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21 nurse focus cannapatientcare.com october/november 2021 | cannabis patient care Continued Education and Social Media Outreach Armed with this new information, Wohlschlagel decided to become a medical cannabis patient in Hawaii to help recover from her back surgery in 2017. She used it to sleep because it relieved her back and leg spasms and got support from people who understood how to dose carefully. Medical cannabis helped her sleep and get off all the pain pills and muscle relaxers she was initially prescribed. Her desire for more education was still growing, so in April 2017 Wohlschlagel attended her first cannabis conference hosted by Patients Out of Time. It was there she met many researchers, doctors, and like-minded nurses who were interested in learn- ing of the potential medical cannabis had to help patients. One nurse practitioner, Eloise Theisen, was particularly helpful in mentoring her about the use of cannabis in patients with cancer. Wohlschlagel decided to start interviewing every patient that she could who had shared stories of medical cannabis success on social media pages, such as Facebook. She quickly discovered that there were a lot of Facebook groups focused on particular forms of cancer and the use of cannabis. "There were big websites that were kind of wild and crazy, truly. They were just focused on the use of cannabis oil and implied that they were all success sto- ries. I encountered bullying happening that if a person tried using cannabis like they'd read and then if it didn't work instead of ac- cepting that cannabis might not have been capable of working in that case, the patient would be told, 'oh, you must have eaten too much sugar. You didn't have the right strain. You need to do this. You didn't use enough. You need a gram a day.' It was quite scary! There were also many kind people—medicine makers and advo- cates—all trying to help. And many tried to help raise awareness about these problems. But the overwhelming situation was what I described. If a patient admitted they were using convention- al treatments, there was often chemo shaming. And these people who had 'failed' in the use of cannabis, in their opinion, they just left. They were ashamed or dealing with metastatic cancer and they left. Their voices were being missed," said Wohlschlagel. "I didn't have a negative attitude about cannabis, but what I witnessed was a lot of problems happening because of the fact that there were no medical professionals that understood can- cer seeming to rise up and help. So, I began to just put myself out there. I joined a couple of the groups quietly and would do what I could to encourage the women to understand, for exam- ple, breast cancer," explained Wohlschlagel. "Breast cancer is not breast cancer is not breast cancer. There are subtypes. And then there are subtypes within subtypes. And in most cases, they re- ally need to do conventional therapies." Wohlschlagel said she doesn't mean every single convention- al therapy, every single time, but patients really need to consider the hormonal aspect if they have hormonal breast cancer. "If they have HER2 positive breast cancer, there's a monoclonal antibody treatment that is usually very effective. That drug is called Trastu- zumab or Herceptin and it may work a lot better if combined with at least some chemotherapy, especially Taxol type. And I found that these patients believed that they had to do one thing or the other and never consider how it might all work together," she said. Actually, Wohlschlagel said it's not surprising because there was nobody telling patients this information or answering ques- tions like: Can you use these things together? Is it safe? Is it logi- cal? Is it supported by even a little bit of science? As Wohlschlagel continued speaking with these patients and documenting as much information as she could, she began to gather large amounts of anecdotal evidence that in some sub- types of some cancers there seemed to be a pattern of response. "These people could explain their pathology report to me or share it with me. They could tell me how many milligrams of THC they were getting, where they kept track of how many grams of Rick Simpson Oil or other cannabis medicines they used in a month or so. I began to study these so I could estimate. And pat- terns of response began to show up," she said. Drug-Drug Interactions Wohlschlagel's interviews with real-world patients also brought to light the potential for drug to drug interactions. She found that there was a significant drug interaction with commonly used CBD oils and a particular breast cancer drug called Ibrance (palboci- clib) and likely similar medications such as Kisqali (ribociclib). "I accumulated over 100 cases where women on the drug Ibrance had started using CBD oil heavily because they could," explained Wohlschlagel. "These patients thought more CBD was better because it didn't make them horribly high. A couple of weeks later, their blood counts dropped in significant ways, par- ticularly their neutrophil counts. That was actually the blood cell that was counted every two weeks when patients were on Ibrance because that drug could reduce neutrophils. Sudden- ly, the neutrophil counts dropped, and there was a big warning on Ibrance against using anything that would inhibit one particu- lar metabolic pathway. That pathway was called CYP3A4. People know that pathway is also called the grapefruit pathway." Wohlschlagel explained that people often get prescription bot- tles with warnings against use with grapefruit or other inhibitors of CYP3A4. What people don't realize is that CBD could inhibit that same pathway and would likely do so much more potently than THC because of the complexity of the molecules and how much process- ing is needed by the liver. Stunned by these findings, Wohlschlagel presented her data at the Cannabis Science Conference in 2018 and shared her poster with researchers in Spain and Israel. Wohlschlagel is quick to point out that she is not a PhD or mo- lecular biologist. She is a nurse just trying to do right by patients. "The scientists in Israel and Spain appreciated what they called 'getting feedback from the bed to the bench.' The lab bench nor- mally sends info to the bed," she said. "In this case, the bed was in- forming the bench, meaning I was working with real humans. They were working with lab animals. They appreciated learning what I was seeing and they applauded my efforts, generally speaking."