed support for our frontline workers at more than 20 sites. Thank you to the many individuals, organizations, and local businesses that have helped to make this possible. Visit our website to learn more about the great work the team is doing to support the frontline, donate or sign up as a participating restaurant.

Donations are tax-deductible and fees are being waived until June 30, 2020, so 100% of your donation goes to helping feed frontline workers and support Seattle restaurants. 4

MAY 2020 COVID-19

10 COVID-19 + CANNABIS 14 TRENDS IN ENDOCRINOLOGY + METABOLISM 18 AMERICANS FOR SAFE ACCESS + COVID 23 KEEPING LOVE AND FAITH ALIVE HOT TOPICS 28 CANNABIS TESTING - 1 OF 4 34 YEAR OF THE NURSE - ELOISE THEISEN THROWBACKS 38 CANNABIS BASICS 42 CHOOSING FLOWER 46 CANNABIS + ANXIETY 48 ANXIETY - DIS-LIST 50 INSOMNIA - DIS-LIST BONUS 52 WHATâ&#x20AC;&#x2122;S WORKING - RELEAF DATA 54 VALIDVET, DR. ZAC PILOSSOPH 56 CELESTIAL EVENTS

*Certain articles have been previously published by Leilani Publishing Company in Florida Grass Roots Magazine and GRAM. 5

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Aias-Theodoros Papastavrou, PhD Ben Owens Dawn Hayford, EdD Debra Kimless, MD Heather DeRose Jordan Person, LPN, LMT

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FEATURED WRITER

DR. AIAS THEODOROS PAPASTAVROU Dr. Papastavrou is a consultant physician, with over 35 years’ experience in hospital medicine. His current job title is Medical Director at Biomed Aid Ltd in Skopje, North Macedonia; he is also in private international practice, providing support to people with cancer and severe chronic disease by integrating evidence-based lifestyle consulting with complementary therapies alongside standard care. The medical division of Biomed Aid Ltd specializes in integrative and personalized medical counseling and treatments focusing on patients with malignant and/ or chronic disease. Their treatment approach is based on comprehensive molecular diagnosis, detailing all the genetically determined strengths and weaknesses of the specific cancer [or other chronic disease (ie MS, ALS, metabolic syndrome, obesity etc)]. Based on laboratory specifics, all conventional treatment modalities are potentially used (when and to the extent they are indicated), supplemented by innovative ones, like oncothermia, dendritic cell immunotherapy, anti-SENSE oligonucleotide therapy, nutrition (ie medical ketogenic diet for cancer or epilepsy), tailored made physical exercise, epigenetic supplementation, ozone therapy, cannabis therapy, psychotherapy and more. The goal while attending to patients is to offer them life extension with quality. At present, Dr Papastavrou serves as vice-president of Hellenic Society of Integrative Oncology (HellSIO) and member of the Int’l Interest Committee of SCC (Society of Cannabis Clinicians). He has served as president of ICHS (Int’l Clinical Hyperthermia Society), and general secretary the Hellenic Society for Oncologic Hyperthermia (HSOH).

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COVID -19 SPECIAL EDITION 9

COVID-19 + CANNABIS

IS IT ETHICAL NOT TO INVESTIGATE THE USE OF PHYTOCANNABINOIDS? BY AIAS-THEODOROS PAPASTAVROU, MD, PHD I have been very curious to see what experts had to say about cannabis use in the COVID-19 epidemic, and thus have been researching extensively. I have found only broad generalizations, along with the popular refrain “cannabidiol does not cure coronavirus”. I find it to be a very oversimplified statement (who is talking about treatment of the virus itself, anyway?) and so I decided to do my own research. According to all the studies to date (Nichols & Kaplan, 2020), there is no doubt that CBD is immunomodulatory and anti-inflammatory. By “immunomodulatory” we mean basically immunosuppressive, since it generally suppresses the proliferation and activation of mitogen stimulated T-cells, as well as the production of pro-inflammatory cytokines (Chen et al., 2012); the point that should be made here is that the immuosuppressive action of CBD is in no way related to the immunosuppressive action in drugs such as methotrexate or cyclophosphamide. These drugs alter immunity as suppressors only, while CBD (and THC for that matter) modulates its response either by suppressing or by enhancing it, depending on the level of existing T-cell activation (Chen et al., 2012). These findings apply to HIV infections and it remains to be proven if they apply to other corona viruses as well; nevertheless, some data are avail10

able: In SARS-CoV infections (very similar to current SARS-CoV-2), a severe decrease in circulating T-cells was observed in the acute phase (Channappanavar et al, 2014). It is therefore possible and worth investigating whether the same applies to COVID-19, which would mean that the two basic phytocannabinoids, namely CBD and THC, would be indicated for the treatment of the acute phase. We have no definite proof at this point. In the COVID-19 epidemic, people are dying mainly of an inflammatory cytokine storm, leading to non-reversible ARDS (Acute Respiratory Distress Syndrome). Several drugs, new and old are tested in the pursuit of a means to contain the storm reaction of the immune system in a balanced way. Since bibliographical evidence suggests that CBD has multiple modes of anti-inflammatory action, very comparable to colchicine (Drugs.com) save the serious adverse side effects (Leung et al, 2015), it is only reasonable to have it tested in the present contingency. There is also some preclinical evidence that THC is useful in preventing the equivalent of ARDS in mice (Rao et al, 2015). I propose that it should be included in the therapeutic protocols on equal terms as colchicine and chloroquine.

Overall, phytocannabinoids manifest their effect by directly suppressing effector T-cells, and by inhibiting kinase cascades and transcription factors leading to production of pro-inflammatory molecules. One such example is the inhibition of phosphorylated p38, which leads to a decrease in the functionality of the inflammatory transcription factors AP-1 and NF-κB, thereby reducing inflammation. Another interesting aspect is the emergence of pro-inflammatory micro-RNAs (miRNAs) at the onset of ARDS (Umbrello et al, 2016), associated to Toll-like Receptor (TLR) and NF-κB signaling (Juknat et al, 2019). miRNA-induced inflammation is not amenable to corticosteroid treatment, but is responsive to CBD and THC (Umbrello et al, 2017). This is another line of research, very much worth pursuing. In particular, the aforementioned actions of phytocannabinoids are manifested by the inhibition of the production and/or activity of important inflammatory cytokines such as, IFN-γ, IL-6, IL-1β, IL-2, IL-17A, TNF-α (mediated through enhancement of endogenous adenosine signaling (A2A receptors) (Nichols & Kaplan, 2020, Carrier et al, 2006), and chemokines such as CCL-2, which attracts monocytes, T-cells and dendritic cells to areas of inflammation. CBD, with its inhibitory effect on cryopyrin (NALP3), inhibits macrophage inflammasome activation, and thus the caspase-1 cascade is not activated or, were it activated, it would be controlled (Han & Mallampalli, 2015, Libro et al., 2016). Two pro-inflammatory interleukins, IL-1β and IL-6, are emerging as the decisive factors that dictate whether a

THERE IS NO DOUBT THAT CBD IS IMMUNOMODULATORY AND ANTI-INFLAMMATORY COVID-19 case will evolve into ARDS (through the combination of macrophage activation syndrome and immune dysregulation [Hellenic Institute for the Study of Sepsis, 2020]) or will self-cure. IL-1β is responsible for 25% of cases, while IL-6 for 75% (Professor E. Giamarellos, personal communication). Interestingly, they are both mitigated by CBD (Nichols & Kaplan, 2020). There is less evidence for THC (Kozela et al, 2010, Keen et al, 2014). In view of this knowledge, not testing CBD as a preventive of ARDS in the context of COVID-19 might even be considered unethical. In addition, cannabidiol directly induces inflammatory immunocyte suppression by up-regulating the IκB kinase complex, which inhibits the activity of the NF-κB transcription factor (Nichols & Kaplan, 2020). CBD also plays a regulatory role in inflammation by triggering the production of Treg and MDSC (Myeloid Derived Suppressor Cells) (Dhital et al, 2017), as is the case in simple respiratory viral diseases, especially during the early phase.

All the above actions of CBD are related to the suppression of innate (primary) immunoreactivity. Innate immunoreactivity is extremely useful at the beginning of viral infections, but harmful when it eventually gets out of control in the course of the disease: In high risk groups, it can lead to ARDS (acute respiratory distress syndrome). This is what patients have been dying from in the ICUs of the world.

CBD SHOULD BE WELL SUITED FOR THE EXACERBATION STAGE OF COVID-19 INFECTION Apart from this, CBD exerts an immunoapoptotic activity (ie withdraws inflammatory immune cells by the programmed cell death mechanism that is called “apoptosis”), as well as an apoptotic activity on infected cells; both actions appear to be important in controlling the degree of inflammation and the progression of infection (Nichols & Kaplan, 2020). In addition to treating uncontrolled inflammation in the context of viral disease in general, cannabinoids cause significant changes in epigenetic mechanisms (D’Addario et al, 2013), including methylation, histone modification, and non-coding RNA. The epigenetic regulation of viral infections through cannabinoids has received considerable attention in the literature, but this line of knowledge is not fully understood yet. With the increased methylation of host DNA under the influence of cannabis and methylating agents, the expression of many genes may be inhibited, and in particular of the genes re12

lated to cell-virus interaction, i.e., genes governing the entry of the virus into the cell, its structural integration, its output and subsequent inflammation (Tahamtan et al, 2016). Based on the above theoretical / bibliographical data, CBD should be well suited for the exacerbation stage of COVID-19 infection, for exactly the same reasons as colchicine, which has already begun to be administered experimentally. The only difference is that CBD is free from important adverse effects. By the same token, its use as a prophylactic should be discouraged; the same applies to the initial phase of the infection: Full capacity of innate immunity is what is required initially. Concerning patients that already use CBD for other conditions; given the fact that immunosuppression is dose dependent, they should probably keep using it during the epidemic, but in small doses, arbitrarily estimated at less than 15mg/day in divided doses. If larger doses are needed, and in order to err on the safe side, then CBD combined with strict social distancing should suffice. Smoking and vaping should be discouraged altogether (Williams, 2020). A final word of caution: Neither CBD nor any other cannabinoid and anti-inflammatory terpene have been systematically tested in the clinical setting of the present epidemic, and therefore cannot be formally recommended by clinicians. Cannabinoids can contribute to infectivity and/or pathogenicity in certain viral infections; in others, they can diminish make viruses less infective and/or less pathogenic. In both cases, multiple biochemical routes affect host immunity, cell signaling and effector mechanisms involved in the viral cell cycle. In this respect, the role of vitamin D is extremely important in the enhancement of public health, but beyond the scope of the present discussion. In any case, caution is in order and medical supervision as well (Reiss, 2010).

N OT E S

NOTE 1: CBG, other cann abinoids and terpenes ha ve not been taken into account in this small review because a) they would greatly confuse understanding of an alrea dy complicated matter b) Th ere is little research availab le in the literature of cannabis to da te. NOTE 2: In the literature, CBD and THC are conside red as isolated substances, thus without the notorious “en tourage effect” of preparations fro m whole plants (Russo, 20 18). The main exception is a few stu dies with AIDS/HIV patients , who were also smoked cannab is users. There is a possibil ity that the use of whole spectrum oils would have a different effect on the immune response to viruses. NOTE 3: Other supportive measures (like vitamins D and C, glutathione, acetaminoph ene etc) that could enhanc e innate immunit y are available, bu t have not been addresse d here.

SELECTED REFERENCES Carrier, E. J., Auchampach, J. A., & Hillard, C. J. (2006). Inhibition of an equilibrative nucleoside transporter by cannabidiol: A mechanism of cannabinoid immunosuppression. Proceedings of the National Academy of Sciences, 103(20), 7895–7900. Channappanavar, R., Zhao, J., & Perlman, S. (2014). T cell-mediated immune response to respiratory coronaviruses. Immunol Res, 59(1–3), 118–128. Chen, W., Kaplan, B. L. F., Pike, S. T., Topper, L. A., Lichorobiec, N. R., Simmons, S. O., Ramabhadran, R., et al. (2012a). Magnitude of stimulation dictates the cannabinoid-mediated differential T cell response to HIVgp120. Journal of Leukocyte Biology, 92(5), 1093–1102. Chen, W., Kaplan, B. L. F., Pike, S. T., Topper, L. A., Lichorobiec, N. R., Simmons, S. O., Ramabhadran, R., et al. (2012b). Magnitude of stimulation dictates the cannabinoid-mediated differential T cell response to HIVgp120. Journal of Leukocyte Biology, 92(5), 1093–1102. D’Addario, C., Di Francesco, A., Pucci, M., Finazzi Agrò, A., & Maccarrone, M. (2013). Epigenetic mechanisms and endocannabinoid signalling. FEBS J, 280(9), 1905–1917. Dhital, S., Stokes, J. V., Park, N., Seo, K. S., & Kaplan, B. L. F. (2017). Cannabidiol (CBD) induces functional Tregs in response to low-level T cell activation. Cellular Immunology, 312, 25–34. Han, S., & Mallampalli, R. K. (2015). The Acute Respiratory Distress Syndrome: From Mechanism to Translation. J.I., 194(3), 855–860. Hellenic Institute for the Study of Sepsis. (2020, April 9). Personalised Immunotherapy For SARS-CoV-2 (COVID-19) Associated With Organ Dysfunction — Full Text View — ClinicalTrials.gov. https://clinicaltrials.gov. Retrieved April 14, 2020, from https://web.archive.org/web/20200414135606/ Juknat, A., Gao, F., Coppola, G., Vogel, Z., & Kozela, E. (2019). miRNA expression profiles and molecular networks in resting and LPS-activated BV-2 microglia — Effect of cannabinoids. PLoS ONE, 14(2), e0212039. Keen, L., Pereira, D., & Latimer, W. (2014). Self-reported lifetime marijuana use and interleukin-6 levels in middle-aged African Americans. Drug and Alcohol Dependence, 140, 156–160. Kozela, E., Pietr, M., Juknat, A., Rimmerman, N., Levy, R., & Vogel, Z. (2010). Cannabinoids Δ9-Tetrahydrocannabinol and Cannabidiol Differentially Inhibit the Lipopolysaccharide-activated NF-κB and Interferon-β/ STAT Proinflammatory Pathways in BV-2 Microglial Cells. J. Biol. Chem., 285(3), 1616–1626. Leung, Y. Y., Yao Hui, L. L., & Kraus, V. B. (2015). Colchicine — Update on mechanisms of action and therapeutic uses. Seminars in Arthritis and Rheumatism, 45(3), 341–350. Libro, R., Scionti, D., Diomede, F., Marchisio, M., Grassi, G., Pollastro, F., Piattelli, A., et al. (2016). Cannabidiol Modulates the Immunophenotype and Inhibits the Activation of the Inflammasome in Human Gingival Mesenchymal Stem Cells. Front. Physiol., 7. Nichols, J. M., & Kaplan, B. L. F. (2020). Immune Responses Regulated by Cannabidiol. Cannabis and Cannabinoid Research, 5(1), 12–31. Rao, R., Nagarkatti, P. S., & Nagarkatti, M. (2015). Δ9Tetrahydrocannabinol attenuates Staphylococcal enterotoxin B-induced inflammatory lung injury and prevents mortality in mice by modulation of miR-17–92 cluster and induction of T-regulatory cells. Br J Pharmacol, 172(7), 1792–1806. Reiss, C. S. (2010). Cannabinoids and Viral Infections. Pharmaceuticals, 3(6), 1873–1886. Russo, E. B. (2018). The Case for the Entourage Effect and Conventional Breeding of Clinical Cannabis: No “Strain,” No Gain. Front. Plant Sci. , 9. Tahamtan, A., Tavakoli-Yaraki, M., Rygiel, T. P., Mokhtari-Azad, T., & Salimi, V. (2016). Effects of cannabinoids and their receptors on viral infections. J. Med. Virol., 88(1), 1–12. Umbrello, M., Formenti, P., Bolgiaghi, L., & Chiumello, D. (2016). Current Concepts of ARDS: A Narrative Review. IJMS, 18(1), 64. Williams, V. (2020, March 24). What Smokers Should Know About COVID-19. Https://newsnetwork.mayoclinic.org/ . Mayo Clinic News Network. Retrieved April 14, 2020, from Colchicine Uses, Side Effects & Warnings — Drugs.com. Retrieved from https://www.drugs.com/mtm/colchicine.html, Apr 14, 2020

TRENDS IN ENDOCRINOLOGY + METABOLISM THE QUEST FOR A HEALTHY ENDO - CANNABINOID SYSTEM (ECS) EMPHASIS ON IMMUNOREGULATION BY DR. AIAS-THEODOROS PAPASTAVROU

The ECS is a disperse system, extending throughout the body; it is in constant interplay with all other organ systems promoting homeostasis in almost every aspect. Despite that, the ECS is still neglected and not included in the curricula of medical schools. For this reason a few introductory notes are in order (Battista et al, 2012). The ECS is the regulator of cognition, mood, nociception, energy metabolism, oxidation, in-

flammatory processes and a disease modifier as well (Tantimonaco et al, 2014). The ECS consists of receptors, ligands to these receptors and enzymes that synthesize and degrade these ligands. The number of known endocannabinoid receptors is still growing to more that 55; the two most outstanding receptors are CB1R, mainly distributed throughout the nervous system and responsible

for the psychoactivity of cannabis, and CB2R, mainly distributed on immune cells, even those "disguised" as specialized cells within other organs. Other receptors include TRPVx, GPR55, PPaRs etc; all these receptors form dimers between them as well as heterodimers with other types of receptors, like opioid, dopamine, serotonin, adenosine, catecholamine receptors and many others, thereby promoting 15

a universal regulatory interplay throughout the body. The ligands to these receptors are the endocannabinoids (ECs): lipids of the eicosanoid family, derivatives of arachidonic acid (AA); the latter abounds in cell membranes; five of these are well characterized to date, but two are well studied: Anandamide (AEA) and 2-Arachidonoyl-Glycerole (2AG). ECs in the nervous system act in negative feedback loops, more or less like neurotransmitters, but, unlike them, they are synthesized and degraded on demand, and not stored in micro-vesicles. Several formerly unrelated morbid conditions are now recognized as ECS 16

deficiencies, including, among many, migraine, autism, fibromyalgia, irritable bowel syndrome, etc (Russo, 2016). The endocannabinoid system is involved in immunoregulation through the CB2 receptor and through receptor independent biochemical pathways. The mechanisms of immunoregulation by ECs include modulation of immune response in different cell types, effect on cytokine network and induction of immunoapoptosis; in brief, ECs down-regulate the innate and adaptive immune response in most, but not all, instances. Manipulation of endocannabinoids in vivo may consti-

tute a novel treatment modality against inflammatory disorders. It is obvious that the health of the ECS is of great importance in many ways, including the facing of a viral infection like COVID-19. A healthy ECS depends on many factors, most importantly from proper nutrition (McPartland et al, 2014). Dietary Ď&#x2030;3 fatty acids seem to act as homeostatic regulators of the ECS, acting in opposite directions if consumed by obese or nonobese individuals. Little change in EC levels are seen in individuals with normal weight, not fed a high Ď&#x2030;6 diet.

Dietary ω6 fatty acids are also essential, but should be in a balance to ω3s; suggested balance is ω3:ω6=1:1 to 1:3 for proper ECS signaling and prevention of peroxidation in general. Arachidonic acid is an essential component of the ω6 fatty acids. Probiotics and prebiotics play a significant part in ECS health, but, for a bizarre reason, they are generally not mentioned: They up-regulate CB2Rs residing on immune cells of the gut; they also modulate CB1Rs, depending on conditions, for instance, they down-regulate CB1Rs in obese individuals and help them gain less or no fat. Some flavonoids, like kaempferol, genistein, epigallocatechine gallate, and curcumin enhance the ECS; same happens with some anthocyanidins, like cyanidin and delphinidin, although with a different mechanism. Phthalates, pesticides, additives to pesticides like piperonyl butoxide act as ECS disruptors, mean-

ing that consuming organic food may be a sound protective measure, along with intake of detoxifiers, in case of health problems consistent with ECS deficiency not otherwise explained. Chronic stress impairs the ECS by decreasing levels of AEA and 2AG, and possibly through changes in CB1R expression too. Stress management may reverse the effects of chronic stress on ECS signaling. Anecdotal reports and common experience suggest that techniques such as meditation, yoga, deep breathing exercises and practicing of sex as well, exhibit mild cannabimimetic effects, thereby balancing the system. Exercise is also an ECS regulator: Long-term exercise leads to sustained elevations of ECs, and predictable CB1R down-regulation. Chronic alcohol consumption and binge drinking likely desensitize or down-regulate CB1R and impair EC signaling. Alcohol is not compatible with a healthy ECS.

Nicotine is an ECS deregulator: It induces EC production in some areas of the brain, while decreasing them in others. It should be avoided too. Caffeine, acutely administered, potentiates CB1R-mediated effects through antagonizing adenosine at the A1 receptor (AA1R). At the undisturbed state, AA1Rs tonically inhibit CB1R activity; Caffeine antagonism on AA1Rs sets CB1Rs free of inhibition, thereby enhancing ECS function, for example by letting 2AG activate CB1Rs. During chronic administration of caffeine, the effects are blurred by individual differences in adaptation. In general, CB1Rs are down-regulated. Chocolate: Cocoa contains small amounts of at least three N-acyl-ethanolamines with cannabimimetic activity, expressed either directly by activating cannabinoid receptors, or indirectly, by increasing AEA levels (di Tomaso et al, 1996).

Selected Bibliography: Battista et al, 2012: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3303140/ Tantimonacco et al, 2014: https://pubmed.ncbi.nlm.nih.gov/24526057/ (Russo, 2016): https://pubmed.ncbi.nlm.nih.gov/28861491/ (McPartland et al, 2014): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3951193/ (di Tomaso et al, 1996): https://pubmed.ncbi.nlm.nih.gov/8751435/

+ COVID BY JORDAN PERSON

Americans for Safe Access (ASA) is a 501(c)(3) nonprofit with the mission of ensuring safe and legal access to cannabis for therapeutic use and research. The organization began in 2002 and has been helping educate people, change laws, and get more research out there about the therapeutic benefits of medical cannabis. “We also care about safety, and we want to make sure patients are using cannabis safely and legally throughout the United States,” explains Debbie Churgai, Interim Director for ASA. GRAM sat down with Churgai to discuss how they are handling COVID-19 for patients throughout the U.S. She tells us, “When it first started, patients were really concerned about there being a lack of access to their medicine. So, one of the first things we did was host a stakeholders call. We contacted a bunch of people: patients, industry professionals, medical professionals, legal professionals, and within two hours, 15-20 people were on the phone strategizing. From that phone call, we then created a letter that we

sent to Governors, medical cannabis commissions, and health departments urging them to keep medical cannabis businesses as essential, not just the dispensary but also cultivation and manufacturers so that there was no stop in production or supply chain.” “It also meant, we needed to make sure patients were receiving safe products, that employees were also being kept safe. Then we started thinking about delivery for states that did not have that yet, and the states that did not yet offer telehealth - we wanted to encourage the changing of regulations at least temporarily to help accommodate the patients. As well as things like tax relief and adding additional caregivers, it wasn’t just about keeping businesses open, it was about making sure that patients were being protected and that products and employees were safe.” In Colorado, we have seen dispensaries adapt to this crisis by adding hand sanitizer at checkout counters,

WE NEEDED TO MAKE SURE PATIENTS WERE RECEIVING SAFE PRODUCTS, THAT EMPLOYEES WERE ALSO BEING KEPT SAFE

wearing gloves and masks and only allowing one person in the purchasing area at a time. 33 states now have some sort of medical cannabis program. According to news around the U.S., cannabis is now considered essential. But it wasn’t that way at first. According to Churgai, “Some states seemed to hold back on making any temporary changes in regulations. Within two weeks though, all the other states began implementing the suggestions we recommended.” “California has reached out more than any other state, I believe that is due to the fact that every single county there is different, from its tax structure to its implementation of the laws. Massachusetts was high with the questions as well because of them deciding to close down their recreational dispensaries for adult use. Now there is an influx of new patients. Now there are new concerns.” Each state has a different set of rules and regulations surrounding their medical cannabis programs. “We

wanted businesses to all have the same information so we offered a live training on health and safety during COVID-19, that can now be purchased as part of our Patient Focused Certification.1 In the training we provide information such as how to properly put on and take off gloves, how to properly touch things, how to properly sanitize surfaces, and more to make sure that businesses are being as safe as possible during this time.” “When we realized that we helped assist in making these services essential, we wanted to learn how they actually worked for patients throughout the U.S. We wanted to understand, what do they still need during this time? Are their needs being met as patients? Would they like to see services like telehealth and delivery continue after COVID-19? We realize that we really need to streamline our advocacy efforts at this time, and we felt the survey would be a great way to learn what we can do for patients out there,” Churgai explains.

HELP ASA DISCOVER WHAT PATIENTS NEED AROUND THE UNITED STATES. TAKE THE SURVEY HERE: https://www.safeaccessnow.org/covid-19_survey

COVID-19 PATIENT EXPERIENCE SURVEY ASKS QUESTIONS LIKE:

• HOW DO YOU OBTAIN CANNABIS?

• DO YOU FEEL YOU ARE AT RISK FOR COVID AND WHY?

• RATE YOUR STATE'S RESPONSE TO THE COVID CRISIS.

• HOW SHOULD YOUR STATE BE ASSISTING YOU MORE?

Patients are at greater risk for a variety of reasons so ASA is working to ensure that the needs of patients are taken into account. So, in addition to creating this survey, Americans for Safe Access has also created a page on their website dedicated to resources for patients seeking information surrounding COVID-19.2 Churgai says, “Cannabis is real medicine. I have been in this industry for so long, and I am a realist, and I know things will not change overnight. But I do feel the pandemic has highlighted the need for this medicine to be seen as real medicine. At ASA, patients are our priority, we are unbiased, we are not paid to play, and patients will always be our top priority.” You can learn all about Americans for Safe Access by visiting their website: https://www.safeaccessnow.org/

References 1. http://www.patientfocusedcertification/training/a-la-carte-trainings/ 2. https://www.safeaccessnow.org/covid-19

MEDICAL CANNABIS PATIENTS:

BE COUNTED!

Take the “COVID-19 Medical Cannabis Patient Experience” survey today! Pass it along to others because the more data we have, the better we can advocate for patients!

www.safeaccessnow.org/covid-19_survey

AFTER LOSING 40 TO COVID-19 BY NANCY MOSS

What started as a "Shelter in Place" check-in with friends Barbara and Daniel Melvin, grew into this article about a family with extreme losses to COVID-19. Barb first told me they had lost 12 family members and friends from COVID-19 in mid-April. By the end of April, the number had grown to 33. The current count is 40 family and friends lost to COVID-19 as of May 18, 2020. Daniel and Barbara lived in Detroit before relocating to Naples, Florida, in 2001. Barbara has worked in banking for 30 years and is currently a Vice President at First Florida Integrity Bank. Dan is a multi-talented

singer, radio personality, and entrepreneur. They are two of the happiest, kindest, giving, and loving people you could be lucky enough to know. Together, they have worked to give back to their community through philanthropic endeavors, as well as volunteering on numerous nonprofit boards. They celebrate their mutual birthdays, Sept 6 & 10 by holding an annual event called "Party Hearty for Charity," formerly known as "Party with a Purpose," their nonprofit organization., They have raised over $90K in the past six years to help support several nonprofit organizations in SouthWest FL. 23

Barb says, "The coronavirus is real. I first heard about it in March, but like everyone else, we didn't understand it, and at that time, we didn't personally know anyone that was sick from it. Then, as time went on, we started to hear about people that we knew who were dying. My husband and I hated to wake up and look at Facebook because it seemed every time we checked someone close to us or someone we knew had died." Barbara tells us, some of the churches in Detroit continued to hold services, after the recommendation not to gather in large numbers. The members met to seek comfort in the face of the pandemic. Barbara believes that was crucial for most of the people she knows who were infected and died.

How could one couple know so many people who have passed from COVID-19? They are an extensive close-knit family, descendants of Tom and Etta Rhoades, born slaves. Tom and Etta's dreams were to keep their descendants together spiritually, in harmony, and in brotherly love. They have honored their ancestors by gathering each year, for 46 years, for a three-day family reunion. Friday is meet and greet (you would need it with over 200 attending). Saturday is picnic time, complete with a softball game between the North and the South. Sunday, everyone goes to a local church, followed by a family dinner. With all those family members together, not an argument or fight ever. Until 2020, when the pandemic hit the family, and they canceled the family reunion.

Barbara shares with us information on a few of those they have lost. "My aunt, Mary Rhoades, died on April 22, 2020, she was 97 years old. She was in good health, and we were praying she made it to 100." Several of her siblings had achieved that milestone, and she was reasonably healthy for 97 years of age so that expectation was a real one. "Aunt Mary became infected in early April; two weeks later, she was gone. She went to the hospital in Philadelphia for minor surgery, and we believe she was infected there. What hurts the most is she died alone; no family or friends could visit her."

His death was not in vain as the Detroit Department of Transportation made many changes to enhance the safety of their drivers. Jason was a Deacon at my church."

"Jason Hargrove was a close friend of ours. He was the bus driver who went on Facebook Live to talk about a woman coughing on his bus without covering her mouth. Two weeks later, he was diagnosed with the coronavirus, and he died shortly thereafter.

"It spread so much faster in the churches. Many Pastors we knew caught the virus and were gone. They were older and many had health issues, when the virus attacked them they could not fight it off. These 4 Pastors were all a part of the Church of God In

Barbara continues, "Another close friend of ours was Larry Griffin. He died on April 16. He sang in my husband's band called "In Full Effect" when they were performing in Detroit. He continued to sing in a new band called "Serieux," who performed mostly in Detroit but also in Las Vegas. He had a beautiful voice and some great dance moves. He was so healthy until he caught the virus, and, in weeks, he was gone."

Christ (COGIC). Many had large congregations and were still holding services after the call for social distancing. These great men are a true loss for the COGIC community." "On April 23, we lost a very dear friend of mine, Lynn Raimey. I called her my sister as her father was the Pastor of my church in Detroit. Her family took me in and treated me like family when I first moved to Detroit and didn't know anyone. She had many health issues, so when she was infected by the virus, it killed her very quickly." "Although we have lost many family, friends, and associates, we know God is good, and he continues to show us favor even through the midst of this storm. Even though we know of many deaths, we also know of many survivors and to that we are grateful. These people are given a second chance so their test can become their testimony. I know of an entire household, The Washington family of Detroit, who are survivors. Pastor Jamonty, his wife Tamela and their daughter Ariel Washington all recovered and are doing well." Barb specifically finds strength in the Beatitudes; “Jesus said in Matthew 5:4, Blessed are they that mourn, for they shall be comforted. It is during these tough times of losing loveda ones that I can refer to scripture to give me the comfort I and my family needs. The question is have you ever suffered? Please know that we all have. But I have come to know through leaning on God and his word, he meets me at my very point of need. As believers, the Bible speaks about plagues and famine and death, and its teachings prepare us for what life has to offer. Oftentimes we don’t understand the current situations, but when we look back, we realize this had to happen.” As of May 5, 2020, there have been over 72,000 deaths in the United States, and over 257,000 deaths Worldwide. It is critical to find strength either within or in a higher power, focus on the positive, and stay connected. It is GRAM’s honor to recognize this incredible family.

BLESSED ARE THEY THAT MOURN, FOR THEY SHALL BE COMFORTED.

IN MEMORIAM FAMILY & FRIENDS LOST TO COVID-19 (40 AS OF 5/18/20)

Mary R. – PA Jason H. – MI Rachelle Lynn R. – MI Rev. O’Neil S. – MI Gerald H. – MI Curtis H. – MI Larry G. – MI Rosalind C. – MI Rev. Gerald G. – VA Skylar H. – MI Rev. David F. – MI Laneeka B. – MI Ejuan W. – MI Darnielita B. – MI Bishop Phillip B. – MI Bishop Robert S. – MI Bishop Robert H. – MI Tatia W. – MI Rev. Lonie J. – MI Carrie W. – MI

Helena J. – VA James J. – VA Robert J. – VA Annette W. – NY Helen L. – MD Walter H. – DC Carol T. – DE Benjamin T. – DC William B. – KY Daniel R. – TX Karen S. – NC Denise B. – NC Doris M. – OH Trina D. – MI Earl T. – VA Nathaniel S. – MI Lonnie L. – MI Nathaniel S. Sr. – MI Nathaniel S. Jr. – MI Angel R. – IL

WHEREâ&#x20AC;&#x2122;S

NOW?

In these unprecedented times everyone is having to figure out how to keep going and that includes GRAM. You can find the full digital issue along with easy-to-read, mobile-friendly articles on our website. We will be back in print as soon as we can. You can always get GRAM now.

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TESTING REQUIREMENTS

FOR MEDICAL MARIJUANA PART 1 OF 4 BY JORDAN PERSON State by state, when rules and regulations are written for medical marijuana one very important area is often overlooked - testing. The need for testing cannabis seems like a no brainer. However, when most states launch their medical marijuana programs the parameters for testing are not always laid out. It often takes additional laws being written to mandate testing. The regulation of pesticides on cannabis, including the difficulty of setting specific residue limits is not the only thing that needs to be considered. Solvent residues, microbes, and heavy metals each pose regulatory challenges of their own. Another hot topic regarding testing is terpenes. It is not mandatory to test for terpenes and from what science is teaching us, we should all be paying close attention to which terpenes are in the cannabis strains we are consuming. This article is the first in a series focused on the various needs for testing cannabis. Each article will cover the need for testing and why, as well as a call to action so that you can feel educated and empowered to make your voice heard wherever you live. Cannabis consumers are not just healthy adults. In most states, medical marijuana programs are legalized before recreational laws are even considered. This means that consumers consist of all age groups with various types of illnesses and conditions, and everyone is entitled to clean medicine.

THE NEED FOR TESTING CANNABIS SEEMS LIKE A NO BRAINER.

Third party testing is required in all states to show the amount of THC and CBD the marijuana cultivars possess. But, testing for pesticides, terpenes, and anything else varies from state to state. Regulations for testing are vital, and laboratory analysis is the bare minimum for medical cannabis facilities. A medical marijuana treatment center must retain all records of testing, as well as the samples, for a minimum of nine months (depending on the state.) Then, if a sample does not meet the set legal standards, the treatment center must recall all other products from the same batch.

solution for bug problems is often to spray the crops down with chemicals. 33 states now have medical marijuana in the US, and they all have different rules and regulations surrounding pesticides. A major cause for this could be the fact that pesticide use in agriculture is regulated by the U.S. Environmental Protection Agency (EPA) and overseen by state and local governments. But, the federal government considers cannabis an illegal drug.1 Therefore, the EPA has not approved any pesticides for use on the plant, nor has the

Pesticides are used in the growing of cannabis for pests, insect infestations, mites, and more. Cannabis crops are very expensive, and the fastest and most inexpensive

REGULATIONS FOR TESTING ARE VITAL.

agency provided any indication of the level of residues on cannabis productsâ&#x20AC;&#x201D;if anyâ&#x20AC;&#x201D;that could be considered safe. Each state has had to create new laws and executive orders. Colorado for example, passed Amendment 20 in 2000 legalizing medical marijuana. But, their emergency rules for testing for pesticides took place in 2015 when the Governor issued an executive order directing Colorado state agencies to address the threat to public safety posed by marijuana contaminated by pesticides. By March of 2016, the Colorado Department of Agriculture passed rules and regulations for the Pesticide Applicators Act to apply to cannabis as well.3 Now, 20 years after medical marijuana was legalized, the state of

Colorado maintains a very thorough list of which pesticides can be used on growing cannabis. The list is now up to 46 pages.4 Whenever the list is updated, notifications are sent out to all cannabis businesses and anyone registered on the list to receive updates. This streamlined process took years for the state of Colorado to fully develop. This type of list is something every state should implement. Another example is Washington state. Five years into their recreational cannabis program, they are still working on laws related to pesticides used on recreational cannabis. Currently, their medical cannabis testing requirements for pesticides are simply to detect the general presence of any pesticides prohibited by the Washington State Department of Agriculture. Florida is an agricultural state. Many crops are exported from the state and many pesticides are already in use for these large scale crops. The difference isâ&#x20AC;&#x201D;we donâ&#x20AC;&#x2122;t smoke strawberries or oranges. Some pesticides are deemed safe to be eaten if the produce is thoroughly washed off before eating. We donâ&#x20AC;&#x2122;t wash our cannabis. Instead we add fire to it when consumed through a pipe or a joint, or we add solvents to it to turn it into concentrates, or we cook with it to become edibles. None of these methods of usage have been studied for the pesticides in question. This can lead to people becoming sick after consumption if the plants are not properly flushed.

Florida created emergency rule 64ER20 in January 2020 requiring that testing results be reported accurately to three significant figures as the concentration in milligrams per kilogram, dry-weight for any test reported in parts per million (ppm,) and to three (3) significant figures as the concentration in micrograms per kilogram dry-weight for any test reported in parts per billion (ppb).5 They also provided a list of some 67 agricultural agents used in the growing process and what the testing parameters are for each chemical. This is a great step in the right direction.

WHAT ARE THEY TESTING FOR IN MY STATE, OR HOW CAN I MAKE SURE WE HAVE TESTING FOR PESTICIDES? Now you may be wondering, “What are they testing for in my state, or how can I make sure we have testing for pesticides?” The first place you can check, is the website your state has created for their medical marijuana program. You can find this by searching “medical marijuana Washington” or whatever state you live in. In Florida, the Department of Health created the OMMU (Office of Medical Marijuana Use) to be the official source of all things cannabis.6 They are responsible for writing and implementing the department's rules for medical marijuana, overseeing the statewide Medical Marijuana Use Registry, and licensing Florida businesses to cultivate, process, and dispense medical marijuana to qualified patients. You can also try reaching out to cannabis organizations currently fighting for your rights as patients, such as Americans for Safe Access. The mission of Americans for Safe Access (ASA) is to ensure safe and legal access to cannabis (marijuana) for therapeutic use and research.7 There are also groups like the National Organization for the Reform of Marijuana Laws (NORML) working towards cannabis legalization as a whole. NORML has chapters in almost every state working towards broadening the conversation surrounding the cannabis plant.8

THERE ARE STEPS YOU CAN TAKE TO FEEL EMPOWERED AND MAKE YOUR VOICE HEARD. 31

CALL TO ACTION FOLLOW THESE 4 STEPS TO EMPOWERMENT 1. REACH OUT TO YOUR LEGISLATORS. If you don’t know who they are, that is okay. Our government has made it incredibly easy to find out exactly who represents you at the local, state, and federal levels. By visiting the site www.usa.gov and clicking on the tab at the top of the screen that says “Government Agencies and Elected Officials,” you will then see the question pop up that says, “How do I contact my elected officials?” Simply click on that and away you go.9 Pro-tip: Do your homework before you write a letter to your representative. What does that mean? It means to research them and their opinions of things, especially the issue you are contacting them about. Follow the Ten Commandments of speaking with lawmakers and you will do great. 2. GET INVOLVED. Whether you are a keyboard warrior or you are better at walking the halls of your state Capitol or medical cannabis business offices. Become proactive and interactive with your elected officials. Don’t just send emails, try calling their offices too. Remember, if you call, have a plan of what you want to say. 3. INTERACT DIGITALLY In addition to platforms like Facebook and Instagram increasing the amount of interaction politicians make, Twitter remains the place where most are active daily. Consider making an account to interact and read their opinion on current events. 4.ATTEND TOWN HALL MEETINGS Your representatives will hold local Town Hall events where the public is encouraged to attend and voice concerns. You can usually find when and where these events are going to take place on your representative’s website. If you do not see any upcoming events listed, call their office and ask their assistant. They will be happy to provide an engaged citizen with the information.

THE TEN COMMANDMENTS FOR SPEAKING WITH LAWMAKERS 1. Thou shalt not lie to thy legislators.

2. Thou shalt not forget to thank thy legislators for their help. 3. Thou shalt not ignore thy legislators between sessions.

4. Thou shalt not be hypercritical of thy legislator’s voting on any bill.

5. Thou shalt not hesitate to praise thy legislators publicly for their good works.

6. Thou shalt not insist thy legislators desert their party on important party policy. 7. Thou shalt not fail to recognize the importance of thy legislator’s office.

8. Thou shalt not forget thy legislators too hath problems and sometimes needeth assistance in their day. 9. Thou shalt not become completely partisan. 10. Thou shalt not nitpick.

DO YOUR HOMEWORK ON THE OFFICE YOU WILL VISIT: ● Familiarize yourself with your representative’s position or votes on relevant issues. ● It is nice if there is something you can thank them for right from the start. GREETING: ● A warm greeting is a great ice breaker. ● Begin your meeting by thanking your representative for his/her time. ● Introduce yourself and all members in your group and state why you have requested a meeting or why you are stopping by their office. ● Identify your association and no more than three priority issues. STAY ON MESSAGE: ● Be professional, but assertive. ● Be brief. Representatives appreciate it when you get to the point and respect their time. ● Ask for something; be specific. ● Never make up information or ‘guess.’ ● It is best to say, “I need to get back to you.” Other than making up an answer. ● Encourage a conversation. Ask questions of the staff. TIPS FOR AFTER THE MEETING: ● Take notes to help you remember what was accomplished. ● Find the answers to questions you were unable to answer during your meeting and follow up with them like you said you would. ● Send a thank you note and other relevant information when you get home/back to your office.

Sources: 1. Seltenrich, N. Environmental Health Perspectives. April 25, 2019. doi: 10.1289/EHP5265 2. https://www.safeaccessnow.org/amendment_20_to_colorado_s_state_constitutionnew “Amendment 20 To Colorado’s Constitution” Americans for Safe Access.” 3. https://www.colorado.gov/pacific/agplants/pesticide-use-cannabis-production-information “Pesticide Use in Cannabis Production” Colorado Department of Agriculture. 4. https://drive.google.com/file/d/1upPu4MArl5Wcdy0eOgP7fkgFDTTSmQo0/view “Pesticides allowed for use in cannabis production.” Colorado. 5. https://www.flrules.org/gateway/ruleNo.asp?id=64ER20-9 Florida Department of Health. Emergency Rule for 2020, 64ER20-9. 6. https://knowthefactsmmj.com/ OMMU, Office of Medical Marijuana, Florida. 7. https://www.safeaccessnow.org/ Americans for Safe Access. 8. https://norml.org/chapters NORML (National Organization for the Reform of Marijuana Laws) “How to find a chapter near you.” 9. https://www.usa.gov/elected-officials “How to contact your elected officials.”

YEAR OF THE

NURSE BY DR. DAWN HAYFORD

FEATURING

ELOISE THEISEN

Eloise Theisen is the president of the American Cannabis Nurses’ Association (ACNA). She has been a nurse for 20 years and a cannabis nurse for six years. With the focus on healthcare workers during the pandemic of COVID-19, GRAM felt talking to a cannabis nurse about COVID-19 issues would benefit our readers. The number one challenge across the country is rapid change and uncertainty. This uncertainty is no different for the cannabis industry. “One of the challenges we’re seeing in the industry right now are these rapid changes that are coming out around deeming cannabis as an essential business in some states and not others; requiring adult-use states to now only supply cannabis to medical patients again. I think we’re seeing the industry--as a whole--is in jeopardy in terms of being able to sustain and weather this storm because of the fact we don’t qualify for any of the business stimulus relief at the federal level because we’re federally illegal still. So we have all these challenges as an industry that I am concerned about how, eventually, the ripple effect comes to patients. If manufacturers can’t weather this storm, if dispensaries and growers can’t weather this storm, who’s going to be there for patients when we start to come out of this?” Eloise said. A challenge for healthcare providers is providing the opportunity for cannabis as an alternative to opioids. Eloise said, “The way that the laws are set up, you have to go in and physically get your prescription refilled. And with all the practices trying to limit patients coming in, some of these chronic pain patients on opioid prescriptions are having a hard time getting their prescriptions refilled. So it’s a good time to 34

explore cannabis as a medicine, as either an alternative to their pain medication or something they can use in conjunction, which may allow them to spare some of the dosages.” Eloise highlighted the extreme variations happening across the healthcare industry that she sees through ACNA. “What we’re seeing right now is there are hotspots in need of healthcare professionals, but outside of that, we’re seeing layoffs, furloughs, and places closing down because the ERs aren’t at capacity or the hospitals aren’t at capacity. So there’s a real interesting extreme happening in healthcare where we’re either in crisis mode like in New York City, Michigan, Chicago, or you’re getting laid off.” One of the things ACNA is working on is a position statement on post-traumatic stress. Eloise anticipates a “huge increase in that diagnosis from the frontlines, first responders. So we want to get out there and get the states to list PTSD as a qualifying condition because not all states do.” Eloise addressed the various concerns floating around about using cannabis in these times. “I think a lot of people are nervous about inhaling cannabis right now because there’s been some mixed reports, some clickbait, fear-mongering articles coming out. A lot of those articles, they’re using information based on tobacco studies and not cannabis studies.” “We do have legitimate research to show that cannabis is effective for things like anxiety, chronic pain, and insomnia, and those are three major conditions or symptoms that people are struggling with right now,” she said. “I would say if you’re new to cannabis, inhalation is not the route you should choose to start until COVID settles in. If you’re a long-term can-

nabis user and you’re having any respiratory distress or any type of respiratory symptoms like a cough or shortness of breath, you should stop, contact your healthcare provider. Know that there are other options out there.” It is important to note that cannabis is not a treatment for COVID-19. The ACNA came out with a statement1 addressing cannabis or CBD products being marketed as a cure or treatment for COVID-19. Eloise said, “I think it’s essential for patients to know that the FDA says there’s no coronavirus treatment or cure, and what we know about cannabis and immunity is mixed. So if you’re seeing people making claims about how cannabis or CBD can improve your immune system to fight COVID, you should be suspicious of those claims, and they haven’t been founded in science.” If you are trying to save money on cannabis or hemp-based CBD products, you are probably sacrificing quality and putting yourself at risk. Eloise said, “Right now, because people have limited income, they may be turning to the grey market to try to save some money, and there’s concern about what’s in those products in terms of mold and pesticides.” One frustrating aspect of the current environment is that in the race to find a treatment and develop a vaccine for coronavirus, doctors and scientists are basing decisions on extremely small subject groups. “The gold standard of the double-blind, randomized placebo trials, that the healthcare community requires or requests for any type of treatment has been getting a lot of pushback with cannabis, and here we are seeing very small sample sizes with coronavirus and different treatments. And you understand, people are desperate. They’re theorizing how COVID is behaving in the body and what mechanism of action and trying to find the right medication for it. But we see mixed results. Even The New England Journal of Medicine published and basically said there’s not enough evidence to support that hydroxychloroquine and azithromycin are effective treatments for COVID right now.2 Yet we have our current leadership out there promoting this treatment [which has] devastating side effects. It can be toxic to the heart, among other things. It’s this double standard that we’re experiencing right now. I would love to see some leniency or some opportunities open up for cannabis,” Eloise said. “You’re reading about shortages in the hospitals for the different things we need to treat patients, not just with personal protective equipment, but now medication. It’s like if there was ever a time for cannabis, now is it.” 35

CANNABIS

FLOWER IT’S NOT JUST FOR SMOKING ANYMORE. BY DEBRA KIMLESS, MD

WHY ARE SMOKABLE FLOWERS NEEDED WHEN THERE ARE SO MANY OTHER OPTIONS FOR CONSUMING MEDICAL CANNABIS? The medical community has done a great job of getting the word out against smoking (and smokeless) tobacco. There is lots of evidence proving a direct link between consuming tobacco products and human diseases. There is less correlation between adverse effects associated with cannabis smoking and diseases. Nonetheless, the medical community may have some negative thoughts about encouraging smoking of any kind—even if it is a medicine. Patients, too, may not be eager to smoke. But smoking is just one way to consume cannabis flowers. Vaporization, a technique where cannabis is heated to a temperature where, prior to combustion, steam or vapor is created containing the plant’s bioactive molecules. The steam or vapor is inhaled for a quick delivery of the medicine into the body. Using the lungs for administering medicine is a fast and efficient delivery method for patients who have acute, sharp pains or muscle spasms and are seeking immediate relief. But wait, vapor pens with concentrated extracted cannabis oil are already available. Why are flowers needed? There are many people who prefer to vaporize flowers over oil, believing that the closer to the plant they are the more they can access the naturally-occurring molecules.

the different compounds, like terpenes, within the plant Terpenes are one group of important bioactive chemicals in cannabis. Terpenes turn to vapor at lower temperatures than cannabinoids. By using a temperature adjustable vaporizer, patients can have access to terpenes and take advantage of the benefits of the whole plant. These types of vaporizers come with instructions and a chart to show what temperatures vaporize which chemicals making it easy for new users. Inhalation is not the only use for cannabis flowers. Flowers can be steeped in hot water to make a tea. The resultant tea is a liquid medicine consisting of the raw forms of the cannabinoids, as the tea is not hot enough to convert the cannabinoid acids (the raw chemicals) to its chemically neutral form. There are tremendous medicinal benefits to the raw or acid forms of the cannabinoids and the intoxicating effects are not felt since there is not enough heat. There are advantages to having a range of administration methods available to patients. As cannabis has been stigmatized for multiple decades, patients may feel uncomfortable with certain dosage forms. Excluding a particular dosage form may prevent a patient from accessing the benefits of cannabis as a medicine.

Some believe that vaporizing cannabis flowers is a kinder, gentler inhalation experience with less harsh afterburn in the throat. Some like the option of purchasing a sophisticated vaporizer where temperatures can be adjusted so they can procure 37

CANNABIS

BASICS BY HEATHER DEROSE

The Sunshine State is moving in the right direction and is working to provide regulated and safe access to this remarkably beneficial plant. Read on for an overview of cannabis basics for new patients just like you.

A BRIEF HISTORY

Cannabis has been used for thousands of years, dating back to Chinese Emperor Shen Nung in 2727 B.C. Before Nixon’s war on drugs, cannabis was grown for the use of rope, clothing and fiber in North America. It’s been over 80 years since the Marijuana Tax Act of 1937 was passed,which made possession or transfer of marijuana illegal throughout the United States under Federal law. There are now over 30 states with cannabis legalization and a recently passed Farm Bill that allows the growth of hemp for industrial use. In 1992, Raphael Mechoulam discovered the Endocannabinoid System (ECS—a complex receptor system found in humans and animals designed to respond to the active compounds found in the cannabis plant. The ECS has been recently recognized as possibly the most important modulatory system in the body that regulates the functioning of the brain, 38

endocrine, and immune tissues, as well as creating and supporting homeostasis of the body’s cells. Because the ECS is designed to regulate the body’s functions, it comes as no surprise cannabis helps with so many conditions. Since its discovery, research continues to enlighten us on how and why cannabis has played such a pivotal role in the health and wellbeing of humans for such a long period of time. Cannabinoids, the Entourage Effect, and Full Spectrum medicine. Though hemp and marijuana have very different properties, both come from the cannabis plant. The terms hemp and marijuana are typically used to describe the difference in THC content. THC (tetrahydrocannabinol) is one of hundreds of known cannabinoids found in the cannabis plant. It is most commonly recognized as the psychoactive compound in cannabis that causes the “high” affect.

Hemp contains less than 0.3 percent THC. Marijuana, on the other hand, is any plant that contains more than 0.3 percent THC. But despite THC’s popularity and prevalence, it is not the only beneficial cannabinoid present in cannabis. CBD (cannabidiol) is another cannabinoid found within the plant and does not produce a psychoactive effect. CBD can be extracted from both hemp and marijuana, and it exists in some products in its isolated form. Other cannabinoids, including CBN, CBG, THCa, and others are being researched and found to contain their own unique therapeutic properties. In Florida, however, the most commonly-used cannabinoids in retail products are THC and CBD. When isolated, CBD and THC can have wonderful healing properties, they work even better used together

plant: all cannabinoids, essential vitamins and minerals, fiber, chlorophyll, flavonoids, and terpenes, for example. Just like with nutrition, the less processed and more natural the plant medicine is, the more effectively it can provide benefits.

FLORIDA LAW While dispensaries in other legal states offer hundreds of different strains, concentrates, edibles, topicals, tinctures, patches, sublingual products and more, Florida residents are still limited in their offerings due to restrictive laws and controversial politics. After integrating the Compassionate Medical Cannabis Act of 2014, Florida allowed qualified patients in the state to obtain “low-THC cannabis.” In order to qualify as low-THC, the flowers, seeds, resin and any other product derived from the cannabis plant had to contain 0.8 percent or less of THC and more than 10 percent CBD by weight. The statute was amended in 2016 to include all levels of THC marijuana, termed “medical cannabis.” With the increasing growth of knowledge and education, the beneficial impact patients could see when allowed to utilize the important cannabinoid THC without restrictions is crucial. Growth is constant and progression is visible, which gives hope to those affected by the limitation of the laws.

in their whole-plant forms. Products that utilize all of the naturally-occurring cannabinoids and other properties of the plant are called Full Spectrum products. In the same way that eating an orange is healthier for you than drinking only the juice, full spectrum products offer a broader range of healing benefits by way of a natural phenomenon called the Entourage Effect. This means that CBD and THC are excellent on their own—but when combined, they work even better. Full spectrum products also include other compounds in the cannabis 39

COMMON CONSUMPTION METHODS One of the most commonly-asked questions about cannabis is how and where to begin comfortably. Fear of feeling “too high” or experiencing no relief are common amongst patients. Knowing how different products affect the body is important to understand where to begin.

There are variations in potency, up to 15 percent in some products, which is something to keep in mind when consuming. Liquid products, such as tinctures, are measured in milliliters and will have a ml serving size and its cannabinoid equivalent for consumers to correctly dose.

Remember: each individual endocannabinoid system is unique. Different cannabis products will affect each individual differently based on absorption, bioavailability, and countless other variables.

Tinctures are best to drop sublingually, or under the tongue to infuse the herb directly into the bloodstream. These can also be used to infuse drinks or smoothies, depending on the consumers’ preferences. For many, vaporized cannabis flower is the preferred consumption method. Inhalation of cannabis provides a fast-acting effect and is popular amongst patients who need immediate relief. Cannabis flower is available in hundreds of different cultivars, or strains, in other legal states—and Florida is beginning to boast some of its own unique strains from local cultivators as its medical industry grows.

Take edibles, for instance. Edibles often have a stronger perceived effect because the body converts the cannabinoid THC into 11-hydroxy-THC when metabolized by the liver—in simpler terms, this means your body absorbs orally-ingested medicine differently than it absorbs inhaled medicine, and the effects of each delivery method will therefore be different. Edibles may take up to an hour or more to absorb and the effects to be felt, and it may last longer than inhaled cannabis.

Each strain of cannabis has its own unique cannabinoid and terpene profile, and each profile offers a subtly different medicinal effect. Research on terpenes (the

essential oils found in cannabis that house therapeutic benefits) suggests that our natural attraction to certain terpene profiles in the scent of cannabis can provide us with information on what strain may be best for our condition. As the saying goes, “Your nose knows.” Smelling your cannabis in its whole flower form is one of the best ways to choose your medicine. Since our sense of smell is so unique and different and cannabis has a huge array of profile combinations, you’ll know when you smell the terpenes if you’re into the particular flower. If you smell a strain and are drawn to it, chances are that your body will respond positively to its effects. Alternatively, if you are turned off by the scent of a product, steering clear may be the best option. In most medical and recreational states, as well as some Florida dispensaries, patients are presented will “smell jars,” or small containers of sample products to view and smell to make sure that the product is free of pests, pesticides, and other contaminants. Smelling also provides the body with the knowledge it needs to choose strains effectively. Without this access, it is very difficult for a patient to determine the quality of what is going into their medicine. Because not all dispensaries offer the opportunity for a patient to view and smell their product before purchase, deciding which strain to consume can be a daunting and overwhelming task for new patients. If your dispensary does not offer this option, ask the manager to consider providing this beneficial service to patients. Thankfully, Florida is moving towards more reasonable access laws for patients, and it is important that patients lend their voice to protect their right to transparency around the production of their medicine. In the meantime, it is beneficial for patients to educate themselves on the basics of cannabinoid and terpene science to help determine which strains and terpene profiles may be best for them. Vaporizers are another growing choice for healthconscious consumers due to their discretion in delivery. Small size and lack of odor make them popular amongst those who need fast-acting relief and anonymity. Concentrates, however, come with their own set of challenges.

many of the products used to create solvents contain thinning agents and additives with proven health risks attached. It is important to remember that the state of Florida has no regulation or testing requirements around the use of many of these hazardous chemicals in the production of cannabis concentrate products. In addition, concentrates are typically much more potent than flower products. Flower potency usually ranges between 10-25 percent THC. A concentrate, however, may have 50-80 percent THC or more. Knowing your tolerance and desired effects can help you decide which product is best for you.

DOSING One of the most common answers everyone wants to know is how much should be consumed for a dose. Unfortunately, dosing with cannabis is a process that requires individual attention, experimentation, and time. However, a good cannabis physician can help you determine where a good starting point is for you. The best advice for cannabis patients is to follow your marijuana doctor’s recommendation. However, the old adage still applies: “Start low, go slow.” Monitoring the effects and dosage of each product through journaling will also help you find your ideal dose. By slowing selftitrating (or adjusting your dose as necessary) and keeping track in your journal of what products have the desired effect, you’ll be able to effectively dose based on your comfort levels. Remember: each Endocannabinoid system is different, and each individual will respond to different doses and delivery methods in their own unique way. Until research offers us more insight on how to approach dosing in a more streamlined manner, it is up to the patient and their doctor or educator to spend the time getting to know which dosing procedures are best suited to the ailment.

It is important to remember that concentrates are concentrated forms of cannabis. There are several extraction methods used to create concentrates, each with its own set of health hazards. The use of solvents or CO2 in extraction practices are controversial— References 1. https://www.deamuseum.org/ccp/cannabis/history.html

CHOOSING YOUR CANNABIS FLOWER WRITTEN BY LEA HOLZ

The conversation around whole, raw cannabis flower access is growing. How do patients in Florida prepare for this new legal landscape? What does one look for when purchasing medicine in its whole plant form? How do we determine its safety and utility?

In this article, we open a dialogue to introduce the many uses and benefits of raw cannabis flower, providing a map for the new patient on what to expect, consider, and be wary of when purchasing raw cannabis flower from their local dispensary. To help pave the way, we invited Max Montrose, Founder and President of the Trichome Institute, to share his views and perspectives on whatâ&#x20AC;&#x2122;s important when choosing your whole flower medicine. Here are the top three most important things a patient should consider.

FOLLOW YOUR SENSES

It seems rudimentary, but the old adage is true: The nose knows. According to Montrose, you have the ability to decipher for yourself if the medicine you’re ingesting is something your body will respond well to. But why is smelling cannabis so important? “For the same reason it is important to use your senses when shopping for food at the grocery store,” explains Montrose. Our bodies are constantly absorbing information from all around us. Sight, smell, taste, touch—these senses allow us to take in our surroundings, sending signals to our brain on what is and isn’t good for us.

“It’s just like shopping for food,” Montrose explains. “If there is a pyramid of apples, why did you pick this over that? It didn’t have a bruise. Its form was consistent. It was robust. In a shamanic way, it is called out to you. Anything that you are attracted to from a scent perspective is good for

your body from a chemical perspective.” If you are buying meat, for example, and it smelled rotten, you likely wouldn’t buy it. Whether or not we realize it, we use our natural signals to determine what to put in our bodies, and what isn’t safe for consumption. Shopping for cannabis flower is the same. Cannabis contains compounds known as terpenes, which are oily organic compounds contained in the resin. Aromatherapy-like in nature, terpenes are responsible for the plant’s unique smell and taste and have many therapeutic benefits and effects. When combined together in their natural state, they contribute to cannabis’ entourage effect. In a revolutionary paper by Dr. Ethan Russo, the researcher finds that cannabinoids and terpenes work together to enhance and regulate the effects of one another.1 This means that terpenes are as important as— if not more important than— cannabinoids.

There are many different terpenes that exist, and each strain of cannabis has its own unique terpene profile. This profile is responsible for the strain’s unique smell, taste, and medicinal effect. Like cannabinoids, terpenes work together like a musical group, each plays its own part, and when they work together—their unique natural combination provides a symphony of balanced medicinal effects. All plants, and some animals, contain terpenes. When we hold a ripe piece of fruit or a flower to our nose and are attracted to its scent, what we are actually acknowledging is the body’s attraction to its unique terpene profile. So, how do we use this information? In short: If a strain appeals to your senses, give it a try. If you find yourself overcome with

attraction and curiosity, this is a good sign. However, if your nose tells you to put the jar down, then listen. Even though a terpene profile may be labeled on the product, our nose is our first point of contact for knowing which terpene profiles to choose. And as it turns out, your nose may be your secret weapon. “When shopping for flower, most people look for two things: strain name and THC percentage. In reality, these are the two most meaningless things,” says Montrose. “Science has proven how and why strain names do not correlate to an effect or variety type, so this doesn’t really tell you anything. But if you can see and smell the quality for yourself and know how that smell correlates to different psychotropic effects, you have

more control over the medicine and what it provides.”

For this reason, it is absolutely essential for medical patients to have access to smelling and visually assessing their flower before purchase. As Florida shifts its weight over the topic of smokable flower, patients and educators alike must contact their legislators to explain why access to whole flower medicine—before it is rolled into prerolled joints or stuffed into small ceramic containers—is imperative to the process of properly medicating with cannabis. If your dispensary does not offer you this experience, it may be wise to ask a manager why. Explaining our needs as patients is a great way to help encourage dispensaries to meet their patients’ needs.

QUALITY Just like with food, the quality of your cannabis matters. Did you know that your cannabis, just like the food in your refrigerator and pantry, has a shelf life? Cannabis’ terpene profile and cannabinoid levels will shift and change depending on when it is harvested and how long it is left to sit between production and sale. Something that may surprise you is that cannabis actually has a peak ripeness in the same way that fruit does. A green tomato picked before peak ripeness, for example, is bitter, flavorless, and less nutritious than a tomato that is left to ripen on the vine. Cannabis is no different, and once again, it all comes back to terpenes.

portant for patients to be able to grow their own. In the same way that fresh vegetables are more nutritious than after a week in the fridge, fresh cannabis is much more beneficial to “If you let your beer sit over- our health. night, your beer is flat,” Mon- Finding fresh cannabis can be trose says. And the same goes a challenging task even in the for terpenes. “It is all about the most liberal of markets, but terpenes. Just like beer, canna- Florida is well on its way tobis can go flat. You can slow the wards establishing more reaprocess down but can’t prevent sonable laws. In the meantime, it 100 percent, so when this there are resources available to happens, cannabis no longer help train your nose and body has it’s stimulating or sedating to tune in to the quality of your properties, polypharmacy, or cannabis flower. entourage effects. When ter- “For people that are new to this, penes are gone, what you now it can be overwhelming at first have is a lacking product.” In because the things you look most instances, the cannabis for are small and subtle,” says “People should think about ter- sold in dispensaries is “flat”— Montrose. Some signs of qualipenes as the beer bubble in a and for this reason, it is im- ty are easier to spot than others. 44

freshly-tapped mug of beer,” Montrose explains. Terpenes are in a constant state of evaporation. But what happens to your beer if you leave it to sit for a long period of time?

According to Montrose, poor quality cannabis that hasn’t been flushed, for example, will smell like salt before you smoke it. “Because macro and micro nutrients have not been flushed from the flower properly, you will be smoking salts, and this will feel painful,” he explains. Flower that has been treated with harmful chemicals can give off a scent that reads as metallic, or chemicallypungent, but not always. These subtleties can be difficult to determine for the new patient.

Thankfully, there are resources available. The Trichome Institute, for example, has developed tools to help people train themselves on how to see these subtle differences. Their mission aims to solve one of the most complex problems in the cannabis industry: offering high-level education to cannabis professionals. In addition to government standard courses, The Trichome Institute offers a cannabis sommelier program called Interpening which teaches patients and professionals how to understand cannabis at an expert level by dissecting cannabis flower. Tools like this can be very valuable to new patients to help navigate the way.

“Not one lab currently tests for or has a standard for cannabis ripeness,” Montrose says. “And as previously explained, it is important that your cannabis be ripe if you are going to use it for its maximum benefit.” No lab currently tests for insects on flower, either—a common problem in commercial growing facilities, and a good gauge of how healthy the plant’s growing conditions were.

So, what do we do?

Begin by asking your dispensary questions, and don’t take a verbal affirmation of tested products as a green light. Consider the following: ● Ask your dispensary what they test for, and why.

● Read up on what common pesticides are used to grow cannabis on a large scale and their risks.

● Keep in mind that a company with a retail structure has the company’s best interests in mind, not necessarily your health. In the state of Florida, you need more licensing to apply makeup than to sell a product in a dispensary to a patient. There are some amazing dispensaries and dispensary workers TESTING, CHEMICALS, ETC. out there, but he or she may or may not have the knowledge or experience to point you in a Cannabis flower is the US’s and Canada’s largest safe and healthy direction. It is wise to cash crop—and shockingly, this multibillion dollar remember that the responsibility truly industry has no quality control. “Unlike the grocery lies in our own hands. For these reasons, store,” Montrose explains, “There is no such thing building trusting relationships with educators, as quality testing or certifications.” dispensaries, doctors, and the cannabis This fact is shocking and can be difficult to come community is essential. to terms with. How is it that such a booming ● When in doubt, build a relationship with a industry lacks even a small department to make testing lab in your area and have your product sure its products meet the standards patients tested yourself. Keep in mind that one need? Whether for reasons of rapid growth of batch of cannabis will differ from the next, demand before proper infrastructure was put in so be mindful of the serial number when place or simply lack of diligence, the US cannabis testing product. If you receive a questionable industry currently has no required standardized result, bring it to the attention of your grower testing requirements. State by state, requirements dispensary. As patients, it is up to us to lead vary, and currently in the state of Florida, the only the way for the industry standards to meet the thing required for third-party testing is a test for quality standards we set for our own health. THC. “And as aforementioned,” says Montrose, References 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165946/ “This doesn’t matter much.”

SAFETY

What does matter, and what is lacking, are tests to determine the quality of the bud: tests that provide insight into the conditions under which it was grown, and the health of the plant.

BY D

“What, me? Worry?” This iconic signature phrase was on the front cover of MAD magazine, emblazoned under the face of Alfred E. Newman. Anxiety, and the associated psychological and physical symptoms, is the most prevalent mental illness in the US—affecting approximately 18% of the population. Anxiety manifests differently in each person and it originates from a variety of risk factors including life events, genetics, and personality. And although the “What, me? Worry?” attitude is attributed to male archetypes like Alfred E. Newman, it is women who primarily suffer from anxiety disorder, twice as frequently as men. There are traditional therapies that are used to treat anxiety and its co-associated disorders. The treatment protocols and success rates vary, just like the anxiety presentation itself varies from patient to patient. Patients respond differently to different treatment options, and some may do well with a combination of techniques such as cognitive behavioral therapy, meditation, other complementary treatments, and a pharmaceutical medication. This multi-modal approach is wellaccepted by traditional medical practitioners even though it has varied success rates. 46

So how does cannabis fit? It depends. Some physicians and other health care providers are suspicious of cannabis, believing it will cause more harm than good—and in truth, that is a possibility. The over consumption of cannabis products containing high concentrations of THC, the intoxicating molecule in cannabis, may actually mimic a panic attack. Patients who do not consume

IT IS WOMEN WHO PRIMARILY SUFFER FROM ANXIETY DISORDER, TWICE AS FREQUENTLY AS MEN

cannabis regularly, overconsume cannabis with high concentrations of THC, or who are completely new to consuming cannabis may be sensitive to some of THC’s effects. THC may cause a rapid heart rate, dry mouth, and an overwhelming feeling of fear or anxiety—which is similar to many of the symptoms experienced with a panic attack!

However, there are many patients who use cannabis to help treat their anxiety disorders. How can this be if the effects of THC imitate a panic attack? Well, the answer is that not all cannabis is alike. Cannabis is like an entire pharmacy in a plant. Different cultivars and cannabis products contain varied amounts of THC and the nonintoxicating CBD (the second most predominant cannabinoid), as well as other constituents. The different combinations of chemicals can be used to discover which mix helps reduce anxiety for each individual patient. If you are considering using cannabis to see if it works for your anxiety, you may want to start with a cannabis product that contains all or mostly CBD. CBD is a nonintoxicating chemical that carries no risk of causing panic attacklike effects, as it works differently in the body than THC does. There are also animal studies which report that CBD does work on serotonin receptors—and these are the very same receptors that pharmaceutical drugs known as SSRIs target to treat anxiety.

Another animal study showed that CBD helped increase the number of hippocampal nerve cells in the brain. (Hippo-what?) The hippocampus is a structure in our brain that is in charge of many things, such as regulating memory and emotions. This includes anxiety. Brain scans of people who suffer with anxiety show that they have a smaller hippocampus than people who do not have anxiety. Both CBD and SSRIs may help to regrow the hippocampal nerve cells to increase the hippocampus size and possibly reduce anxiety. What about terpenes? As we know, cannabis is more than just cannabinoids. There are over 400 constituents in the cannabis plant. Terpenes are some of the chemicals that give cannabis its scent and taste. They also have therapeutic effects. Cannabis products that contain the terpenes myrcene and limonene, for example, may create a sense of relaxation and may lessen the feeling of anxiety. Cannabis products that contain a lot of the terpene pinene may create an energized and focused feeling in some, but may make other people feel anxious.

The upshot? Is THC the evil demon? Not necessarily. There are patients who require some amount of THC in combination with CBD to effectively treat their anxiety. It is just prudent to start at a very low concentration of THC or start with no THC and slowly add THC and titrate to higher concentrations of THC if needed. The panic-like feeling dissipates with continued cannabis use. There is no one cure for every person, whether it is conventional medical therapy, medical cannabis, or a combination. Risks and benefits of every treatment need to be weighed before starting any treatment. Consult your recommending physician and be willing to try different combinations, as every person responds differently.

NOT ALL CANNABIS IS ALIKE 47

ANXIETY BY MATT JACKSON, PHD

This article hits close to home. I have an anxiety disorder. I work hard at it, and I’ve been pretty successful coping. But there are still days when I just can’t control it. Sometimes I wake up, and without a conscious thought to it, my nervous system is on fire. My muscles feel permanently constricted. My mind races frantically from one point to the next. What I need most is to relax, but even thinking about trying to relax intensifies my anxiety. I’m not alone—40 million adults in the United States experience an anxiety disorder every year1—and about half of all people use medicinal cannabis to manage anxiety.1,2 Count me in.

It’s normal to worry about things big and small: about work, a presentation, paying the bills, where the world is heading. But when worries interfere with day-to-day functions, anxiety becomes a disorder. Past trauma, specific phobias, or just daily life can trigger panic—the quintessential anxiety disorder is post-traumatic stress disorder (PTSD)3—and what gets triggered is a neurological response centered in fear. For example, people with PTSD have a hyperactive amygdala, an evolutionarily ancient part of our brain that stores fear-related memories and responds to threats with fear, aggression, and defensive behavior.3 The effects aren’t just psychological, though. Anxiety can cause physical symptoms such as headaches, nausea, and gastrointestinal problems. Treating anxiety disorders is generally a two-part process. The first part is medication, primarily with selective serotonin reuptake inhibitors (SSRIs) for long-term anxiety management and benzodiazepines such as Valium—which can be addictive—for acute attacks. As with any medication, there can be side effects: nausea, drowsiness, headaches, and sexual problems. The second part, cognitive behavioral therapy (CBT), is just as important. CBT is a type of professional counseling that helps people recognize thought patterns and change behaviors that lead to anxiety. Both medication and CBT are equally effective, and their effects combine for the best chance at long-term anxiety management.4 Millions of people are using cannabis as an alternative medication for anxiety disorders, and in several surveys, most people reported exceptional anxiety relief.2,5,6 But there’s also a bit of a paradox, because 10–20% of users consistently report anxiety as a negative side effect of cannabis.2,6 Honestly, at this point in time, we have more questions than answers. We know our ECS plays a role in anxiety. Patients with PTSD have more type I cannabinoid (CB1) receptors in their nervous systems and lower concentrations of natural endocannabinoids that activate those receptors. We also know that anxiety is a major negative side effect of pure THC, but pure CBD can reduce anxiety by decreasing neural activity in the amygdala, similar to benzodiazepines.2 However, when we look at how people respond to the whole cannabis plant, these trends don’t really hold.

DIS-LIST

We often focus on THC and CBD as the main components of cannabis, but they alone can’t explain the differences between cannabis cultivars. A cannabis plant

has over 150 different terpenes; different combinations give each cultivar its unique smell and taste.2 It’ll take a long time before we understand how all these components work in concert—a synergistic action called the “entourage effect”—but meanwhile, scientists have asked the experts: cannabis users! One thing is clear, not all cultivars of cannabis are equally effective for relieving anxiety. In one survey, 84% of users in Canada reported that medical cannabis helped relieve their anxiety. About 40–50% of people reported anxiety relief using C. indica and hybrid cultivars, compared to 7-10% reporting increased anxiety. The results for C. sativa cultivars were far more mixed; 30% reported increased anxiety, the same percentage of people reporting relief.5 Another study went even deeper and examined the total cannabinoid and terpene content in cannabis cultivars that were reported as best for anxiety (Bubba Kush, Skywalker OG Kush, Kosher Kush) and least effective (Chocolope, CBD Shark, Tangerine Dream). Interestingly, one slightly C. sativa-dominant hybrid (Blueberry Lambsbread) made the list as both most effective and least effective,1 meaning people had vastly different experiences with the same cultivar. So, how can you find the cultivar of medical cannabis uniquely suited for your anxiety? Try focusing on cultivars that are pure C. indica or C. indica-dominant hybrids and have low CBD. Try a few cultivars at different doses and keep notes on which is most effective for you. But what about long-term anxiety management? Well, here’s where it gets a little tricky. If you find that medical cannabis helps with sudden anxiety attacks but doesn’t reduce how often the attacks occur, then there are concerns about dependency, even if cannabis itself isn’t considered addictive. After all, long-term management is the main reason why SSRIs are prescribed first, instead of benzodiazepines. But if you want to avoid pharmaceuticals altogether, you should consider integrating medical cannabis with professional therapy—CBT counseling in particular. Unfortunately, easy access to medical cannabis appears to be leaving therapy out of the equation for some. In one study, 80% of Californians who used medical cannabis for anxiety or depression were not prescribed cannabis for that reason,1 so they wouldn’t have received professional recommendations for therapy. In another study, only 20% of Canadians using medical cannabis for anxiety disorders had ever received CBT counseling. Some of these people were also using considerable amounts of cannabis—23% used ≥3 grams cannabis per day.5 Another study hinted that stronger doses of cannabis may not provide better symptom relief but could cause more side effects, both positive and negative6. Overall, medical cannabis could prove extremely effective for relieving anxiety symptoms. Each person is unique though, so finding the cultivar and dosage that works for your anxiety will require some experimentation. But even with that, conventional medication or cannabis is only half the battle. If you face persistent anxiety attacks, talk to your doctor; professional CBT counseling may be the missing piece for long-term anxiety management.

References | 1Kosiba, J., Maisto, S., and Ditre, J. “Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: Systematic review and meta-analysis.” Social Science & Medicine 233 (2019): 181-92. https://doi.org/https://doi.org/10.1016/j.socscimed.2019.06.005. 2Kamal, B., Kamal, F., and Lantela, D. “Cannabis and the anxiety of fragmentation—a systems approach for finding an anxiolytic cannabis chemotype.” Frontiers in Neuroscience 12 (2018): 730. https://doi.org/10.3389/fnins.2018.00730. 3Zoellner, L., Rothbaum, B., and Feeny, N. “PTSD not an anxiety disorder? DSM committee proposal turns back the hands of time.” Depression and Anxiety 28, no. 10 (2011): 853-6. https://doi. org/10.1002/da.20899. 4Cuijpers, P., Sijbrandij, M., Koole, S., Andersson, G., Beekman, A., and Reynolds, C. “Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis.” World Psychiatry 13, no. 1 (2014): 56-67. https://doi.org/10.1002/wps.20089. 5Turna, J., Simpson, W., Patterson, B., Lucas, P., and Van Ameringen, M. “Cannabis use behaviors and prevalence of anxiety and depressive symptoms in a cohort of Canadian medicinal cannabis users.” Journal of Psychiatric Research 111 (2019): 134-39. https://doi.org/https://doi.org/10.1016/j.jpsychires.2019.01.024. 6Stith, S., Vigil, J., Brockelman, F., Keeling, K., and Hall, B. “The association between cannabis product characteristics and symptom relief.” Nature Scientific Reports 9, no. 1 (2019): 2712. https:// doi.org/10.1038/s41598-019-39462-1.

INSOMNIA BY HEATHER DEROSE 50

DIS-LIST

If you’ve ever lain in bed tossing and turning or woke up early and been unable to go back to sleep, you may have experienced insomnia. Insomnia is the inability to promote and maintain quality sleep, despite having the opportunity for sleep to occur. Sleep disorders are one of the most common, but treatable, health problems that occur. Approximately 50-70 million Americans chronically suffer from a sleep disorder and are unable to get enough sleep, which negatively affects health and longevity.1 Millions of people have experienced a night without sleep at some point. Maybe it was because of something stressful the next day that you were lying awake thinking about, or maybe you ate too much before bed and you woke up with heartburn and couldn’t fall back asleep. The exact cause of the disorder can be complex and may involve a combination of biological, psychological, and social factors. Being a woman and at an older age may increase the risk of developing insomnia.2 Regardless of the reasons, going without adequate sleep, even for a night, can negatively affect your health and mood. Having a sleepless night here and there is very common, but chronic sleep loss can have detrimental effects on a person’s health and well-being. Chronic insomnia occurs when a person experiences sleep loss at least three times per week, which lasts for a month or more. The exact amount of sleep for each person varies, but most adults need seven to eight hours a night of sleep for optimal health.3 A doctor will evaluate each person before a diagnosis of insomnia, considering other variables which could account for sleep loss, such as other sleep disorders, medication side effects, substance abuse, depression, or other illnesses.

Sleep is important for overall health and well-being throughout our lives. Maintaining quality sleep each night can protect your mental and physical health, quality of life, and safety. Sleep helps the brain transform new information into memory, which is why getting adequate amounts of sleep after learning something new will help process and retain what you’ve learned. Sleep can affect metabolism and weight, by altering hormones and carbohydrate storage. Sleep loss also affects energy levels and mood throughout each day. Sleep loss can cause irritability, loss of patience, inability to concentrate, and moodiness. More serious side effects of chronic sleep loss may affect cardiovascular health. Sleep disorders have been linked to hypertension, increased stress hormone levels, and irregular heartbeat.4 There’s

APPROXIMATELY 50-70 MILLION AMERICANS CHRONICALLY SUFFER FROM A SLEEP DISORDER AND ARE UNABLE TO GET ENOUGH SLEEP also an increased risk of disease associated with chronic sleep loss because of its effect on our immune systems. Inadequate sleep alters immune function, including the activity of the body’s killer cells, which help fight cancer.5 Since maintaining sleep is crucial for overall health and wellness, there are options to consider to promote a more restful night’s sleep. With the growing knowledge about the abilities of cannabis to help promote sleep naturally, many have successfully used it as a tool to promote a restful night’s sleep, and many more are curious about trying it to promote sleep. Cannabis works with the receptors in our endocannabinoid system. “The discovery of the endocannabinoid system, composed of endogenous lipids, receptors and metabolic enzymes, has brought information on its significance in multiple neurobiological processes, including sleep modulation.”6 More studies are needed with cannabis and insomnia patients. Many patients are offered pharmacological therapies to help promote sleep such as benzodiazepine or nonbenzodiazepine hypnotics, which often come with impairment and harmful side effects, as well as dependence. Other pharmacological options may be used for insomnia, such as sedating antidepressants, antihistamines, and antipsychotics. However, their efficacy for treating insomnia have not been thoroughly studied.7 This may be one reason many patients are trying cannabis. It has minimal side effects and offers a natural option that works within each person’s ECS via cannabinoids and phytonutrients. Other tools a patient may find helps promote sleep is keeping your bedtime and wake time consistent daily, including weekends. Staying physically active also promotes restful sleep. Avoiding and limiting caffeine, alcohol, and nicotine may help as well. Patients who make their bedroom comfortable for sleep and only use it for sleep may benefit from better sleep. In addition, creating a relaxing bedtime ritual, like taking a bath, and limiting exposure to light from electronics can help induce sleep.8 Since sleep quality plays such an important role in our daily lives, it’s important to promote behavior and environments where you can get enough rest. Understanding the value sleep brings to our health is the reason many seek help to improve their sleep quality. We know our bodies’ ECS contains receptors for our own endogenous cannabinoids, as well as exogenous cannabinoids from cannabis, and it works to promote homeostasis and modulate sleep function. More studies are needed to understand the efficacy of cannabis and its potential to treat sleep disorders, but many patients are using cannabis as a natural tool to promote sleep quality and are reaping the benefits. 1. NHLBI (National Heart, Lung, and Blood Institute). National Sleep Disorders Research Plan, 2003. Bethesda, MD: National Institutes of Health; 2003. 2. Edinger JD, Means MK. Overview of insomnia: Definitions, epidemiology, differential diagnosis, and assessment. In: Kryger MH, Roth T, Dement WC, editors. Principles and Practice of Sleep Medicine. 4th ed. Philadelphia: Elsevier/Saunders; 2005. pp. 702–713. 3. https://www.mayoclinic.org/diseases-conditions/insomnia/symptoms-causes/syc-20355167 4. https://www.health.harvard.edu/press_releases/importance_of_sleep_and_health 5. https://www.health.harvard.edu/press_releases/importance_of_sleep_and_health 6. https://www.theroc.us/index.php?preview=1&option=com_dropfiles&format=&task=frontfile.download&catid=218&id=1vxCNOrEvpDXKTmFvdl0VHYzowqtk47p4&Itemid=1000000000000 7. Walsh JK, Dement WC, Dinges DF. Sleep medicine, public policy, and public health. In: Kryger MH, Roth T, Dement WC, editors. Principles and Practice of Sleep Medicine. 4th ed. Philadelphia: Elsevier/Saunders; 2005. pp. 648–656. 8. https://www.mayoclinic.org/diseases-conditions/insomnia/symptoms-causes/syc-20355167

WHAT’S WORKING Releaf is a free mobile app that encourages patients to mindfully track their cannabis experiences. They believe you will strengthen your relationship with yourself while also learning how cannabis can help alleviate your specific issues and ailments. GRAM is proud to share with our readers data gathered using Releaf from individuals suffering from stress symptoms.

DOWNLOAD RELEAF APP TODAY TO TRACK, LEARN FROM, 52

FOR STRESS ISSUES? They reported the effectiveness of products for specific symptoms of individuals suffering from anxiety, insomnia, agoraphobia, depression, PTSD, and gastrointestinal problems. The data reflect their individual experiences self-reported using the Releaf App.

AND IMPROVE YOUR USE OF CANNABIS BY VISITING: RELEAF.AT/GRAM 53

VALIDVET

DR. ZAC PILOSSOPH BY JORDAN PERSON

Pet owners can agree, there is nothing more frightening than when your fur baby can’t communicate what is wrong. The way of the world is different at this time. Not all veterinarians are keeping regular office hours during this pandemic, and, in turn, this can make things very difficult and expensive. A trip to the emergency vet can be quite costly. Since the ER staff likely does not know your pet’s history, they will have to perform extra tests out of necessity and this can compound the stress and anxiety. Last weekend, I found myself in that exact situation. My regular veterinarian could not get my poor pup in until almost a week later. When I called the emergency room, the nurse on the phone warned me it would be around $400 to start, not including any medications he may need. My jaw dropped, and I felt incredibly trapped. My 15 year old

Maltese, Jude, was suffering. His tiny body was trembling from head to toe uncontrollably, accompanied by episodes of panting that made him appear like he was in a lot of pain. Since Jude has a history of arthritis and neurological pain, I thought I would try using one of his pain pills and giving him another dose of his CBD oil. The nurse in me said, ok, he’s got 20 minutes; if he is not better, I will spend whatever they ask just to make him feel better. Then I remembered this amazing veterinarian who I had met at a conference the year prior. His name is Dr. Zac Pilossoph. I took a 60 second video of Jude’s symptoms and sent it to him with an attached message asking for his advice. He immediately responded and asked if I could call him. Within seconds of being on our call, he sent me the link to his new veterinarian service he is offering in response to the current crisis in our world. He explained to me, “With Validvet, it is not my goal to take business from people’s regular vets, or from the ER’s if the pets really need those facilities. My goal is to be in between those two options, for moments like right now, where you know you need assistance, but it might not be emergency room assistance.” Dr. Zac watched the video and asked several questions about

Jude’s condition. I told him what medications I had already given Jude, and his first suggestion pleased and shocked me at the same time. He asked if Jude had a CBD oil I felt comfortable increasing his dose with and giving him more. I had to confess that I had intuitively done so just moments before calling him. Expecting to be scolded, my heart melted when instead he complimented my actions and for trusting my intuition. As we spoke I began to notice that his trembling was beginning to cease and so was his panting. Finally after 20 minutes on the phone, Jude was resting comfortably. Dr. Zac was able to rule out certain conditions because the CBD oil was 100% effective at calming his symptoms. The service he has created offering telehealth consults for pets is one of the best things that I have seen come out of this pandemic. It is a game changer for anyone out there stuck in that space of “should we go to the ER or can we wait till next week?” If you find yourself concerned about your furry loved one, it is easy to schedule a call or video appointment with Dr. Zac for a digital health and wellness consultation by visiting his website: http://validvet.org/

DR. ZAC

PILOSSOPH FEAR-FREE CERTIFIED DVM, CAVM, CERTIFIED CBD PROFESSIONAL

ValidVet is an innovative new telehealth service for pet parents and clinics. The service provides concierge-based, and highly objective, harm reduction educational and advisory services, sourced from a real-world licensed and practicing contemporary veterinarian. All you have to do is book an appointment and Dr. Zac Pilossoph will connect with you via phone or video.

VALIDVET.ORG

97-ValidVet or 978-254-3838 | info@validvet.org 10% of sales are donated to Global Strays, an animal welfare non-profit organization, which supports and empowers animal rescuers worldwide.

M XINE TAYLOR’S

CELESTIAL EVENTS Maxine Taylor became America’s First Licensed Astrologer after mounting a legal challenge to legitimize astrology in the 1960s Bible Belt state of Georgia. She became CNN’s Original On-Air Astrologer when the network launched.

MAY 2020 ARIES (MARCH 21 - APRIL 19) Your mind is filled with lots of new ideas, and you want to share them with the people you know. Since you will be editing them all month, think twice before expressing them prematurely. If you are writing a book, check carefully for typos. TAURUS (APRIL 20 - MAY 20) Whatever you focus on grows, so put your attention on your finances and watch them increase. Throw yourself into your career, and shoot for the top slot. You should see improvement early in the month. GEMINI (MAY 21 - JUNE 20) You may want more solitude and privacy the first few weeks of May, but after the Sun enters Gemini on the 20th, you hit the ground running. Then your mantra becomes, “It’s my way or the highway!” And it is!

LIBRA (SEPT 23 - OCT 22) You are ready to spread your wings, soar, and live according to your principles. Your finances improve around the 7th. This allows you to play the first half of the month and get down to business after that. SCORPIO (OCT 23 - NOV 21) You are a private person who guards others’ secrets as well as your own. This month, the secrets may deal with other peoples’ money/ joint ventures. Use your psychic detective ability to get to the cause of any problem. SAGITTARIUS (NOV 22 - DEC 21) While you start off the month focused on your work, your desire to be with people increases, so plan to divide your time between working behind the scenes and putting others first. You can balance the two.

CANCER (JUNE 21 - JULY 22) While you begin May enjoying the company of friends, your desire for solitude and privacy increases until you enjoy your own company best of all. Use this time to meditate and expand your vision.

CAPRICORN (DEC 22 - JANUARY 19) You begin May enjoying your social life, your friends, and your children. As the month moves along, your work requires more of your attention. This will be the time to tie up the loose ends of unfinished projects rather than starting new ones.

LEO (JULY 23 - AUG 22) You may be torn between expressing your natural talent as a leader and enjoying the company of friends. Focus on your career till the 20th, when your desire to be a friend to all takes over. Then, have fun!

AQUARIUS (JANUARY 20 - FEBRUARY 18) Both your home/family and your career require your attention, but by mid-month your social life, and possibly your children, take on more importance. There is a potential career advancement on the 7th, followed by a financial increase.

VIRGO (AUG 23 - SEPT 22) You see a bigger picture in May, which can affect your beliefs and principles. After midmonth you will be able to put new beliefs into action in your career. Then express yourself, move upward, and don’t look back.

PISCES (FEBRUARY 19 - MARCH 20) You may be torn between the urging of the Full Moon on the 7th to fly away, and the pull of your home and family. Do both, if possible. Your ability to increase your income is still active, so focus on that. The travel urge resurfaces mid-month.

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T N A L P L . S P. . E A U T R N I NEX U T DIC A N ME

Grass Roots America Magazine - May - COPING with COVID-19

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