Episode Transcript

Trevor:  Kirk! We're back.

Kirk:  Hey how's it going.

Trevor:  Good and trying to do this at the beginning like we've been asked I'm Trevor Shewfelt, I'm the pharmacist. Who are you?

Kirk:  I'm Kirk Nyquist. I'm with the Registered Nurse. You're at Reefer Medness the Podcast and we are, we're talking, we are talking, you went out for breakfast. Was it lunch or breakfast?

Trevor: Lunch, lunch, and it sort of comes up so it's just funny. For those of you who haven't seen me in person, I am a physically big person. Ariana, the pharmacy student we talked to, is tiny. She's a tiny little human, which is, I'm not good, bad, and different, but you know, I was eating a lot and the whole idea is you get a to get a student to do anything, offer them food, so she was absolutely happy to go out and have lunch bought for her. I had a lunch. And she had coffee so you know it just yeah the huge person is eating the little person just having coffee but anyway it was it was a very I really appreciate the fact that Ariana chatted with us and the other thing just to tell you up front I because remember she's in student mode she's a student everything is you know a quiz, a project a grade. So she really thought I was going to quiz her on this she came with notes. So she was super prepared, which is good, you know, but I think by the end you could tell we were finally getting into conversation mode, but at the beginning I think she thought this was yet another quiz slash evaluation slash I was going to give her a grade. So no, I just want to have a chat about what you're learning in school.

Kirk:  Okay, so background, you're at the pharmacy, you're work. You guys deal with students all the time, so she is a second-year pharmacy student?

Trevor: Yeah so students have to do what's called rotations or so they have to go out and work in hospitals, work in community pharmacies, work in different places as part of their education. So this was I believe a six week, five-to-six-week rotation that Ariana who's going to school in Winnipeg, lives just outside of Winnipeg, was doing in Dauphin. So, she basically moved up to Dauphin for a month and worked with us.

Kirk:  So she's going to come out with a Ph.D. In pharmacy.

Trevor: No, that's different just to keep things good and confused. So a thousand years ago when I was in school, you could get a bachelor's of pharmacy and then if you wanted to sort of specialize, you wanted be kind of the kidney pharmacist on a dialysis unit in a big teaching hospital.  You can go get a clinical degree called PharmD which was a couple extra years of schooling after your bachelor of pharmacy. Or if you wanted to go do research then you would go get a PhD that that's a non-clinical more research degree. Now for the last couple years just a pharm your first level pharmacy degree they call it entry level Pharm D. So like we have a pharmacist now who's uh she grew up in Manitoba went to school in Alberta came back she is she is not a bachelor pharmacy she is a Pharm D.  So she's technically Dr. Cassandra. And when Ariana comes out, she's going to be Dr. Ariana. That's just what you do now. There's no bachelor of pharmacy anymore.

Kirk:  So it's an education creep.

Trevor: It is, yes. Okay,.

Kirk:  So let's go into the conversation.

Trevor: Let's listen to Ariana and then we'll chat a little bit on the way out. So I'm at Smitty's here today with Ariana, she's a pharmacy student who's been with us for a month-ish and we're gonna talk about what she learned in school about cannabis.

Ariana: Mm-hmm.

Trevor: Ariana, please introduce yourself to us.

Ariana: Okay, thanks Trevor. So my name is Ariana. I am a second-year pharmacy student at the University of Manitoba. I am in my first pharmacy practicum rotation now, so doing that at the pharmacy in Dauphin. And we are just out having lunch to talk about what we've learned today.

Trevor: Okay, so back a thousand years ago when I was in pharmacy school, they taught zero about cannabis. In the last five-ish years, I periodically have gotten to talk to some of the medical residents, the family medicine residents here, on some of their learning days and talk to them a little bit about cannabis. And I'd say five years ago, they hadn't learned anything about cannabis, but in the last couple years, it seems like they have learned a little bit so.

Ariana: Okay.

Trevor: The main reason I ask you is what have you been learning about cannabis in pharmacy school now?

Ariana: Yeah so cannabis actually kind of came into the conversation in our pharmacology class in first year. It was part of like a three-part series on street drugs but the cannabinoids were part of their own class so outside of the stimulants and outside of The Depressants kind of going into more where this can be utilized medically and where it is being utilized medically. So we kind of broke it down from there just seeing what the benefits are, what the different types of the cannabis are to work in the system and in the body and how that can be utilized for pain and inflammation and stuff like that.

Trevor: Cool. Now, Kirk, my co-host, will love to harass me if I don't ask about this. So, was it treated more as a medication of abuse, like, you know, a cocaine-heroin type thing, or was it talked about as a therapeutic or a little of both?

Ariana: Um a little bit both but less so of a drug of abuse more so in like a therapeutic sense if anything. Um so like i was saying it was introduced as part of that drug series on the street drugs quote unquote but outside of like your normal drugs of abuse. Um so we did go into like the different receptors in the body and how this can be utilized for different sorts of pain or different sorts of inflammation, even things like nausea and vomiting. How it can be therapeutic in those senses.

Trevor: And so there are many, probably hundreds of different cannabinoids in a cannabis plant. Did you guys talk about different cannabinoids?

Ariana: We did, so we went into like the different cannabinoid pathways and receptors to whether that be like a CB1 receptor or a CB2 receptor and then what those are utilized for differently in the body. So a CB1 is more so the response to pain and then the CB2 is more so the immunosuppressive type so that can be used to treat inflammation.

Trevor: Did you talk about different ways of, you know, pharmacists, we love to talk about routes of administration. Did you talked about how cannabis gets into the body, the different ways people get it, put it in themselves?

Ariana: Yeah, so we actually went exactly into the routes of administration, funny enough. We talked about how inhalation will be your fastest onset of action, and then there's also options that you can take as either an oral capsule or an oral spray. That one would have a slower onset, but that produces a longer duration of action. Then it can also be used topically, so either as like a patch or as gels. And then there's also options for suppositories to be used as well.

Trevor: Cool. You guys mentioned suppositories. Kirk teases me all the time. I seem to be a little suppository obsessed. Back when we were compounding, we made a bunch of different suppositories for different things. I haven't actually made a cannabis suppositories, but we've talked to people who use it by that route and...

Ariana: The option is there.

Trevor: The option is there and it's always an interesting group because a third of it-ish skips the liver, skips that first pass metabolism, so you get different effects.

Ariana: Mm-hmm.

Trevor: And inhalation skips the liver too so that's one of the reasons people talk about the oral lasting much longer is you get this different metabolite out of out of oral after it goes to the liver where inhalation sort of for the THC anyway skips it all together.

Ariana: Right. Yeah.

Trevor: Something that we have learned as part of the podcast, which I didn't realize was the thing at all, did you guys talk about the difference between the acid and the non-acid forms of things like THC and CBD?

Ariana: I don't think we went into that, no.

Trevor: Was brand new for us as well and it's interesting we think because like the acid if you went and ate a cannabis bud the flower right now you probably wouldn't feel anything because all the THC or most of the THC and that would be the acid form which is not psychoactive. You have to do something to it most common thing is to heat it to get rid of the acid group and it's THC and that it's psychoactive but many of the Medicinal people who like cannabis for medicinal stuff are big fans of the acid form thinking it does more more medicinal stuff than the THC non-acid form and same thing with the the CBD and other cannabinoids. So no Not that it's bad that you didn't learn it But I had no idea what it was that there was differences at all until we started doing the podcast. So just wondering if that came up

Ariana: Right. No, I don't think that's actually something we talked about, but it is interesting for sure.

Trevor: And then, because pharmacists, we also love this, did you talk about drug interactions?

Ariana: Drug interactions, we sure did talk about drug interactions. So hold on here. So we talked about it less so with specific drugs, but more so how they're metabolized. Okay, so the CYP3A4 that we always talk about so that one is CBD and THC are metabolized by that same enzyme. So if you're taking a medication that is an inducer of this enzyme, then your CBD and THC levels will be lower. And on the contrary if you are taking a medicine that is an inhibitor of these enzymes, then if you're taking THC or CBD as well, then these levels will increase. So those are just things to be mindful of if you using it therapeutically, making sure that you do like a drug interaction check to see if a patient's other medications could be inhibited or enhanced by using these products. But aside from that, we didn't go into anything too in depth. We talked about how there can maybe be some additive adverse effects if you're taking a CNS depressant. Or if you're taking an anti-cholinergic medication. Outside of that, that was kind of the depth we jumped into.

Trevor: No, and those are absolutely things we have to think about. So CNS, depressant, and non-pharmacy language is, you know, things that make you feel sleepy, and cannabis can make you feel sleepy. So you add the two of them together, you might feel really sleepy.

Ariana: Extra sleepy.

Trevor: And it's a complicated thing, and we've actually talked to a few actual scientists and pharmacologists who are looking into exactly what cannabinoid is affecting most things but one of my sort of rules of thumb it's not perfect is the the CBD seems to be especially involved in the the cytochrome P450 the CYP3A4 interactions. So it and that's interesting because we talk about the CBD being used more medically so, you add CBD to people who odds are they're on a bunch of other medications that you just kind of have to be careful.

Ariana: Mm-hmm.

Trevor: But, and again, this is my opinion, so. We probably only have to really worry about things that are the narrow therapeutic index. So warfarin, which was really common when I was at blood thinner when I came out of school. It's still out there but less common now. Some of the anti-convulsants like clobazam. So again, we can use CBD for seizures in children and clobazam we can use for seizures in children. So we have to if, we're going to use two of those together we'll have to be careful and then one that I don't know all the ins and outs but kind of surprised me is some of the immunomodulating cancer treatments. Get your oncologist involved. But because the CBD seems to actually make your immune system quote unquote work better and some of the amino modulating cancer treatments do the same thing, it can actually, my simple way of thinking about it is it makes your immune systems maybe work too well. So if you are on cancer and on some of these immunomodulating therapies, just make sure you have a chat with your oncologist, kind of most of the oncologists we've talked to are now getting more and more familiar with cannabis because many, many people who have cancer treatments are trying it anyway. But yeah, just keep the oncologist in the loop because, you know, one of the semi-non-controversial things what cannabis is using as a treatment for Chemotherapy-induced nausea and vomiting. So it's definitely being used, but just again, keep your oncologist in the loop if that's something you're going to do.

Ariana: Yeah we talked about that as well actually how you can use CBD to kind of suppress the or settle the stomach and help with appetite so that's something that we could see a lot with like chemotherapy patients that their appetite has gone away or having a lot of nausea and vomiting so using it in that sense that's the thing that we went into in class as well.

Trevor: And so then just kind of a general things, I noticed this with the medical students. I, my impression is there's just a whole lot less stigma in quote-unquote the younger people about cannabis in general. What did you find in your class? Do you think cannabis use is still stigmatized? Less so, more so, might be hard for you to tell since you're in the middle of the younger generation.

Ariana: I would say less so I think, I think especially because we are having conversations about it not just amongst ourselves but rather being taught about it in class. That kind of takes that stigma away a little bit, just so more like eye-opening to the fact that it's not always a drug of abuse or not necessarily a drug of abuse depending on what it's being used for and how it's being used so that there is more room to have conversation about it in a therapeutic sense. That I think that kind of limits the stigma around it a little bit especially from what I've seen and heard in my class but I'm sure the stigma is still out there depending on who you ask but I think it would be less and less as time goes on.

Trevor: I agree, well, this has been very nice. I appreciate you, you know, coming here for lunch with me and chatting with cannabis. Ariana, it was really nice to meet you.

Ariana: Thanks, Trevor.

Trevor: So Kirk, what did you think of my chat with Ariana?

Kirk:  Well, I love those kind of interviews. I love having the background noise of a restaurant. I always strive for those kind interviews. So I like that. It was just cool. So essentially, pharmacist students are learning about the cannabinoid system. But they're learning about it in a chapter the chapter is, what was the chapter that it falls under?

Trevor: Street drugs. I knew you would latch right onto that.

Kirk:  That's what I got onto. So in that chapter, they learn about cannabis, but they're going deeper. So I didn't hear her talk about the endocannabinoid system, she did talk about receptors.

Trevor: She did talk about receptors and that's probably my bad. I'd never used the word endocannabinoid system, so I don't know if they used it or not, but whether they used or not the fact they talked about, you know, I probably, in pharmacy school, I probably heard the word THC, but I certainly didn't hear that it had receptors and it had enzymes and so whether they call that the endocannabinoid system or not, they are at least learning basic parts of it. So I thought, you know, and again, what, Ariana, we weren't quizzing you, from just the chat about what she learned, you, know, of course you can always learn more and learn different, but I think they basically have learned about cannabis or given sort of a primer to if they're going to do cannabis stuff down the road. Compared to what I learned, nothing, they learned something.

Kirk:  Well, I was impressed that when I heard that, you know, it's part of the street drugs module and, okay, here it goes. But no, no, it was nice. They got into receptors. And I guess the next question would be to ask, or do they learn that about the other, like the opiate receptor? Obviously, if we're talking about street drugs, opiates would be there, and you have a whole chapter on opiates for sure. So that would just relate to that. So all those other street drugs, the The pharmacologist, pharmacist, pharmacologist.

Trevor: And pharmacology.

Kirk:  Pharmacology would all be linked already in other modules. So I guess this is good, it's a first step, but it's not a whole module on the endocannabinoid system or ya.

Trevor: No, but again, extrapolating a little bit, like you learn so many different types of drugs and pathophysiology, like this part of the body went wrong, here's what drug to throw at it. That, you know, it doesn't, as you know if you ask me what did I learn about the kidney in pharmacy school and how to treat it, I think I learned something about a glomerular filtration something, but you know... It's not this, but you can almost think of pharmacy school as at least if we introduce you to X, Y and Z, then later on in your career, if you need to know more about it, you've got some some scaffolding to hang stuff on. And I think they've got the scaffolding.

Kirk:  And I think that's fantastic, and I compliment the University of Manitoba. Yes. Yeah, fantastic. I mean, I'm always learning about something. I just had an event last night, actually, learning a little bit about ibuprofen. I always thought ibuprofen was a good analgesic anti-inflammatory effects, given the analgesics because they're inflammatory, for bones and ligament type injuries, right? But what I just learned yesterday was that if you fracture your bone, ibuprofen is not the drug of choice because it impedes the binding of the bone. I didn't know that. That's new knowledge to me.

Trevor: News to me, too.

Kirk:  Yeah, yeah, it has to do with bone healing and I guess NSAIDs may impede bone healing. And I went, well, hold on. I always thought that that was a first line, well besides opiates, because the individual who's telling me about her injury, first thing they prescribed to her was opiate. And I said, God, you know, opiates.

Trevor: I'm not saying they're not without problems, but let's not take away from opiates are really good at acute pain like breaking a bone.

Kirk:  I agree, but my experience with opiates and breaking a bone is that the pain didn't go away. I just didn't care because I was too busy trying to hang on to the roller coaster ride the opiate was giving me. But that was how opiate affected my brain. I didn't like, I did not like the opiates I was given when I broke my bones. And I took one dose and I said no more. So I lived with the pain because I didn’t want the opiates. However, I also self-medicated using cannabis back in the 90s, you know, but who knew?

Trevor: But yeah, circling back to Ariana, you know, thank you Ariana for agreeing to sit down. If this was a quiz, you aced it. You did great. Again, just poor kid, poor kid. She's literally the same age as one of my kids. So I keep, she is a full grown adult, but I'm trying not to call her. She will shortly be a colleague of mine. So I will stop calling you a kid any second now.

Kirk:  But yeah, you will be calling her doctor.

Trevor: Dr. Ariana, will you give me some advice, please?

Kirk:  Yes.

Trevor: But when she was here in January, it was so brutally cold, her and a classmate came up, they went to different pharmacies, but they tried to do stuff on the weekends, like they went for a quick snowshoe at Northgate and they enjoyed it. Another friend of theirs was in McCreary, so they went to McCreary and did a few things there. I went to a Kings game, so I did a few things but it was so brutally cold now it's almost too warm like I'm going winter camping next weekend that's what I'm packing up to do now and I'm hoping it stays below zero so everything doesn't turn mushy you know Manitoba weather. We can't get through one of these without complaining about Manitoba weather but full credit to Ariana for coming up here too Dauphin. Do a little bit learning in the brutal brutal cold of January

Kirk:  Yeah. Thank her very much. I enjoyed listening to her speak.

Trevor: And I think that this is a good short one. So let's wrap it up here with I'm Trevor Shewfelt. I'm the pharmacist. You are?

Kirk:  I'm still Kirk. I introduced myself at the front, remember?

Trevor: Excellent.

Trevor: And this is Reefer Medness, the podcast. Everything Reefer Medness, it's Reefermed.ca and all of them, their socials, usually at Reefer Medness. So check them out, tell us what you think, and we'll talk to you next time.