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22 cannabis patient care | vol. 2 no. 1 cannapatientcare.com nurse focus regularly and follows them along their medical cannabis journey. By providing that extra layer of calm, this helps give her patients a little bit more confidence in their treatment plan. "There are times though where people are taking cer- tain things and I'm like we have to limit your use because there is a potential for drug-drug interaction," said Theisen. "One example is immunotherapy and THC. In the cancer pop- ulation, we do have patients who want to use high doses of cannabinoids to treat their cancer. Again, this is sor t of the internet's version of what cures cancer. We do have some an- imal data to demonstrate that the cannabinoids can play a role in cancer treatment. But there's been some small stud- ies demonstrating that if you're using high amounts of THC with immunotherapy, that it can decrease your response rate to that immunotherapy treatment." She also mentioned that using these products didn't affect the overall survival rate, but that there are times when the amount or dosage could have an affect on their other treat- ments. It is very important to educate patients on the prop- er dosing of cannabis so they can better understand that the plant also has bidirectional effects. Theisen explained that by starting patients out on a lower dose and slowly increas- ing that dose, it helps avoid negative side effects and also aids in them finding their therapeutic window so that they are not over-consuming and are getting the best benefit with the least amount of side effects. As we age, our ability to process medications decreas- es by around 30%. This may begin happening in our 40s and 50s. Theisen star ted recognizing that standard dosages be- ing provided in dispensaries were inappropriate for her most common clientele —the older adult. "I really star ted to look into reducing those. Again, there is no real standard out there for cannabis dosing. The studies that we have with some dosing comes from either Sativex—that one-to-one tincture out of the United Kingdom—or Dronabinol, which is a synthetic THC, Food and Drug Administration (FDA) ap- proved medication," she said. Theisen explained that her dosing recommendations have changed over time. "I've evolved with THC and cannabidi- ol (CBD). I've gathered information around gender dif ferenc- es. There are def initely dif ferent protocols based on your gender and your age," she said. "We've also been really for- tunate to have an evolution of cannabinoids available to us like cannabigerol (CBG), delta-8-THC, tetrahydrocannabinol- ic acid (THCA), and cannabidiolic acid (CBDA). The more in- formation that comes out, the more the dosing regimen evolves and changes." Lack of Support from Medical Professionals and Insurances With the legalization of cannabis growing in the United States, you would think that medical professionals would become more open to prescribing medical cannabis to their patients. Theisen has been witnessing a shift in the healthcare field, but still sees a majority of healthcare professionals as not being fully on board with the medicinal plant. They will often mention that there's not enough research to support this method for treat- ment. Theisen believes that there is still a lot of fear and stigma among healthcare professionals because of its Schedule 1 ruling and status (4). "Often I hear from other healthcare professionals that they don't want to discuss it or even learn about it because of that schedule and status. It does prohibit them from exploring it. I've seen more nurses and nurse practitioners' sort of lead the change and get educated, which is not surprising," Theisen said. Nurses have a boots on the ground mindset and are usually with patients the most. Physicians typically say that if they want to use cannabis that is fine, but that they cannot prescribe it which leaves patients without the proper resources to safely and effec- tively access this plant medicine. When patients come to Theisen for their chronic pain, they already have it in their minds as to what type of regi- men they want and that usually involves CBD. They do not want to smoke it and they do not want to get high from it. What Theisen and other medical professionals have found is that THC may also play a vital role in their treatment. "We f ind that a lot of the research that does come out around Sativex for chronic pain does demonstrate that THC is a ver y impor tant par t of that regimen also, especially if they're coming of f some of their opioids or other pain medications, the THC can really help with the withdrawals," said Theisen. "Their protocol might change from the time they begin to the time that they come of f their medications. If that's their choice. It evolves during that. I think cannabis is best when it is personalized. We can cer tainly have best practices around it, such as stating which is the right cannabinoid for a cer tain condition and a good star ting dose. But the more we personalize it, the better outcome we'll see." In order for a patient to begin their medical cannabis journey, Theisen is ver y thorough on going through their LEFT TO RIGHT: Theisen, Mary Lynn Mathre, and Alice O'Leary Randall at the ACNA confernece in 2019.