Episode Transcript

Trevor:  Kirk, we're back.

Kirk:  How's it going, Trevor?

Trevor:  Good. I had a really nice chat with Dr. Vlad Gueril from Germany. Yeah, it was amazing. He just kind of reached out to us on LinkedIn. I'll talk more about that later as we can listen to Dr. Vlad, but I was literally in Wal-Mart. Buying foam to try to make my microphone less echoey and suddenly a message came up and a few things later we had pretty much agreed on interviewing him so that was just really cool I don't usually have Thursdays off I suddenly had a Thursday off and was getting messages from Germany that turned into an interview

Kirk:  Yeah, and he's a fan of the podcast. He's been listening to us for six months. He said that's kind of cool.

Trevor:  Yeah, fan of the show. So do you want to just get into him and then we'll discuss lots of interesting things to say, medical legalization, etc. And patients he's been treating. Want to talk about more of that when we come back out? We should introduce ourselves. We're trying to get into that gig right.

Trevor:  We do keep forgetting that. Okay, I'm Trevor Shewfelt. I'm the pharmacist.

Kirk:  I'm Kirk Nyquist, I'm the registered nurse and welcome to Reefer Medness - The Podcast. You have found us and we tell stories about our learning in cannabis. So you're going to learn how we learn about cannabis. And this is actually an interesting episode because we just spent the last 15 minutes trying to educate ourselves on the laws in Germany so that we could sound semi-intelligent in this conversation.

Trevor:  Yeah it's probably good we don't record everything we do but yeah we just spent a little bit of time googling and and whatnot about laws in Germany but uh we'll talk about that on the way back up

Kirk:  Yeah, let's go into the interview.

Trevor:  Yeah, hello, first of all, thank you for like inviting me. It's really an honor to be here since I really enjoy your podcast. Like I'm a GP from Germany. And I am listening to your podcast like every week whenever there is a new episode since almost half a year now. So like I said, I'm GP, but like I'm focused on the treatment with cannabinoids. I'm interested in it since almost six years now. But like I got my license three years back now and since then I'm prescribing also because before of course I was just consulting and I was not allowed to prescribe myself.

Trevor:  Okay, so what first got you interested in cannabis for for patients? What often there's one patient who sort of gets people interested. Was it a single patient or what got you interested?

Dr. Vlad Gavril:  To be honest, no. It was one of my best friends back then. He started a wholesale company in Germany back in 2017. And then he started telling me more and more about cannabis, to be honest. I myself didn't have much contact with cannabis. I have a brother who misused cannabis. So I was like, kind of negatively on it. But then he told me about the medical use of it. And then I started reading about it. And then when COVID hit, I really went into a went deep into it, I contacted people from all over the world, like I was talking to Raphel Meshulam, I was talking to Dustin Tulek, Mara Gordon, I just contacted them via LinkedIn. And like we do now, we set up a meeting on We talk, we exchange ideas, and I got more and more interested. And then I decided for myself to like focus on it because in Germany, unfortunately, we don't have many doctors who are like we have more and more doctors prescribing it. But to be honest, in my opinion, not many doctors know a lot about it. So they prescribe it because patients are coming to their office, they are asking for it. And basically, patients are telling the doctors what they want to have on the prescription and then the doctor just prescribes it, tells them to be careful and that's it. So this was my aim to go in there in this niche, let's call it like this, and to specialize in it and to really also give knowledge to the because, in my opinion, if you use cannabis properly... It's totally different than the recreational use, then cannabis can really be powerful.

Trevor:  Tool. That's very interesting. So let's talk a little bit about cannabis in Germany. So even if I didn't have a cannabis specialist like you, I could just go to my GP and say I want some cannabis and they could write me a prescription or how does that usually work?

Dr. Vlad Gavril:  Yeah, basically, yeah, true. So when you get your license in Germany, it's called Approbation, the German term for it. As soon as you get it, then you back then, like till the partial legalization in Germany which took place in April 2024, it was supposed to be like given to a patient on a narcotics prescription. And these are really like, like doctors are really careful with them to issue them. Because of course, there are a lot of restrictions on fun. But as soon as you get your license, you can apply basically, to get those prescriptions and you don't even have to have medical training already, like in a clinic. You don't have to be a specialist doctor, you can prescribe them, yeah.

Trevor:  Okay, and then as a patient with the prescription, what do I do? Do I walk down to my Apotheke my pharmacy and get it? Does it mail to me? How do I get the cannabis after I've got the prescription?

Dr. Vlad Gavril:  So there are different kinds of ways. Many pharmacies by now, they are specialized on cannabis in Germany. So they have their normal day-to-day thing going on with whatever medication that you know. And then they have a separate website most of the time, which is like their cannabis department. And you can order it and get it delivered to you via DHL, for example. Or, of course, you can go to the doctor, take your original prescription, and then you go in person to the pharmacy. And then of course I like this more because then also from the pharmacist you get a bit more of some education on how to take it properly and all this kind of stuff because like I said in the beginning, we have a lot of telemedicine platforms and the doctors there are in my opinion way too loose with issuing them. So the patients are not getting the education I need to use it properly.

Trevor:  That's fascinating. So a regular pharmacy in Germany can have cannabis sort of sitting there besides the cholesterol pills and the antibiotics that it's allowed in pharmacies.

Dr. Vlad Gavril:  Yeah, it is allowed. They don't have it in the, like, let's call it in the place where you go as a patient, as a client. They don't have it there, like on the shelf next to the normal other drug, but they have it and they're like in their storage. And then when you go there and you give them their prescription, some of them they will issue you the cannabis really fast. In the containers, like I think the podcast is was on video, like, but like in these containers, like that you see here, for example, one, and then you get it. And you can take it with you. But like most of the pharmacies, they are really careful because of the smell and because it's still like, let's say a field where most of the German people are really reluctant. They still have those stigma around that it's like, like, I don't know, a gateway drug and all this kind of stuff. So many pharmacies, they see especially the economical value in it. So they do it out of reason financially and so on. But they still want to have it separated from the normal day-to-day business in the pharmacy.

Trevor:  Okay, are there recreational stores in Germany too? Like if I didn't have a prescription, can I walk into a recreational store and purchase cannabis or is it just medical?

Dr. Vlad Gavril:  No, like, as I told you already, like from the from April 2024, there was the partial legalization it like this was the pillar number one. And they said there will be pillar number two or column, I don't know the English term to put it. Yeah, they want to do it in two steps. So first step was like the medical use, that it like it went out of the narcotic prescription sector. So every doctor could just issue it on a normal prescription. So it was way easier also for doctors to prescribe. So the availability, the access for patients got way easier, then a lot of telemedical platforms went in and you can see it also on the numbers, they exploded. When this happened in Germany. So, but if you just wanna use cannabis for relaxation or whatever kind of reasons, recreational use, then the only possibility you have is to like grow it yourself. At home, you are allowed in Germany per like household, to have... I'm not sure if it's two or three plants per person or per household, but if you can't this, the the only way still in Germany is to have a doctor prescribing it to you. And then there, this is a big discussion in Germany, because the recreational and medical sectors are really going into each other. There is no clear border. And there are politicians who really criticize it and so on. And now there's also in the German parliament, like a debate going on to change the laws again. Because they say there is a lot of miss use.

Trevor:  Okay, so let's go now into your practice that that was fascinating what's going on in Germany but so you you you specialize we'll call it specialize in in in cannabis and patients what what do typical people come come to you for that you're using cannabis to help them with what what sort of what sort of conditions are you treating with cannabis and cannabinoids?

Dr. Vlad Gavril:  So number one condition for sure is chronic pain, like for whatever reason, like, for sure back pain, but also like pain as a type symptom of other chronic illnesses. Then we have for sure insomnia, many, many patients with insomnia that are working like a shift system, like we have many people working at big industry facilities that they work day and night shift and then their whole circadian rhythm gets like disturbed. So they use cannabis for sleep aid before like going to benzos and other drugs. So they are really afraid of side effects. So they come to us as doctors and then we give them medical cannabis. For sure, we have like the indications where also like the Marinol we know, I think in America or like in Canada, it's called Marinol know it's the same, I believe. So these ones are like, for example, for chemo induced nausea and vomiting, like to stimulate appetite. But like, in my office, most of the patients come for chronic pain, insomnia, but also, and this for me, especially, it's really important to mention this for psychiatric disorders, for example, depression, ADHD, and so on. And there in Germany, we have like doctors work in this, like specialty, and they are really alarmed by it, because their their experiences are with patients. Or users who end up in the psychiatry because they got a like a disorder from it. But they're like, in my opinion, three important doctors to step in there because I ask myself, but why do they end up there? And in my opinions, because they don't find a doctor, They don't find anyone to talk to. And tell them about how cannabis helps them. And then you can like really check the terpene profile and so on and give them a proper strain, which helps them more. Because patients in Germany, a lot of them, they don't know anything about entourage effect and all these kinds of things. They know Indica, they know Sativa and that's it. So most of them. Not all of them like sometimes I'm surprised, Sometimes I have patients. That they use cannabis for decades. And they, I'm honest, they know even more about cannabis than I do, because I am really deep into it since six years, I would say. But of course, like after using it for 30 years, and when you read about it, of course your knowledge is much brighter, broader. So I learn every day.

Trevor:  No, that's fascinating. I want to talk more about the mental health things, but just before I forget, how are most of your patients taking their cannabis? Are they smoking it? Are they vaping it? Are they eating gummies? Is there a way they get it into them the most often?

Dr. Vlad Gavril:  So, in Germany, it's not allowed to smoke medical cannabis, because on the prescription we write to vape and inhale. So when you use a joint, you burn it so it's not allowed. Then the patient also can get into trouble with police and so on when they are stopped and when they ask. So like I instruct patients to get a vaporizer and to start vaping because also there the temperature is much lower so they get like I always tell them you get everything out of it. All the good and the bad like the carcinogenic effects and so on are way less with vaporizing. For me, it's important to tell patients vaporizing isn't healthy, but it's healthier than smoking because like some doctors telling patients vaping is really healthy for you and so on. So I'm really like, I really want to educate my patients correctly and don't tell them vaping is healthy, because I'm quite sure it's not. But I always do a risk. How do you call this risk benefit ratio?

Trevor:  Risk, risk, risk benefit. Yeah. Yeah,.

Dr. Vlad Gavril:  And then like I go for vaping, but I also try to show my patients the whole picture. So in Germany, we can prescribe flour. Cannabis flower, which is to be weighed. And then we can also prescribe oil. And most of it we have in Germany full spectrum oil. And there we have like different kinds of strengths, you say, like 10, 10, 25, 25 25, 1, and so on, 51, 101, 100, 100. So many different. And this for me is really important since in Germany, like the insurance companies are really reluctant to take the cost for cannabis if it's flower because they say with flower it's really hard to reproduce the effect and so on. So for me as a doctor, I always like you have to fill in a formula.

Trevor:  Form.

Dr. Vlad Gavril:  Yeah, form. And this is quite hard to get the insurance company to cover the cost. It's really just when you are basically, we have the guidelines and you have to fulfill the guidelines. And as a last resort, maybe they then they will pay for the cannabis therapy with flowers impossible by now. So I try to tell my patients, try both. Try flower and try oil. And then we will see which works for you the best. But in Germany, since there's education for patients, it's really low, I would say. Most of the patients only know from also recreational use and so on, the vaping or slash the smoking part.

Trevor:  The smoking parts. Okay so let's talk more about the mental health things because it seems to come up in Canada lately a lot too. If someone had depression or anxiety and was coming to see you maybe they're on an SSRI maybe they are not. What has been working for your patients or what sort of cannabinoids or terpenes. What have you been doing with them?

Dr. Vlad Gavril:  Yes, so unfortunately in Germany, we don't get much information about the minor cannabinoids. We get the, as doctors, I can see a certificate of analysis, but there I only get the THC, the CBD content, and the terpene, but not the CBN, CBG, and all the other cannabinoids. So I really look forward to because I believe for sure also minor cannabinoids are really important. But like I go especially for the terpene profile. So to patients that let's say like depression in the morning with like a lack of energy, you just want to stay in bed and all this kind of stuff. Then I would go for terpenes, which are like more in the, which give you the feeling of like getting energy, but like, I don't want to put it like you take the cannabis and then boom, you are like totally energized and you are happy and so on. But with time, I believe that what my patients are also telling me, when you choose the right strain with the right terpenes profile, and it's really, really individual, but I go for limonene, for terpinolene, for those kinds of terpenes. Then they see that they are like getting out of bed more easily, they get motivated again, and then you can start like doing a bit of sports, because for me it's also really important to tell my patients you have this endocannabinoid system in you, okay? And there are also again two like pillars. One is the endogenous part, which we have, which we can like activate by doing stuff like meditation, yoga, sports, going for a run and all this kind of stuff. But when you are depressed, and unfortunately, I know how it is to be depressed, because I myself suffer from depression in my life. So then it's really, really hard to get the motivation to go for a run. So I tell them, like we will introduce cannabis, we will get your endocannabinoid system activated but when you get again, to this point where you feel a bit of more motivation, then it's really important for you to take this motivation and to go for a run. So you have like both systems, both parts, like activated the endogenous one. And of course, extra genus, you can add the cannabinoids, the type of cannabinoids, and they also work on your receptors. And when you tell the patient that it works like this, then they understand it more properly. And then they also see it as medicine. I believe, like, that's my experience in the years since I do cannabis. Many patients still don't see it really as medicine. They see it as something that helps them, but not as real medicine, like something like more like herbal. Herbal medicine, but in Germany, like, unfortunately, many people don't think like really highly about herbal medicine or like other ways of medicine. Like, like it's more like concentrated on Western medicine on you have a symptom, you give a drug, then you're fine. But like, I use also cannabis, I always tell my patients before you take it also put yourself an intention. Why do you use it? Why? What do you want to achieve by using it? And like this, I believe the use is more conscious and then also misuse happens way less. That's at least my experience. No, uh, that's-

Trevor:  That lends really well with some of the other people we've been talking to about mindset before they use it. And yeah, no, we've come across that a lot lately about being in the right frame of mind and what you're trying to get out of it ahead of time. So no, that's fascinating.

Rene:  It's Rene here back in the studio. That's where we're going to pause the conversation with Dr. Vlad Gavril. And we're gonna continue that conversation, while Trevor is, next week in part two. And then Trevor and Kirk are going to add their insights and analysis into what was discussed. But that's all in the next episode of Reefer Medness, the podcast.